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Title: The Lettsomian Lectures on Diseases and Disorders of the Heart and
Arteries in Middle and Advanced Life [1900-1901]

Author: J. Mitchell Bruce

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Most recently updated: October 23, 2024

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*** START OF THE PROJECT GUTENBERG EBOOK THE
LETTSOMIAN LECTURES ON DISEASES AND DISORDERS OF THE
HEART AND ARTERIES IN MIDDLE AND ADVANCED LIFE [1900-
1901] ***

HEART DISEASE
IN
MIDDLE AND ADVANCED AGE

The Lettsomian Lectures

ON

DISEASES AND DISORDERS
OF THE

HEART AND ARTERIES
IN
MIDDLE AND ADVANCED LIFE

Delivered before the Medical Society of London, Session 1900-1

BY

J. MITCHELL BRUCE, M.A., LL.D., M.D.,
F.R.C.P.,
Physician to Charing Cross Hospital; Consulting Physician to the
Hospital for Consumption and Diseases of the Chest, Brompton

LONDON:
HARRISON AND SONS, ST. MARTIN'S LANE
PRINTERS IN ORDINARY TO HIS MAJESTY

1902

To
JOHN H. MORGAN, C.V.O., M.A. Oxon., F.R.C.S. Eng.
President of the Medical Society of London, 1900-1901
from his friend and colleague
The Writer

CONTENTS
LECTURE I.
PAGE
Introduction 1
Natural State of Heart and Arteries after 40 3
Causes of cardio-vascular disorder and disease 6
Physical Stress 6
Nervous Influences 8
Cardiac Poisons 9
Disturbances of Metabolism 9
Gout 9
Syphilis 10
Acute specific fevers 11
Chronic affections 11
Complex causes 11
Old-standing Rheumatic Lesions 13
Family heart 14
LECTURE II.
Clinical Characters and Course 14
Clinical Characters and Course of Tobacco Heart 15
Clinical Characters and Course of the Heart in Alcoholism 18
Clinical Characters and Course of the Heart in Gout 20
Clinical Characters and Course of the Heart in Obesity and
22
Glycosuria
Clinical Characters and Course of Cardiac Strain 23
Clinical Characters and Course of Cardiac Strain before 40 25
Clinical Characters and Course of Syphilis of the Heart 28
Clinical Characters and Course of cardio-vascular disease from
29
Nervous Strain
LECTURE III.
Diagnosis, Prognosis and Treatment 30

Differential Diagnosis 31
Value diagnostically of different physical signs 33
Value diagnostically of different symptoms 35
Prognosis 36
Treatment 37
Conclusion 50

THE LETTSOMIAN LECTURES
1900-1901

LECTURE I.
Mr. President and Gentlemen,—My first duty this evening is to thank you,
which I do most heartily and gratefully, for the honour you have done me
by selecting me to deliver the Lettsomian Lectures for the present year. My
second duty is to spend as little time as possible on preliminary remarks, for
—as you, Sir, know, having yourself occupied this distinguished place on a
former occasion—three hours are all too brief for useful presentation of
material which one has collected for a purpose like the present. In selecting
the subject of my Lectures I was mindful of the character and objects of this
Society. In the Medical Society of London there is a fuller blending of men
engaged in family practice with men holding hospital appointments than is
the case at most of the other learned societies connected with our profession
in London; and there is here an opportunity for free communication of
experience and interchange of opinion between these two classes of our
Fellows which cannot fail to be profitable to both. Therefore, I have taken
up a subject of thoroughly practical interest; and not only this, but I will
attempt to present it to you, to put you in a position to look at it, from the
point of view of the practitioner. The problem of the diseases and disorders
of the heart and arteries in middle and advanced life may be said to come
before the family practitioner every hour of his work, and to offer
difficulties and create a sense of responsibility or even anxiety which are
not sufficiently appreciated by the hospital physician. There comes before
him the case of one of his patients, an active business man of 45, who has
been seized with angina pectoris when hurrying to the station after
breakfast, or that of an old friend, whose proposal for an increase of his
insurance at 50 has been declined because of arterial degeneration and
polyuria; or he is asked to say whether a man of 60, occupying an important
and possibly distinguished position in the community, ought to retire from
public life because he has occasional attacks of præcordial oppression and a
systolic murmur at the base of his heart. What, again, is he to do for the
stout, free-living man, just passing the meridian of life, who consults him
for weakness and depression, whose heart is large and feeble, and the urine
saccharine and slightly albuminous? There is not one of my audience who

has not met with such cases as these many times in his practice, and a
variety of other cases of cardiac disorder and disease after 40, where the
importance of the individuals, the value of their lives, and the gravity of
their complaints and their prospects have exercised him very anxiously.
What is the prognosis in cases of this order? What can be done for them in
the way of treatment? These are the questions which we would desire to
answer usefully. The answer, it seems to me, can be given only after an
analysis and study of a considerable number of instances of the kind, in
respect of their origin, their clinical characters and course, and the result.
This is the method of inquiry which I propose to follow. It will be a study of
cardio-vascular disease in older subjects from the clinical point of view, and
it will be approached not only from the ordinary clinical side as it is
approached in hospitals, that is, by an investigation of symptoms and signs,
but also and especially in the light of that particular order of knowledge
which the family practitioner has learned to appreciate and has so intimate
an opportunity to acquire correctly—a knowledge of the origin or causes of
the different affections, which it is always difficult, and often impossible,
for the hospital physician to ascertain. For the same reason, although, to be
complete, a study of the diseases of the circulation at and after middle life
should include an account of the post-mortem characters found in fatal
cases, and whilst the basis of the account I submit to you will be essentially
pathological, I shall not attempt to describe the pathological anatomy and
histology of this group of lesions of the heart and arteries. This part of the
subject has been remarkably advanced during the last few years; and even if
I had the time and the necessary knowledge to deal with it now, I should
have nothing original in it to lay before you. Indeed, if I may venture to say
so, our attention lately has been too much confined to the pathological
states of the heart and arteries and too little directed to the causes which
produce them. "Arterial sclerosis" is now an ordinary diagnosis in every-
day practice, as if it were sufficient for purposes of prognosis and treatment
to have determined that the radial artery is thicker and longer and more
dense than normal, without regard to the actual nature of the pathological
change, whether strain, or syphilitic, or gouty, or otherwise. And in the
same way the phrase "dilatation of the heart" is now in everybody's mouth,
irrespective of considerations of its origin. Not only has the profession
suddenly woke up to the recognition of a form of enlargement of the heart
which was fully described fifty years ago by physicians in our own country,

but the public have made "dilated heart" a fashionable disease which calls
for the advice of a specialist and an annual visit to a Continental spa. We
ought to have advanced beyond this stage of cardiac pathology long before
this time. Besides, of how much greater interest is it in our every-day work
to study the causes or circumstances that lead up to disease than the simple
state of disease itself! And there is in a study of this kind an opportunity
afforded to the family practitioner of advancing Medicine—scientific,
preventive and therapeutical—as surely as if he were a pathologist in the
post-mortem room or laboratory.
Before, however, examining the influences and circumstances which
disorder and damage the circulation in middle and advanced life, let us see
what the normal or natural state of the heart and arteries is after 40. It has
been ascertained that the different parts of the circulatory apparatus pass
through certain definite phases of change in the different stages of that
decline of existence and energy which leads to senility and ends in death.
We have to thank Professor Beneke, of Marburg, for the results of a
laborious investigation of this subject which are generally accepted and
which I will attempt to summarise.[1]
We should all expect the cardio-vascular system to undergo important
changes with increasing age; but few of us would be prepared to find that
these changes are neither uniformly progressive nor indeed continuously
progressive in the same direction. To make more easily intelligible the
nature and as far as possible the origin of these anatomical alterations in the
heart and arteries during the second half of life, I will first refer for a
moment to the circulation from 20 to 45. During this period of life the
blood-pressure is relatively high, reaching its maximum about 36; the aorta
and other large arteries increase in diameter from the stress of the blood-
pressure on their elastic walls, particularly between 35 and 45, and the heart
increases in size year after year at a nearly uniform rate. We have in these
facts anatomical evidence of the great functional vigour and activity of the
circulation in manhood. At 45, which is practically the commencement of
the period with which we are concerned, remarkable changes occur. Whilst
the arteries continue to increase in circumference (somewhat more slowly
than before), the blood-pressure falls and the heart begins—almost
suddenly—to diminish in size; and these three features characterise the
circulation for the next 20 years, that is, until the age of 65. How is this fall

in the size of the heart to be accounted for? Partly by the widening of the
arterial trunks and the consequent fall of pressure. But not by these only; for
although the arteries had been widening even more rapidly between 20 and
45, the pressure was actually at its maximum then and the heart large, and
we shall presently find other facts opposed to this view. The peripheral
resistance in the systemic arteries must fall from some other cause or causes
in middle age than the loss of elasticity of the arterial walls, and these
causes are probably reduction of mechanical stress, due to comparative
bodily relaxation, loss of vaso-motor tone in the splanchnic area, and the
chronic diseases of which the subjects have died whose hearts and vessels
are measured post mortem. During this phase of life also, the blood
becomes more venous in quality and its hæmoglobin value is lowered.
At 65, other changes which occur in the heart and arteries are not less
striking than those which I have just described. The decline of circulatory
energy, and the effects of time itself on the protoplasm of the cells of the
body, have so lowered the metabolic and functional energy of the tissues
and organs and the activity of the blood-supply, that a considerable
proportion of the capillary network becomes obsolete. The peripheral
resistance is thus increased, and the blood-pressure rises; therefore the heart
once more increases so much in size that at the end of the 10 years (age 75)
it is found as large as it was at 45, and at the same time the hæmoglobin
value of the blood again proves to be higher. During this period, also, the
arteries continue to grow wider and thicker and longer—another proof that
the size of the heart is not determined solely by their calibre. Regarded as a
whole, the process of senescence of the cardio-vascular system presents to
us a beautiful instance of anatomical readjustment and compensation—the
counterpart, in a way, of the growth of the circulation in energy and activity
during the period of full manhood. The arterial walls, which have been
stretched in their diameter and in their length by exhaustion of their
elasticity under the stress of cardiac systole, are strengthened afresh by the
development of stays formed of fibroid and muscular tissues in the intima
and media; and the heart responds to the altered mechanical condition ahead
of it in the arteries, and to the increased peripheral resistance caused by the
obsolescence of many capillaries, by growing afresh.
This account relates to the size of the arteries after 40; now let us inquire
what is the condition of their structural elements. The changes described do

not necessarily involve disease of the tissue elements, unless we were to
call every senile change morbid. My friends Dr. Bosanquet and Dr.
Mullings have given me an account of the state of the heart and aorta in the
bodies of 25 men, aged 40 and upwards, examined in the post-mortem room
of Charing Cross Hospital, who had died from accident or suicide. The
average age was 53½ years, and the aorta presented some degree of
atheroma in half the cases. When we consider how very slight a change in
the arch of the aorta is habitually described as "atheroma," and that in a few
of the cases the valves were diseased and the heart enlarged, we are justified
in concluding that in the majority of persons of 53 the arteries are still
sound. This result is in accord with that obtained by the late Professor
Humphry, who devoted his attention so long and so successfully to the
investigation of old age. He states that in the great majority of cases the
arterial system appears to present a healthy condition in those who attain to
great age.[2] Even among the majority of centenarians the evidences of
arterial degeneration were not manifest.[3] And we know that we
occasionally meet with people of 80 and upwards whose pulses are
unexceptionable, beyond presenting a trace of thickening and enlargement.
For my present purpose, therefore, we may conclude that as age advances,
the arteries naturally become wider, longer and thicker, and altogether
larger than in early life; and that we must not speak of "vascular
degeneration" in an evil sense as often as we find these conditions present.
As for the heart, we know that it may remain structurally sound, and is
more often regular than irregular, to the most advanced years of life.
Conversely, these facts suggest that actual diseases of the arteries and heart,
that is, other than the changes which are found in all persons after 45, are
not properly senile in their nature. As Professor Humphry said, they are no
part of, but are rather to be regarded as deviations from, or morbid
departures from, the natural phenomena.[4] They must be the effects of
pathological processes due to a variety of pathogenetic influences which
assail the circulation. Now we are in a position to study these.
After the age of 40, many of the influences that threaten the heart and
arteries with disorder and disease are peculiar to this period of life—that is,
different and distinct from the causes of cardiac and vascular affections in
childhood, adolescence and manhood; others of them have been
encountered already, with or without permanent damage as the result. I will

now examine them in detail, and at the same time refer to certain provisions
with which the heart and arteries are endowed for resisting them and
recovering naturally from their effects, as well as to the circumstances
which render these provisions abortive or insufficient, and thus predispose
to disease or indirectly determine its occurrence.

1. Physical stress is still a definite cause of cardiac and vascular damage
during the second half of life, in the forms both of sudden violent exertion
and of ordinary laborious occupations. I have met with instances of acute
and serious strain at all ages over 40, up to and even after 70. I am aware
that I must speak on this part of my subject—the evil effects of muscular
exercise—with great caution in the presence of you, Sir, our President, who
have long been recognised as one of the principal patrons in our profession
of athletic sports, and so highly distinguished yourself in them at Oxford
and in the inter-University contests. I assume that you are unwilling to
admit that muscular exercise is dangerous to health. But I feel sure that you
will agree with me that when the man of 65 rushes from his breakfast-table
to catch his train, or the lady of 70 hurries up a hill in Wales to be in time
for morning service, or the middle-aged father on holiday, who has just
started a bicycle in order to reduce his weight, takes the pace from his son
of 17, the effect on the heart and arteries is likely to be serious. I have notes
of a good many cases of cardiac strain in middle-aged and old persons from
cycling; a very few from violent efforts to drive at golf; a few from efforts
at lifting or resisting heavy weights; and one notable case in which a
member of our own profession, a man of 45, belonging to the Royal Army
Medical Corps, broke down with acute cardiac dilatation during General
French's memorable ride to relieve Kimberley. In some of my cases there
was no reason to believe that the heart was other than sound before the
strain; but in a majority of them (and I have analysed 40, of which I have
more or less full notes) one or more of the safeguards of the circulation
against strain were already defective or wanting. What are these? In the
heart, chiefly a high degree of extensibility or elasticity of its tissues,
permitting over-distension of the chambers, with safety-valve action of the
tricuspid in extreme cases, and a sound and vigorous musculature to effect

the increased action, and if necessary the hypertrophy, which mechanical
stress demands—in a word, healthy, well-nourished cardiac walls. It is an
interesting fact that two-thirds of my cases of cardiac strain in the second
half of life presented also a history of gout, fully developed or irregular—in
other words, a history of perverted metabolism. Equally striking is another
fact in this connection: that in many cases the occurrence of strain in middle
or advanced age was but the latest of a series of similar events as the result
of muscular effort for a period of 10, 20, 30, 40, or even 50 years—in other
words, the heart had been strained originally in youth or early manhood,
and had given serious trouble as often as it was taxed again. Rowing or
running at college was in a good many instances given as the cause of the
first strain. I need not do more than mention previous valvular disease,
usually of rheumatic origin, as a condition powerfully predisposing to
cardiac injury by physical exertion. Excepting in this indirect way,
rheumatism has no effect in lowering the resistance of heart or vessels to
mechanical stress.
The principal safeguard which the arteries possess against strain is, of
course, the extensibility and elasticity of their tissues. Unfortunately the
metabolic disorders, including gout, which we have just found weakening
the cardiac walls, are amongst the commonest causes of arterial
degeneration also; and the two influences—gout and strain—acting together
no doubt are accountable for a considerable number of cases of atheroma
and chronic arteritis. It naturally might occur to us that gout and exertion
could not well be associated, but this very consideration serves to explain
their mutual influence in straining the heart. It is unwise, ill-timed, ill-
planned muscular exercise that injures the circulation, most often on the
part of the middle-aged man, who, awaking to the consciousness of growing
fat and gouty, rushes inconsiderately to violent exercise for relief.
2. It is generally recognised that nervous excitement and other nervous
influences tax the circulation; and endless phrases and expressions,
articulate and inarticulate, testify to the universal belief in the close
connection between the heart and the emotions. Quite recently Dr. Leonard
Hill and Dr. George Oliver have demonstrated instrumentally the rise of
blood-pressure that accompanies cerebral activity.[5] No doubt many cases
of disorder and disease of the walls of the heart and arteries originate in
distress, worry, anxiety and protracted suspense; and the connection is most

often seen in middle and advanced life, because these depressing emotions
fall most heavily upon mankind at this period. Of the instances which I
have met with I will mention but one or two by way of illustration. A
member of the Reform Committee at Johannesburg at the time of the
Jameson Raid, who had been confined in Pretoria Jail, came home
sometime afterwards with the ordinary symptoms and signs of fatty
degeneration of the heart, and died suddenly on the street. A detective
officer who had tracked suspects and criminals all over the world, facing
great personal danger, and on one occasion had to convey a parcel of
dynamite found near a Government office to a place of safety many miles
away, came under my care later on with arterial sclerosis and cerebral
thrombosis, for which no other cause but a life of adventure could be
discovered. These were cases of actual disease of the heart and arterial
system respectively; and I need not add that disturbances or disorders of the
circulation, of every degree and variety, the result of nervous excitement or
depression, come constantly under our observation, especially in women. I
would particularly mention, however, a group of cardio-vascular troubles
that lie between these two extremes. I have frequently observed that persons
of anxious and energetic temperament, burthened with responsible work of
a heavy, constant and prolonged character, when they break down, as they
often do, present the clinical features of high tension: the pulse is full, the
heart is large, the second aortic sound is loud and ringing; there is polyuria,
and a trace of albumen may be found. This disturbance of the circulation,
strongly suggestive of contracted kidney, is as common in women as in men
—for instance, in matrons of schools or hospitals. Nevertheless, however
clear the direct connection between nervous strain and cardio-vascular
disease may be in many instances, it is in other instances unreal, or more
correctly indirect only. This is a matter of great practical importance. First,
the nervous temperament often drives the subjects of it to physical
overwork in the form of incessant and prolonged devotion to work, with
insufficient hours of rest and sleep, and to unwise attempts to remove
nervous exhaustion by violent muscular exercise, as we have just seen. In
the second place, alcohol undoubtedly plays an important part in many
instances regarded as overwork and worry and nervous exhaustion, both in
men and in women—alcohol taken to enable more work to be
accomplished, to steady the nerves, to promote sleep, to drive away care, or
to relieve the faintness which it has itself induced. And thirdly, many of the

complaints of nervous depression, lowness and worry are really due to gout,
to influenza, and the like, which are at the same time the true causes of the
cardiac symptoms.
3. What I have just said in connection with nervous causes of cardio-
vascular affections brings us naturally to that important group of agents
which may be summarily called extrinsic cardiac poisons—alcohol,
tobacco, tea, coffee and lead. I will not dwell on this subject at present, for
there is no need to prove the reality of the connection, and I shall have
occasion to refer to some of these poisons at greater length under the head
of diagnosis. Alcoholic heart occurs both in men and women; tobacco heart
is extraordinarily common in our own profession, and common in
clergymen and in retired members of the public services; tea-, coffee-, and
cocoa- poisoning I have met with principally in students.
4. There can be no question but that by far the most prolific causes of
cardio-vascular disorder and disease after 40 are disturbances of
metabolism, including gout—at any rate amongst the middle and upper
classes in this country. This period of life brings with it in many instances
comparative relaxation from work, and a disposition to substitute quiet or
even passive for active exercise; and whilst the demands of growth and
development on the alimentary system have greatly declined, the pleasures
of the table and ease generally are too often indulged in as a privilege of
advancing years and the legitimate reward of previous years of work. The
results are functional disorders of the liver, gout in regular and irregular
forms, gravel, and the many associated disorders of the muscular, nervous
and other systems. At the same time the arterial tension rises, for the body
possesses a physiological provision for eliminating the nitrogenous
products of metabolism, whether normal or abnormal, namely, the kidneys,
the vaso-motor mechanism and the heart. Stimulation of the vaso-motor
centre by nitrogenous waste raises the arterial pressure; the heart is excited
to more vigorous contraction (if necessary it hypertrophies); and the
consequent polyuria washes the intrinsic poisons out of the system. Thus it
happens that in metabolic disorders, from excessive or unwholesome eating
and drinking, the heart, vessels and kidneys are kept under incessant strain;
and, like other organs working under strain in the gouty subject, they are the
readiest to suffer—first from disorders of many kinds, and ultimately,

unless reform be enforced, from cardio-vascular degeneration and chronic
Bright's disease.
Of the many cases of this kind that I have seen at all ages between 40 and
80 (and others before 40), the proportion of irregular gout to acute articular
gout was about 3 to 2. Under irregular gout I include goutiness in its many
forms—sick headache, eczema, sciatica, lumbago, acid dyspepsia, irritable
bladder, asthma, insomnia, vertigo, depression, and the familiar complexion
and appearance generally of "the gouty individual," all variously combined.
In other cases the metabolic disturbances come before us not as gout or
even goutiness in the ordinary acceptation of the term, but in the forms of
obesity, of diabetes, of gravel, of irregular albuminuria, and of the effects of
large eating and free living in general.
5. Syphilis—that fruitful cause of vascular disease, and both directly and
indirectly of cardiac disease—has by no means ceased to attack the organs
of circulation after 40. Whatever the date of the primary infection, syphilis
is a standing danger to the heart and arteries in the middle-aged man and
even in declining years. Thus, in 11 cases belonging to this group, the
average age at which they came under my observation (most of them but
not all complaining of cardiac distress) was 55. All of these were men. I
ought to add that in a considerable proportion of the cases either physical
strain, alcohol, tobacco or Bright's disease was associated with syphilis in
the etiology, and sometimes more than one of these.
6. For the man and woman of forty years of age and upwards, most of the
acute specific fevers are affairs of the past. But the liability to several of
them remains, and, very unfortunately, the liability to those acute specific
processes which may attack the cardio-vascular system—influenza in
particular, and less often typhoid fever, rheumatism, diphtheria and
pneumonia, as well as septicæmia of different forms or kinds, which works
havoc throughout the entire circulation. I should have had more to say
under this head but for the fact that our distinguished Fellow and former
President, Dr. Sansom, has thoroughly investigated it, and on more than one
occasion laid the results before you.
7. I will not occupy your time this evening in tracing the origin of certain
cases of cardio-vascular disease in middle and advanced life to chronic
affections of different kinds. Besides the obvious effects upon the heart,

blood and blood-vessels, of anæmia, exhaustion, &c., we meet with such
grave lesions as fatty degeneration from pernicious anæmia and other blood
disorders; profound circulatory derangements and occasionally valvular
lesions in Graves's disease, and others.
8. I now pass on to complex causes. In addition to the definite and distinct
influences which I have mentioned as threatening the heart in this stage of
life, there are two which are intimately associated with other causes of
cardio-vascular disease, but still deserve to stand out independently. The
first of these is emphysema, and along with it other chronic affections of the
lungs and pleura, which strain the right ventricle; the second is chronic
Bright's disease, which similarly strains the left ventricle. I shall have
frequent occasion to return to these two morbid states in different parts of
my subject. I mention them here to give them the position which they
deserve as influences that threaten the function and still more the structure
of the heart and arteries. They are often associated with each other, and each
or both of them with one or more of the unfavourable influences I have just
enumerated, particularly alcohol, disordered metabolism and gout. And this
brings me to the many instances in which the different influences that
threaten the circulatory organs in middle and advanced life act together in
different combinations. Alcoholism is equally common amongst the poor,
whose circulation is subjected to mechanical stress, whilst it is
impoverished by want; the well-to-do, who lead luxurious, sedentary
enervating lives; and, as I have already observed, the keen active business
or professional man who overworks his brain on stimulants. In this country
at least, gout appears to be all-pervading, and as an unfavourable influence
on heart and vessels it often cannot be dissociated from alcohol, sedentary
habits, worry, plumbism, Bright's disease and emphysema.
Thus, in our study of combinations of morbific influences we come to
appreciate the evil effect of certain occupations upon the circulation in
middle life. The business man is exposed to the unhealthy actions on his
heart of confinement to a close office or shop, worry, irregular hasty
feeding, alcoholic indulgence in connection with his trade or profession,
and unwise attempts at violent muscular exercise at the week-end or in the
holiday season; or he may be guilty of entire disregard of the rules of bodily
and mental hygiene, and bring on in this way premature degeneration of his
cardio-vascular system. Still more numerous are the causes at work in the

production of "soldier's heart." We have but to picture to ourselves, if we
can, the physical strain, the mental excitement, the bodily hardships—
including exposure to both extremes of temperature—and the coarse fare
which have been the lot of many thousands of our brave troops in the Boer
war, to understand how the fighting soldier "ages" quickly, and, in
particular, ages in his heart and arteries. Add to these unfavourable
influences syphilis, alcohol and tobacco (which, unfortunately, must be
added in many instances), and the chance of escape from disease of the
circulation in the soldier is practically nil. But "soldier's heart" is also met
with elsewhere than in the army. The clergyman from the slums of London
or other great city, who has lived and toiled and—it may be said truly—has
fought with various success through alternate periods of excitement and
depression, and has thus suffered much both in mind and body, comes to us
with high-tension pulse, a tortuous radial artery, a large heart and a systolic
murmur over the aorta, and complains of an attack of angina. His wife, who
has laboured in the parish for years (she is 76, and still active in her work of
charity), has also a thickened radial artery, a large heart, and a systolic basic
murmur, with no discoverable cause of these evidences of a diseased
circulation but the life that she has led amongst the poor around her.
Perhaps such cases of cardio-vascular disease might be most correctly said
to be due to the wear and tear of life. They are met with also in the traveller
or explorer, who has spent most of his life in search of adventure; and they
are found in a man who has never left home, but whose years have been
filled with the toil and anxiety of his position as an owner of land, or with
prolonged litigation.

Such are the principal natural influences which individually or in different
combinations threaten or assail the sound heart and blood vessels after the
age of 40. I have given but a broad, hasty sketch of them entirely from my
own recent observations, and I know that I have omitted some which in
your opinion might deserve mention, but which possess no special interest
in relation to this period of life—for example, the agents of acute infections
of the endocardium, and also new growths, pregnancy and parturition. Let
me now sum up the results, and say that whatever changes the cardio-

vascular system may present in middle and advanced life, beyond those
which we have found to be natural to it at those particular periods, are
pathological—the result of physical stress, nervous influences, extrinsic
poisons, disturbances of metabolism, syphilis, acute disease, or chronic
disease; or are associated with chronic nephritis, emphysema or different
combinations of the preceding causes, with various occupations or positions
in life, or with other influences of less importance. It is necessary, however,
to qualify this statement in two respects. In the first place, the heart and
vessels may have been so damaged already, that is, in early life, that they
fall victims to influences which, whether in kind or in degree, would have
been insufficient to produce idiopathic disease of these organs. This brings
me to the subject of old-standing valvular disease (mostly rheumatic in
origin), chronic strain, and adherent pericardium in middle-aged and old
subjects. A considerable proportion of our cases are of this type, and they
have to be mentioned here for the sake of giving completeness to the plan
of arrangement, but they are outside the range of our immediate subject. In
the second place, hearts and arteries at 40 that appear to the naked eye free
from damage may be molecularly weak, and unable to offer effective
resistance even to influences of an every-day character. I have now arrived
at the last, and certainly one of the most interesting, of the causes of disease
of the heart and arteries in middle and advanced life. There are some
persons whose hearts and arteries cannot carry them through the wear and
tear of what may be called ordinary life for more than 40 or 50 years. The
vital energy of the tissues of these organs is exhausted prematurely; they are
already old at 45; degeneration of the muscle and other cells sets in early,
reminding us of the essential myopathic paralysis of children. This type of
case is described as "family heart," for it also runs in families—three, four,
five, or more members of which, as in a number of instances that I have
observed, may have all died suddenly of cardiac disease—some of them at
an early age. Similarly, it is not by any means unusual to find quite young
subjects, say of 30, with vessels already much enlarged; and I may add,
equally young subjects with their lungs already emphysematous although
there is no history of respiratory strain, reminding us of the very common
association of emphysema with arterial sclerosis in old age. These cases of
family heart and premature arterial sclerosis are the links that connect
disease of the heart and arteries in middle and advanced life of definitely
pathological origin with the genuinely senile changes in the tissue-elements

which render existence untenable at last, and which may be said to be the
result of the exhaustion of their nutritional activity by "the thousand natural
shocks that flesh is heir to."

LECTURE II.
Mr. President and Gentlemen,—In my last lecture I presented to you a
brief account of the condition of the organs of circulation between the ages
of 40 and 75, and I then proceeded to direct your attention to the principal
influences which may disorder and damage them during that period of life. I
will now attempt to describe the clinical characters and course of the
affections of the heart and arteries, as I have observed them, in connection
with these different influences respectively—whether gout, mechanical
stress, syphilis, or other. Thereafter, if time permits, I may be able to
examine the different symptoms and signs individually in order to discover
the value of each as a guide in diagnosis.
Now, as I have already pointed out, the causes of cardio-vascular disease in
the second half of life are very often, indeed usually, complex. It follows,
therefore, that if we desire, as we do most particularly, to discover the
effects of each pathogenetic influence as distinguished from the others, we
must begin our study with the simplest, or purest, or most definite of all,
and proceed from it towards those which are more difficult, as well as to
combinations of causes. It is easy to adopt this method in our present
inquiry.

Tobacco Heart.

We have in tobacco a single distinct influence at work; one that is
universally acknowledged to affect the heart and vessels, and the
physiological action of which is understood; one, further, that can be
removed (perhaps not without some difficulty, for I have had a patient plead
for his pipe with tears in his eyes), and certainly that can always be resumed
with remarkable readiness—in a word, a most favourable subject of
observation by experiment. It is well, too, to begin the study of tobacco
heart in young men, whose circulation is still structurally sound, and
thereafter to follow up the subject in middle-aged and old persons.
Adopting this line of inquiry, I have found that the uncomplicated effects of
tobacco on young healthy hearts, as they present themselves clinically, are:

palpitation in every instance; a sense of irregular action,[6] post-sternal
oppression and pain in half the cases; and in one out of every eight sufferers
either angina or uncomfortable sensations in the left arm. Faintness or
actual faints occurred in one-third, and giddiness and a feeling of
impending death in a smaller proportion. Turning to the physical signs, the
heart proves to be of ordinary size in 50 per cent. of the patients; in a few it
is very slightly enlarged; the præcordial impulse is often very weak, but
occasionally increased in force and frequency, and almost as often irregular
as not; the pulse tension, with insignificant exceptions, I have always found
low. Very interesting, in the light of what I shall tell you later on, is the fact
that of 20 of these patients complaining of the heart not one presented a
cardiac murmur beyond a weak mitral systolic bruit, varying with posture
or cubitus. This is in accordance with the teachings of pharmacology —that
tobacco acts on the terminal branches of the vagus.
Now we are in a position to study the tobacco heart in a man of 40; and
again let us begin with a man who is sound, active, and healthy otherwise.
He complains of his heart, and recognises willingly (for he belongs to our
own profession), in the discomfort and anxiety from which he suffers, the
penalty of having smoked for years the strongest and blackest tobacco that
he could buy. Yet his heart is not enlarged, and the cardiac sounds might be
described as ordinary were they not peculiarly irregular, the frequency
changing every moment and a falter occurring at short intervals. There is
not a trace of murmur to be found in connection with the valves and
orifices. At ages over 40 a clinical study of the tobacco heart is highly
instructive from a practical point of view. Whilst palpitation is still the
common complaint, pain, including angina, is put forward more
prominently, and so are faintness, actual faints, a feeling of impending
death, and a sense of cardiac irregularity, each intermission being
accompanied with a sudden stab through the præcordia. Some of you will
remember Mr. Barrie's quaint account in 'My Lady Nicotine' of what he
calls the horrors of his smoking days, when the pain at his heart made him
hold his breath—"a sting" as he describes it, and he believed he was dying.
In these subjects the heart is more frequently found to be large and feeble;
the same weak systolic murmur is occasionally to be heard; the radial pulse
is often irregular, and the vessel wall naturally thick. This, you will notice,
is a combination of symptoms and signs sufficient to alarm the casual
observer. But when we examine it more deliberately, in the light of our

study of the tobacco heart in young subjects, on the one hand, and of our
knowledge of the normal or natural condition of the heart and arteries at 60,
on the other hand, we are able to reassure ourselves and our patients. We are
justified in concluding not only that every cardio-vascular lesion which may
be found in tobacco smokers is not to be put to the credit of tobacco, but,
vice versâ (and this is of more interest to us in our present inquiry), that
every præcordial pain, angina, faintness, or irregular pulse in a man of 60
with a full-sized heart is not to be hastily regarded as evidences of grave
disease without further inquiry as to his habits. The cardiac enlargement and
large pulse may be nothing more than the result of a life of bodily and
mental activity: the præcordial distress may be the result only of tobacco.
How very necessary this caution is will be impressed upon your
consideration by the two following cases. The first is that of a man of 60,
actively engaged in professional pursuits, who first suffered from
præcordial pain of an alarming character four and a half years ago, and has
had attacks since, particularly during exertion and after meals. One day last
autumn, at the end of many hours' hard work, cheered by at least 18
cigarettes, he was rushing off to dine with a friend when he was suddenly
seized with præcordial pain which he described as fearful, radiating down
the left arm. He broke into a cold sweat, thought that his last hour had
come, and for a short time had impairment of consciousness. Shortly after
this event he took the advice of his doctors and gave up tobacco (shall I say
for a time?), and from that day to this, now six months, he has had no
further trouble with his heart.
The second case is equally striking. A man of 55, of fairly active disposition
and somewhat full habit of body, was suddenly seized with angina pectoris
in October, 1899. The pain was of a dull bursting character over the region
of the heart, and it passed into the left shoulder, down to the elbow, and
settled particularly in the wrist. At the same time there was pain in the upper
maxillary region. The heart slowed down from 75 to 50, and the sufferer
felt that he was dying. From that time anginal attacks occurred in rapid
succession, five, six, nine or even eleven in a single day; occasionally they
came on in the night. This experience continued for nearly two months on
end; indeed, it was six months before the angina finally ceased. It was
instantly relieved with amyl nitrite; nitro-glycerin was unsuccessful. In the
course of giving advice to this patient I fortunately discovered that he had

just laid in a stock of 2,000 cigars. The line of treatment was obvious; and
the result has been, as I have said, complete recovery.
I have dwelt on the subject of tobacco heart perhaps longer than was
necessary, addressing, as I am, a meeting of practitioners of experience and
not a class of clinical students. I have done so to bring home to us an
important consideration which we are all apt to overlook in diagnosis and
still more in treatment, namely, that whether in an ordinary senile heart, or
in a heart that is the seat of chronic valvular disease, or in arterial
degeneration, something more than the pathological changes have in many
instances to be regarded—usually some entirely adventitious disturbance
which alone calls for treatment, such as indigestion, flatulence, worry, a
bronchial catarrh, or it may be free indulgence in tobacco, tea or coffee.

The Heart in Alcoholism.

Let us now pass on to consider, from the clinical point of view, the effect on
the organs of circulation of another morbific influence of a definite kind,
namely, alcohol, or perhaps more correctly alcoholism, leaving on one side
the questions of form and strength of the drink taken and its purity.
The direct effects of alcohol on the heart and the blood-vessels are by no
means so easily determined as those of tobacco. In the first place, they are
complicated with the many indirect effects which it produces on these
organs by deranging the functions of alimentation and assimilation, the
nervous system and the kidneys, and with the secondary effects on the
vessels and heart of chronic nephritis due to the same cause. In the second
place, as we saw in my first lecture, alcoholism is very commonly
associated with nervous strain, with gout and goutiness, with tobacco, with
syphilis, and not uncommonly with two, or more, or all of these together.
Eliminating as far as possible these sources of error by careful selection of
cases, I find that the alcoholic heart in middle and advanced life presents
clinical characters, as a whole, very different from those of tobacco heart,
which we have just studied. The most striking and important of these are the
evidences of actual pathological change in the size of the heart and the
condition of the myocardium. We found no evidence that tobacco causes
serious cardiac enlargement, and neither may alcohol in quite young
subjects, who present mainly excited action both in force and in frequency.

But of 28 cases of alcoholic heart which I examined clinically in connection
with the present inquiry in older subjects, only two hearts were of ordinary
size (and as a matter of fact both of these patients were under 40 years of
age). This result is in accord with my pathological observations. For
instance, I have carefully followed the condition of the heart in an
intemperate man of 43, and post mortem found the heart to weigh 17
ounces, to be universally dilated in all its chambers, and to present
enlargement of the mitral opening without valvular lesion, corresponding
with a weak apex systolic murmur heard during life. These results are also
in accord with those in Dr. Maguire's cases of acute dilatation of the heart
from alcoholism, which he recorded as long ago as 1888[7] (when, I may
add, doubts were expressed of the correctness of his conclusions by several
of our best authorities on cardiac disease), and one of which occurred in a
man of 23. Dr. Mott has found fatty degeneration of the myocardium in
patients dying suddenly during alcoholism.[8] With hardly an exception the
præcordial impulse is weak—indeed, it is often imperceptible; the sounds
are small and feeble, and may be almost inaudible; in 20 per cent. of my
cases a weak apex systolic murmur could be heard, varying with posture
and from day to day, significant, no doubt, of leakage through a dilated
mitral opening. The alcoholic heart is irregular and accelerated in about half
the cases. The pulse tension is usually low; in one-third of the instances the
radial artery was sclerosed; in one-fifth of them there was slight
albuminuria; the legs may be œdematous. The complaints which the patient
makes to us are commonly of palpitation of the heart, faintness or actual
faints, and præcordial pain; but it is very interesting to observe that angina
pectoris is rare in the alcoholic as compared with the tobacco heart, in the
ratio of 4 to 15 per cent. With these cardiac symptoms proper there are
usually associated the sweats, coldness of the extremities, and depression,
sinking or lowness characteristic of alcoholism. But it is unnecessary for me
to fill in this outline sketch of the condition of the victim of either acute, or
sub-acute, or chronic alcoholism. I would rather mention one form of acute
alcoholic failure of the heart of which I have recently seen a case, but which
appears to be rare. A middle-aged woman, at the end of each of her repeated
bouts of active alcoholism, has violent sickness; prostration passes into
collapse, and for 24 hours or more she lies flat on her back, with all the
phenomena of what may be called acute air-hunger. She breathes loudly and
deeply, at the rate of 36 per minute, with groaning expiration. The

expression is alarmed, despairing and imploring; the nose is pinched; the
surface is livid and cold; the breath is cold; the pulse is practically
imperceptible at the wrist; and yet the præcordial impulse is both strong and
extensive, and the rate of the heart greatly accelerated. The condition is at
once one of collapse and urgent dyspnœa, quite as in one form of so-called
diabetic coma; and it is further remarkable in that it may pass off suddenly
after having lasted, as I have said, for many hours. It is difficult to resist the
conclusion that in such a condition as this some product of alcohol, present
in the blood, is the cause of the remarkable phenomena.
The course of alcoholic heart in older subjects usually becomes affected by
the appearance of cirrhosis of the liver, Bright's disease, neuritis, and
possibly dementia. The method of termination is very various, including
ordinary cardiac failure with dropsy; and sudden death occasionally occurs.
Still, recovery is far from being impossible, even after dropsy has made its
appearance, for the size of the heart may decline under strict abstinence
from alcohol, and the œdema disappear. This is a matter of great practical
interest, inasmuch as we know that, whilst the effect of alcohol on the heart
and circulation is for a time functional only, it presently becomes truly
nutritional, as in the cases I have just narrated. The myocardium is not
always beyond repair, although it and the fine myelinated fibres of the
vagus undergo fatty degeneration according to Dr. Mott,[9] just as there are
changes in the pyramidal cells and fibres of the cerebral cortex in the
alcoholic; and the feebleness and irregularity of the heart are analogues of
the depression and confusion of the brain.

Gout.

Of the many instances of disorder and disease of the heart and arteries that I
have met with in gouty subjects at or over 40 years of age, I have made a
careful study of 29 taken from my private case-books. Twelve of these (10
M. + 2 F.) had suffered from ordinary articular gout, the other 17 (6 M. + 11
F.) had irregular gout, as defined in my first lecture. The average age was
62. In no instance was there albuminuria. The physical condition of the
heart and arteries and the patient's complaints were remarkably alike in the
two groups. In 23 of the 29 the heart proved to be enlarged, either on one or
both sides. In less than half the number the cardiac action was feeble; in a

small number the impulse was entirely imperceptible; the heart- and pulse-
rate was ordinary; the rhythm was but seldom irregular. It is a very
remarkable fact that in no fewer than 12 out of the 29 cases of gouty heart a
systolic murmur was to be heard over the aortic area, the manubrium and
the right carotid, significant of disease either of the aortic arch or of the
aortic valves—in every instance independently of rheumatism or other
obvious cause than gout. This result is an interesting confirmation of the
pathological observations of Dr. Norman Moore and Sir Dyce Duckworth
given by the latter,[10] and of the statement of Murchison[11] of his experience
"that atheroma of the arteries at an unusually early period of life, and
diseases of the aortic valves which are not congenital, and are independent
of injury or rheumatism, are met with far oftener in persons who are the
subjects of the lithic acid dyscrasia, or who have had gout, than in those
who have had no such tendencies." In seven (25 per cent.) of my cases a
more or less developed systolic murmur was found in the mitral area,
significant either of valvular atheroma and sclerosis or of leakage from
ventricular dilatation. Very curiously I have never met with aortic
incompetence of gouty origin. When no murmur exists the cardiac sounds
are commonly somewhat feeble, and the second sound may be of ringing
quality—this more commonly in goutiness than in developed gout. In
agreement with this connection, the radial pulse is more often tense in the
subjects of irregular than of regular gout[12]; altogether, high tension is found
in more than one-half of the cases. The great majority presented distinct
thickening of the arterial walls. As I suggested in our study of the etiology,
these pathological changes appear to be the result of malnutrition of
structures (the myocardium, valves and arteries) worked at high pressure;
and in addition to the local disturbance of metabolism in the cardiac and
arterial walls, which are fed with gouty blood, there is the damaging effect
on them of similar disease of the vasa vasorum and vasa cordis or
coronaries.[13] Besides a distressing feeling of irregularity, fluttering or
intermittency, and dyspnœa on exertion, men who are the subjects of gouty
heart complain most frequently of præcordial pain; women more often of
palpitation and faintness or actual faints. In quite one-fourth of all cases of
gouty heart the pain is anginal, and such angina may be of the most
pronounced type. A friend of my own, aged 60, began to suffer from gouty
angina (diagnosed to be such by his family physician 40 years ago) at the
age of 20. Almost every year, somewhat more frequently for the last 12

years of his life, he was liable to be seized with intense pain in the left side
of the chest, which rapidly extended to the neck and down the left arm, with
tingling in the hand; a sense of great constriction in the chest; faintness, and
difficulty of breathing. He had immediately to rest, whereupon the distress
subsided; but it did not perfectly disappear for hours. On different occasions
also, in connection with these anginal seizures, I have known him have free
hæmoptysis, complete unconsciousness, vomiting, and sudden violent
evacuation of the bowels. He also suffered from articular gout, and from
irregular gout in almost every possible form.

Obesity and Glycosuria.

Closely related to goutiness is a clinical type of disturbed metabolism,
mainly characterised by corpulence, a bulky, flabby build, and glycosuria.
Of this type, represented by 12 cases in my series, nine had glycosuria and
two albuminuria; eight were men; the average age was 58. Only one had
suffered from true articular gout. Here, again, the interesting observation
was made that no less than three-fourths of the number had a systolic aortic
murmur, none of them a regurgitant aortic murmur, and nearly one-half of
them an ill-developed mitral systolic murmur. Thus there appears to be
more liability to atheroma in the gross corpulent diabetic even than in the
gouty man. In all the cases the heart appeared to be enlarged, but accurate
physical examination is difficult or impossible in many of these subjects.
The impulse was more often feeble than in the gouty; the cardiac sounds
were equally weak, and the second aortic sound was occasionally
accentuated. The pulse corresponded with the gouty pulse in thickness and
tension, but it was more often found irregular and hurried. As for the
complaints of corpulent and diabetic patients, they prove to be very similar
to those of gouty individuals in respect of pain, but neither palpitation,
faintness nor irregularity was so often mentioned.
It must not be understood from what I have just said in my account of these
cases that all disturbances of the heart in gouty subjects progress to valvular
or vascular degeneration, with associated cardiac enlargement and
degeneration. The friend whose case I have just described at some length
had led an active life, as I said, for 40 years; and, as I hope to show in my
next lecture, the condition is amenable to treatment if this is based on a

correct appreciation of the cause that is at work. But it is equally true that if
correct advice be not given, or if it be given but be neglected, as happens so
frequently, the endocardium and the aorta and other arteries steadily
degenerate, chronic interstitial nephritis makes its appearance, and the
patient dies either slowly from cardiac failure or suddenly from cerebral
hæmorrhage.

Cardiac Strain.

I will now proceed to consider the clinical characters of a class of cases in
which you, Sir, are particularly interested—strain of the heart in middle and
advanced life. To make this part of my subject more plain, I will discuss in
the first place acute strain of the heart as it occurs after the fortieth year;
afterwards I will consider the condition of the heart and arteries at this age
in persons who have strained them in youth or early manhood.
A man of 65, who came to me complaining of his heart, gave the following
account of the commencement of his trouble:—Four years previously, on
making a very hard stroke at golf (the ball was bunkered), he was suddenly
seized with a sensation of something having happened in his heart. He
played up to the next hole, but now felt the chest oppressed; he sat down
and got relief. This experience was repeated, and he gave up the round.
Walking home two miles, he had to sit down occasionally with the same
feeling. Ever since that occurrence exertion had produced the same effect. I
found the ordinary physical signs of enlargement of both sides of the heart;
a scarcely perceptible impulse; the cardiac sounds extremely feeble, the
second being of a finely ringing quality; the pulse tense, quiet and regular,
but the radial artery by no means sclerosed. The patient's principal
complaints were of irregular action of the heart, which troubled him on
lying down or when he was dyspeptic; and, as I have said, of post-sternal
oppression on exertion. This man had neither albuminuria nor emphysema,
but he had frequently suffered from ordinary articular gout. Belonging to
this type of cardiac strain I have notes in all of 11 cases, which I will briefly
summarise. Eight were men, three women; and their average age was 56. In
all but one of them the heart was large, with feeble præcordial impulse; the
sounds were small and feeble; the aortic diastolic sound was often ringing;
in but one case was there a murmur—aortic systolic; with few exceptions

the rhythm and the rate of the heart were ordinary. In half the cases the
radial artery was sclerosed; in the majority the tension was not increased.
Persons who strain their heart after middle life chiefly complain of
præcordial oppression, dyspnœa on exertion, a sense of palpitation and
irregular action of the heart, and pain, which may amount to angina; and
they may tell us that distress and disability in these different forms have
troubled them for years. You will have observed that the man whose case I
have read in particular was the subject of gout; and this brings me to the
interesting fact that of these 11 individuals seven were gouty. We have
already seen how greatly reduced is the resistance of the cardio-vascular
system in gouty subjects; and we are prepared for the readiness with which
their heart may be strained by exertion—a matter of obvious importance
prophylactically. In other cases not included in this group the strain took the
form of valvular injury, or it affected hearts already the seats of old-
standing valvular lesions of rheumatic origin; but the present is not the
occasion to discuss these. Nor need I add that a not infrequent result of
acute strain of the aged heart, whether its valves have been already
damaged or its myocardium badly nourished, is sudden death. Now, I can
understand that some of my audience might object to the application of the
term "strain" to the effect of exertion in gouty and senile hearts, just as
Professor Clifford Allbutt, who is universally recognised as the earliest and
highest authority on this subject, suggests that the clinical expression "strain
of the heart" relates only to comparatively young subjects free or nearly free
from degeneration.[14] It might be contended with great reason that exertion
in these subjects is not a cause of strain or dilatation of the heart, but simply
a test, as it were, or the proof, of cardiac debility and disability. But when
we come to consider cardiac strain a little more closely, it may be just as
easily maintained that every dilated heart, every dilated cardiac chamber,
every dilated blood-vessel has been strained. Whether, on the one hand,
valvular disease, Bright's disease or emphysema, or, on the other hand,
myocardial degeneration, has disturbed that cardinal condition of a normal
circulation that the driving power must always exceed the resistance ahead,
over-distension and dilatation of the cavities, with excessive stretching of
their walls, constitute or consist in mechanical strain. However, laying aside
theoretical discussions of this character, the great practical fact remains, that
when the aged and ill-nourished heart is over-distended from sudden and
severe exertion, neither the elastic nor the muscular tissues of its walls can

bear the strain; it becomes dilated; for the future it acts at a mechanical
disadvantage; and as often as this may occur it suffers still more in its
efficiency. On the other hand, it is really in confirmation of this
consideration, though apparently in opposition to it, that the heart may
diminish somewhat in size, and præcordial distress disappear, under strict
treatment continued for a sufficient length of time.

Strain Before Forty.

A more interesting group of cases than those which I have just discussed is
composed of persons who have strained their hearts in youth or early
manhood, have never been quite well since, and in middle or advanced life
are at last driven to us for help. Cases of this character would furnish
excellent material from which we might attempt to judge of the after-effects
of excess or abuse of muscular exercise in the young. This is a tempting
subject of discussion, but one far too long and much too important to be
taken up casually at this time. Therefore, I will content myself with
submitting to you as plainly as I can certain facts bearing on it that have
come before me in my present inquiry, along with a few simple
observations of a practical bearing. First, then, let me read to you the
history of what I should call a typical case of the kind. A man of 69
complains that as often as he walks any distance or climbs a stair he is
arrested by a distressing sense of having a bar across the lower end of the
sternum, breathlessness, irregular palpitation of the heart, and a very little
choking in the throat; the discomfort has lately deserved the name of pain.
His heart is very large, the area of præcordial dulness being increased in all
directions and measuring transversely 7 inches. The impulse is weak over
the left ventricle, but definite in the epigastrium; the sounds come in
couples—moderately good and very weak respectively, without murmur;
and the radial artery is large and thick, with rather low pressure and
irregular rhythm. It turns out that for the last 40 years these uncomfortable
feelings have troubled the man more or less, and that at three different
periods of his life—at 31, at 42 and at 67—they increased so much as to
incapacitate him for many months, the first time with a sudden sense of
something snapping in the heart, the second time with a faint, and always,
as he believes, consequent on overwork. Now this man never had
rheumatism, nor gout, nor syphilis, and was always a temperate, careful

liver; and he volunteers the statement that he first felt his heart at
Cambridge, where he was captain of his College boat, and was tried for the
University boat but felt that he was not fit for it. Belonging to this type of
cardiac strain I have selected 11 cases. The heart is always found to be
enlarged, and in about one-half of the cases it is irregular. It may be weak
and beating at the ordinary rate, but in other instances it is increased both in
force and frequency. Only in quite exceptional cases did I meet with
endocardial murmurs in this group of old strained hearts; as a rule the
sounds were ordinary, with a disposition to accentuation of the aortic
second sound. High tension and sclerosis of the radial artery were
respectively found in about one-half of the cases. The patients complain
most commonly of a distressing sense of irregular palpitation of the heart,
and very commonly of præcordial pain, but rarely of angina. Faintness also
is sometimes mentioned. Let me hasten to add, with respect to these cases,
that they do not include any instances of direct injury of the valves
mechanically. Rupture or stretching of the aortic and mitral valves during
exertion furnishes us with some very remarkable clinical cases; but it is
with parietal strain that we are concerned now—mechanical over-stretching
of the cardiac walls, which are thereafter left with but a narrow margin of
the elastic and muscular reserve required by them to meet trying
circumstances of any kind, particularly exertion. The subjects of dilatation
of the heart from mechanical stress suffer by no means from what is
commonly called "heart disease," excepting in the worst cases, but yet they
feel their hearts comparatively, and it may be seriously, disabled. Naturally
they associate these feelings of disability with fresh attempts at exercise or
exertion, as in the case which I have just read. I pointed out in my first
lecture that such exertion is not by any means connected with the patient's
occupation or daily duties, but quite often occurs during unwise attempts on
his part to resume at 50 the athletic exercises of his youth in order to reduce
his weight, relieve his liver, or dispel gout. It is not wonderful that under
such circumstances a permanently enlarged and badly-nourished heart
should become embarrassed, or even seriously deranged or still further
strained. I have known a man of 43, going straight from London to the Alps,
have not only præcordial distress but dropsy of his legs after his first ascent
in his regular holiday. Indeed, the man who has reached later middle-life
with his heart enlarged by years of great bodily activity in youth, and settles
down quietly on retirement, let us say from the navy, sometimes finds that

ordinary exercise is sufficient to produce alarming cardiac distress and
curious loss of courage, obviously due to the muscular tissue of the
thickened cardiac walls having fallen quite out of condition. How
instructive, for instance, is the following case:—A gentleman of 60, who
has led from his boyhood upwards a life of physical activity and at the same
time of temperance, and has suffered from neither syphilis nor rheumatism,
but possibly from a very mild attack of gout, settles in a relaxing provincial
town, continues to eat heartily, and considers that a little work in the garden
is sufficient exercise for him. He increases in weight, his breath gets short,
his heart flutters, and now he begins to get anxious about his health,
fancying, as he says, that he has all sorts of diseases—a disposition to worry
about himself which is entirely new and provoking to him. I find his heart
very large and feeble, the cardiac sounds scarcely audible, and in the mitral
area a well-developed systolic murmur. The patient is ordered to reduce his
diet as a whole and in respect of carbo-hydrates, to return carefully to
walking exercise on the level, and to take a calomel purge followed by a
saline twice a week, and a mild strychnine mixture. He improves, and
continues to do so; is able to walk miles without discomfort; and in the
course of two months not only do I find his heart reduced in size on
physical examination, but I fail to hear the apical murmur, which must have
been produced by dilatation of the left ventricle. The bearing of such a case
as this on the pathology, prevention and treatment of certain cases of heart
disease in old subjects will be obvious to all.
We must be careful, however, to observe that neither unwise abandonment
of wholesome exercise, nor ill-advised return to physical exertion,
separately or in succession, can be regarded as the only cause of the
recrudescence of cardiac distress after 40 in those who have strained their
circulation in youth. Any one of the many circumstances that produce
cardiac failure and dropsy in chronic valvular disease may lead to
embarrassment and fresh dilatation of the simply enlarged heart: anæmia
and chronic disease, the acute specific fevers including pneumonia,
emphysema, granular kidney, gout, syphilis, tobacco and alcohol poisoning,
as well as anxiety and worry, and in women the advent of the menopause;
and I may say here parenthetically that pains at the heart in athletic youths
are sometimes due to the tobacco smoking in which they often indulge
socially when the exercise is finished—not to strain at all. In these cases of
old cardiac strain, as in every form of chronic valvular disease and of

chronic heart disease of all kinds, not only the original and permanent
lesion, but the recent and probably temporary circumstance that caused the
failure has to be ascertained and fully respected in connection with
prognosis and treatment.

Syphilis.

Syphilis appears to account for a very considerable proportion of the more
serious cases of heart disease which we meet with in older subjects—
excluding of course chronic valvular disease originating remotely in
endocarditis. But I ought to repeat here what I have already mentioned, that
syphilis as a cause of cardio-vascular lesions is very often associated with
other morbific influences, particularly strain and alcohol. Of its position as
the principal cause of grave disease of the valves as distinguished from the
walls of the heart, originating in middle life, there can be no question. No
fewer than nine out of 28 cases, of which I have private notes, were the
subjects of double aortic disease; practically all the others had a loud
ringing second sound over the aorta, significant of degeneration; pain of
anginal type in half the cases was the prominent complaint; and two-thirds
of the subjects had sclerosis of the radial artery. When we consider that
syphilis does also affect the myocardium primarily; that fibroid disease,
chronic aneurysm and fatty degeneration of the heart are all traceable to
specific disease of the coronaries in many instances; and, finally, that many
of the subjects of syphilitic cardio-vascular disease have perished before 40,
the magnitude of this cause can be fully realised. I believe that the
profession in general have not yet woke up, if I may say so, to the gravity of
this subject. How seldom we inquire for a history of specific disease in
patients coming to us with cardiac disease in middle life! To no one, as far
as my reading goes, are we so much indebted for the truth on this subject as
to my friend and colleague Dr. Mott. Thirteen years ago he published a
paper on 21 cases of sudden death from cardio-vascular disease, and in nine
of these there was a history of either actual or probable syphilis. What was
of greater interest, however, at that early date, he drew attention to the
association of syphilitic cardio-vascular lesions with Bright's disease in the
broad acceptation of the term. Dr. Mott's work in the interval on syphilitic
lesions of the arterial system of the brain has been so brilliant, and is so
generally known, that it requires nothing more than this appreciative

mention by me, and it saves me the trouble of an excursion into the subjects
of cerebral hæmorrhage and thrombosis in connection with these lectures.

Nervous Strain.

I confess that it is difficult to say much that is of real diagnostic value on
the clinical aspect of cardio-vascular disorders and disease from nervous
strain. As I remarked in discussing this subject from the etiological point of
view, several factors come into play besides nervous excitement followed
by exhaustion and their effects on the heart, great vessels and cerebral
arteries; and the cases, therefore, are found to present a puzzling variety of
features. Certain clinical characters are, however, common to the majority.
Arterial tension is high; the radial artery is thick, sometimes markedly so;
the heart enlarges; and in about one-half of the cases a systolic murmur is to
be heard either in the aortic or in the mitral area, significant of chronic
endocardial lesions—all readily intelligible results of cerebral strain in the
light of our knowledge of the innervation of the cardio-vascular system. I
have already pointed out that in some of these patients polyuria and
temporary albuminuria occur along with the high tension and the increased
action of the heart; but the heart may fail later on. The direct cardiac
symptoms of which they complain are of the ordinary character, palpitation
with accelerated cardiac frequency and pain (not angina) being the most
common at first, feelings of indescribable discomfort and suffocation in the
more advanced stage. A great deal that I might have had to say on the very
interesting subjects of pseudo-angina, and the climacteric and pre-
climacteric disturbances of the circulation in women, I am reluctantly
compelled to omit from want of time.

After having reviewed, as I have attempted to do, the principal clinical
characters of the disorders and diseases of middle and advanced life under
their several causes, it may appear for a moment strange that the most
important of all the clinical types of cardio-vascular degeneration has been
mentioned only incidentally. This is chronic Bright's disease, which, from
its complex pathological relations, its widespread effects on the heart and

circulation and the organs that they supply, and the far greater gravity of
these than those of any of the other causes which we have studied (unless it
be syphilis), is a subject of endless interest to us all. Fortunately for me my
immediate predecessor in this chair on the medical side, our distinguished
Fellow, Dr. Samuel West, took for his subject the "Clinical Aspects of
Granular Kidney," and thus relieved me of a task which he was so much
better able to discharge than I. Emphysema must also be passed over with
the single remark that it is a very common accompaniment both of vascular
and cardiac degenerations.
I trust you do not conclude that the description which I have just given you
of the clinical characters of these various disorders and diseases of the heart
is in any sense complete. It only relates to the most prominent symptoms
and signs as they present themselves to us in what might be called the
every-day life of the patient, at a period in the history of his case precedent
to failure. In all of them there may occur occasional attacks of acute
embarrassment of the heart and lungs from one or more of a variety of
causes, such as indigestion, excitement or over-exertion. Sooner or later,
also, there occurs either cardiac dropsy—insidiously developed after
increasing local distress, growing dyspnœa and "bad nights"; or Bright's
disease; or cerebral thrombosis or hæmorrhage, or acute myocardial failure
with angina: or the patient dies from failure of the heart in the course of
some acute disease such as bronchitis or pneumonia. Neither have I
considered it necessary in this lecture to dwell on some of the rarer
phenomena occasionally met with, such as tachycardia and bradycardia. I
may have occasion to refer to them next time in connection with prognosis.

LECTURE III.
Mr. Vice-president and Gentlemen,—In this, the concluding lecture of the
series, I will attempt to deal with the applications of the facts and
considerations which I submitted to you on the two previous occasions
when I had the honour to address you. I trust that what I then laid before
you proved to be of some interest. Let us see now whether it is practically
useful. However much the etiology and pathology of the diseases and
disorders of the heart and arteries in middle and advanced life may deserve
study as matters of natural history, we should be disappointed if they could
not be turned to account in prognosis and treatment. These are the subjects I
propose to discuss this evening.
Now, prognosis and treatment, to be rational and useful, have to be based
on as full and as correct a diagnosis as knowledge permits. The present
disposition is to fall short of this; to rest content with an incomplete
diagnosis. We say that the patient's "heart is dilated," that he has "arterial
degeneration," that there is "fatty degeneration." But you will remember
that we have found that cardiac dilatation may be present in every kind of
cardio-vascular degeneration; that the arteries are naturally enlarged and
thickened after middle life, and that we refused to call these changes
morbid. Clearly, therefore, a purely anatomical diagnosis of this sort is
insufficient. If you are asked what the prognosis is of fatty degeneration of
the heart, you answer that you must first be told whether syphilitic or gouty
disease of the coronary arteries, or strain, or alcoholism, or phosphorus-
poisoning or anæmia is the cause of it. When you are planning the treatment
of dilatation of the heart you first determine whether the dilatation is a
result of the stretching of a sound heart by overfilling during muscular
effort, or of the insufficient emptying of failing chambers with degenerated
and feeble walls. Obviously what we ought to determine in these instances
and in every instance is the origin of the disease. The ultimate diagnosis to
be reached for practical purposes is the etiological diagnosis.
Is this possible? Does our knowledge of the nature, characters and course of
these cardio-vascular affections enable us to say, after investigating a case,

what the kind of the pathological change is that constitutes the disease, or in
what respect the physiological mechanisms are disordered? Can the cause
of these degenerations of the heart and arteries be determined in each
instance? How is the practitioner to proceed to do so? What method might
be followed with advantage in making a complete diagnosis of heart disease
in older subjects?
A man of 60 consults us about his heart. He says that it has caused him a
good deal of concern lately. More specifically he describes a sense of
oppression behind the sternum as often as he exerts himself, and palpitation
with consciousness of irregular cardiac action when he goes to bed. We
inquire for other familiar cardiac symptoms, such as pain, angina, fluttering,
faintness, giddiness, and a sense of impending death. We find that one or
more are present occasionally, and that they have increased in number and
degree during the last few months or years. Perhaps cough, nocturnal
orthopnœa and dropsy may be beginning to give trouble. The next part of
the inquiry relates to the patient's previous history from childhood upwards.
Which of the acute diseases has he had? Acute rheumatism, chorea, scarlet
fever, typhoid, diphtheria and influenza must be mentioned individually,
and in women the nature of any puerperal disease from which they may
have suffered. Gout, irregular gout, gravel, eczema, sick headache, asthma
must be inquired after with the same minuteness, and so must syphilis. We
next hear an account of any accident which the patient may have met with,
such as a blow, or a fall from a horse or a carriage. This brings us naturally
to question him about his occupation and modes of relaxation and
amusements—whether active or sedentary, regular or irregular, their
characters otherwise, and their direct effects, including strain. More difficult
to elicit is a correct account of the patient's habits—in respect of food,
stimulants and tobacco, and his manner of life generally. As I said in my
first lecture, this is an inquiry which the family practitioner has an
opportunity to carry out much more successfully than the hospital physician
or consultant. The family practitioner has known for years of his cardiac
patient's work and worries; it may be of his large eating, of his secret
drinking, of the history of syphilis in earlier years. It is always well also to
inquire after a family history of gout, rheumatism and heart disease. A list
of questions like this sounds far more formidable than it is in reality. A few
minutes suffice to arrive at the truth. We already have a pretty fair notion

what we have to deal with, whether strain, gout, syphilis, tobacco, an old
rheumatic lesion, or a combination of two or more of these.
We next proceed to physical examination, beginning with the pulse and
arteries, and passing on to the heart and associated structures. The
characters of the præcordial impulse—particularly the seat of the apex-beat
and the strength of the impulse—are closely (I might almost say
laboriously) investigated. We must never yield to the temptation to
disregard weakness or absence of the impulse. Like many other negative
signs it is apt to be overlooked. Then the præcordial dulness is mapped out
by means of light percussion. Finally, auscultation reveals to us the
presence or absence of murmurs and the characters of the sounds—in the
standing and recumbent postures, and, if necessary, after a little exertion.
The relative loudness of the first and second sounds over the different parts
of the præcordia is particularly worthy of note.
Now let us suppose that we have found a mitral systolic murmur. We ask
ourselves whether it is structural or whether it is functional, that is, due to
relaxation and dilatation of the ventricular walls. If structural, with which
(if any) of the diseases elicited in the man's previous history would it
correspond? Most probably with gout or glycosuria. Thus we attempt to
connect the lesion with its cause, and the cause with its effects, and have
reached the ultimate diagnosis. So with other valvular murmurs: for
example, an aortic diastolic murmur proves to be related to syphilis. If there
be no murmur audible, we naturally think of dilatation with failure, or of
enlargement from strain, from Bright's disease, from arterial sclerosis, from
emphysema, from an insufficient or impure blood-supply in the coronary
arteries, from disordered innervation, or from some rarer cause, such as
adherent pericardium; and then, with these associations in our minds, we
review once more the patient's history, and generally succeed in our
diagnosis.
Here let me recount the significance of the principal signs and symptoms
which I detailed to you in my last lecture, considered in the reverse order on
this occasion, some of which are of real value in differentiating the causes
of cardio-vascular degeneration. To begin with negative facts: a mitral pre-
systolic murmur is never significant of a degenerative lesion. Secondly,
when we meet with an aortic diastolic murmur, whether alone or along with
an aortic systolic murmur, we may safely conclude that we have to deal

with something more than atheroma produced by regular or irregular gout
and associated metabolic disturbance, cardio-vascular disease of nervous
origin and alcoholic or tobacco heart, even if there be evidence of the
presence of one or more of these in the case. Aortic incompetence
developed in later life is the result of syphilis, or of acute or chronic
valvular strain; but, of course, many instances of this lesion met with after
the age of 40 can be traced to juvenile endocarditis of rheumatic or other
origin. Always a serious lesion, aortic incompetence due to syphilis, or to
syphilis and strain, is particularly grave, as being so frequently associated
with coronary disease and consequent myocardial degeneration—fatty or
fibroid, acute softening, and sudden fatal failure. A fully-developed basic
systolic murmur, audible over the aortic area and manubrium and along the
course of the carotid, is a very common sign of atheroma of the aortic arch
and valves and great vessels in association with regular or irregular gout,
diabetes, corpulence and allied disorders of nutrition. It is also one of the
physical signs of syphilitic and traumatic affections of the aorta and aortic
valves and of remote endocarditis. Further, these lesions are so often
accompanied by similar degenerations in the coronary arteries and
consequent myocardial degeneration, that the basic systolic murmur ought
at least to raise the suspicion of this in the observer's mind. An ill-developed
basic systolic murmur is not uncommon in alcoholism, chronic Bright's
disease and nervous strain, but it is difficult to dissociate from anæmia. A
fully-developed systolic murmur audible in the mitral area, I mean
independently of ventriculo-auricular leakage in cardiac failure, is usually
traceable to early endocarditis of rheumatic or other origin, rarely to injury,
including ordinary juvenile strain of the valves or walls, or to Graves's
disease. But in some instances it is unquestionably due to valvular atheroma
and attendant sclerosis, caused by gout or other disturbances of metabolism,
including the effects of free living; and in these instances the observer must
not overlook the possible association of coronary disease and fatty
degeneration. If a systolic mitral murmur prove to be somewhat indefinite
and affected by posture, cubitus and effort, to vary under observation from
day to day, and to disappear under treatment, it is of no more value to us in
differential diagnosis than that it signifies relaxation and weakness, or
disorderly action, of the left ventricle, consequent on any one of the
recognised causes of failure or disturbance of the heart, including the
different cardiac poisons, overwork, anæmia, acute disease, poverty and the

like, and this whether in a heart previously sound or previously enlarged or
previously the seat of valvular disease. An accentuated ringing second
sound in the aortic area, or more extensively, is of great value in the
diagnosis of arterial tension and of aortic atheroma or of both, but it is
associated with far too many different causes to be of much use in
differential diagnosis. It should suggest a most careful search for Bright's
disease. Slight reduplication of the first sound is common over the heart
strained in youth and the heart degenerated by alcoholism and metabolic
disorders, but everyone knows that it is not unusual in a variety of other
conditions, healthy and morbid. On the other hand, the bruit de galop, or
cantering rhythm of cardiac sounds—definite doubling of the first sound
followed by loud, accentuated, ringing second sound—is practically
pathognomonic of Bright's disease, and is one of the most valuable, because
one of the most ominous, of physical signs in connection with the cardio-
vascular system. A normally-sized heart with irregularity, increased
frequency, and a variable systolic murmur in the mitral area, is
characteristic of tobacco poisoning. A heart enlarged on both sides, and
acting irregularly without murmur, is (apart from cardiac failure) suggestive
of strain in early life.
Cardiac symptoms taken individually are of less diagnostic value than
signs. No symptom is pathognomonic. Palpitation is a nearly universal
phenomenon of cardiac disease and disorder. Faintness and actual faints are
not uncommon in cases of early cardiac strain, gouty heart, and nervous
disturbances. Angina we meet with, you will remember, in regular and
irregular gout, tobacco heart, strain (especially strain after 40), and in
syphilis and alcoholism, whilst pseudo-angina is extremely common in
nervous women: thus angina is of less diagnostic value than might have
been expected. A high-tension pulse I have found most often in Bright's
disease, in juvenile strain, and in cardio-vascular affections of nervous
origin; a low tension pulse in connection with alcoholic and tobacco
poisoning, and with senile strain.
When we review these facts, I think we are entitled to conclude that the
physical signs and symptoms carefully determined by clinical investigation
may be confidently employed, along with the patient's previous personal
history, and the history of his present illness, to differentiate from each
other the causes of cardio-vascular degeneration in individual cases. And,

further, that they inform us of the seat of at least some of the lesions,
valvular, parietal and vascular. A little trouble, patience and attentive
observation are all that are required to reach a complete or working
diagnosis. Now we may approach the great practical subjects of prognosis
and treatment with some confidence.

Prognosis.

Beginning with the simplest kind of cardio-vascular disorder, let us see
what the prognosis is in tobacco heart. You will have gathered from what I
had to say on this subject in my last lecture, and indeed you know as men of
observation and experience, that it is comparatively favourable. All the
cases I have had an opportunity to watch did well, provided the cause of
their distress was avoided and the heart and vessels were otherwise healthy.
Further, improvement begins early, and it may be rapid and recovery
complete; but you will remember that one patient, whose case I detailed to
you, continued to have alarming angina for six months after giving up
tobacco. Recurrence attends resumption of the habit, but some of its
votaries contrive to continue to smoke just short of inducing serious
discomfort. Unless a successful effort at reform be made, cardiac trouble
may continue indefinitely. But even then I cannot say that I have seen
serious damage done by tobacco alone in sound hearts, nor arterial
sclerosis, as has been stated by some authorities.
An entirely different and most unfavourable estimate is to be formed of the
prospect of life in the alcoholic heart. Naturally, a certain proportion of
cases recover if the disease be of recent development, the condition
uncomplicated, and treatment faithfully carried out. Unfortunately, as a rule,
we have to deal with alcoholism in which all these conditions of success are
wanting. The habit is established, other organs besides the heart are
involved, other diseases than alcoholism are present, and the patient has
neither the inclination nor the power to follow our advice. Cirrhosis,
neuritis, dementia complicate the cardiac degeneration, or, more correctly, it
complicates one or all of these. Chronic Bright's disease is made to account
for a number of deaths in the mortality returns that strictly belong to
alcoholism. Occasionally the end comes suddenly from fatty degeneration,

or in the course of some acute disease; otherwise, as we have seen, by slow
cardiac failure and dropsy.
Prognosis in gouty heart, including the heart of the man with goutiness,
glycosuria and other irregular forms of the disease, is a subject of
considerable practical difficulty. In my last lecture I read to you a short
account of the case of a friend of my own who had had occasional attacks
of gouty angina for 40 years. And certainly a large proportion of the old
ladies of 60 or 70, whom you all have had as patients for years on end with
weak heart and systolic murmur in the aortic area, owe their disablement to
gout, if my observations are correct. The lesion proper of the aorta and
aortic valves in these cases is atheroma, but the damage is accompanied
with repair in the form of sclerosis, which, by increasing the loudness of the
bruit, adds unreasonably to our anxiety about the case. Equally certain it is
that patients belonging to this class improve under treatment. Still, the
condition of arrest cannot go on indefinitely. In addition to extrinsic
dangers, particularly those of Bright's disease, cerebral thrombosis and
hæmorrhage, and bronchitis, failure of the heart is liable to supervene and
prove fatal from the gravest of all intrinsic causes, namely, coronary
degeneration. As this increases, the myocardium is steadily more and more
impoverished; its contractile vigour declines, and residual dilatation of the
chambers sets in with mechanical congestion of the viscera. Complaints of
"the heart" increase, the breathing becomes oppressed, the face assumes
more and more the characteristic "cardiac" appearance, and dropsy creeps
up the lower limbs. Even then the prognosis is not hopeless, for
undoubtedly a certain proportion of cases of dropsy in old persons with
degenerated heart and vessels are still amenable to rational treatment. But
the case has occasionally a more dramatic termination. As I was able to
illustrate after my second lecture by a specimen from the Museum of
Charing Cross Hospital, a branch of one of the coronary arteries that has
been narrowed by atheroma for an indefinite length of time, with
consequent cardiac weakness and discomfort, may any moment become
thrombosed rapidly, apparently in consequence of some passing depression
or other unfavourable influence, just as in thrombosis of degenerated
cerebral vessels. Fatal angina is the result. This is a point of great practical
importance—that sudden death will occur in old gouty subjects not from the
lesion of which a basic or an apical systolic murmur is the evidence and
which causes us concern, but from associated coronary atheroma, which we

probably never suspect; indeed, that it may occur in those subjects with no
murmur whatsoever to attract our attention and excite our fears.
Still more unfavourable must be the forecast in syphilitic lesions of the
heart and vessels. Of 18 of my cases in which the result was known, only
one-half improved under treatment, and 20 per cent. of them died within a
few years (some indeed within a few weeks) of the discovery of their
disease. Cardiac failure accounts for most of the deaths, whether developed
gradually with dropsy, which proves to be intractable; or progressing
rapidly with great cardiac distress, including angina; or occurring suddenly,
as it often does. Aneurysm makes its appearance in other instances, of
which the patient dies, or he is carried off by general paralysis or Bright's
disease.
What prospect have we to hold out to the man who has strained the walls of
his heart by muscular effort? I believe that one can speak with some
confidence on this subject. The middle-aged patient who over-stretched his
cardiac walls as a youth may be comforted with the opinion that the
condition is not a fatal one. The average duration of 11 cases of this order I
found to have been 30 years when they came under my observation; the
minimum duration was nine years, the maximum 50 years. This last case
deserves particular mention. The patient was first seen by me for failure of
the heart with cardiac dropsy, consequent on fresh breakdown after exertion
during a holiday; and it is most encouraging to observe that compensation
was restored by treatment, and that now, 12 months after that event, he is
not only alive, but able to carry on light professional work. This case also
illustrates what I have told you respecting the course of the affection, and
the prospect before the patients, in long-standing strain—that there is
continual liability to fresh embarrassment of the heart during exertion, in
which they appear to have a lasting inclination to indulge. If they happen to
follow an occupation that entails occasional effort, or effort with excitement
and worry (if they happen, let us say, to be busy practitioners of medicine),
they suffer in the same way from attacks of tachycardia, distressing
palpitation and anxiety. Indeed, as I pointed out in my second lecture, they
are readily upset by other influences besides these, including indigestion, to
which the victim of hurry and worry is peculiarly liable; and they must be
prepared to have to lead a life of comparative temperance and self-denial.

Neither is strain of the heart for the first time after 40 by any means so
grave as might be expected. Of course, sudden muscular effort occasionally
accounts for sudden death in old men. But it is astonishing how, under such
circumstances, quite old persons do recover from conditions of extreme
distress lasting acutely for half an hour—for instance, after running with a
heavy bag to catch a train. The majority of my patients described their
condition as improved after a time, but others relapsed; and on the whole
the correct prognosis is that they must expect to remain variously disabled
—that is, liable to præcordial distress and dyspnœa on more than moderate
exertion, or when subjected to circumstances of other kinds that tax the
heart.
Cardio-vascular disorder and disease referable to nervous strain pure and
simple is amenable to treatment by complete and prolonged rest or
relaxation in the majority of instances. Still, death may occur from sudden
cardiac failure; or should advice be neglected or soon forgotten, as happens
so frequently in these subjects, the attendant high arterial tension and
vascular degeneration too often end in cerebral lesions, with or without
Bright's disease. Of chronic Bright's disease itself and the associated cardio-
vascular changes in their prognostic aspects I need not speak, except to say
that along with syphilis it is by far the most hopeless of all these affections.
In attempting to forecast the life of a man who is the subject of cardio-
vascular degeneration in middle or advanced life, we must not forget the
possibility of the intercurrence of acute disease. Here is a large subject for
us as practical men—one far too large and important for discussion here:
the effect, for instance, of the existence of enlargement of the heart and an
irregular and thickened pulse on the prognosis of influenza, or, let us say, on
the chances of a successful issue after operation. Very naturally, unsound
vessels and a murmur over the præcordia weigh heavily against the prospect
of recovery from pneumonia, for example; and yet how often do we not
find a patient of 70 with one or both of these disturbing conditions come
safely through such an illness! Here, again, I believe it is in great measure
the true nature of the old-standing disease, not the physical signs such as
irregularity of pulse or mitral bruit, that ought to be taken into account. A
heart enlarged and a radial artery thickened by prolonged activity and
nothing else will suffice to carry a man safely through an attack of

influenzal pneumonia; but what chance is there for the chronic alcoholic
under similar circumstances, or for the subject of chronic Bright's disease?
So much for the general prognosis in each of these kinds of cardio-vascular
disorder and disease. But it is the particular prognosis that we have to
attempt to estimate—that is, the prognosis in the individual patient as he
comes before us and asks us that trying question, "What is my prospect of
life and health"? We diagnose, if possible, the precise nature of his cardiac
affection, and apply to the best of our ability the conclusions which I have
just submitted to you, and at the same time we estimate as correctly as
possible the man's personal condition, character and disposition. For,
whatever may be determined with respect to the average patient by an
analysis of a large number of these cases, the individual patient's future in
disease of the heart of every kind, degenerations included, greatly depends
on the care that he takes of himself. This introduces us to another
consideration. However earnestly we may attempt to estimate the prognosis
on a strictly rational system—that is, by basing it on an accurate and
complete diagnosis—we cannot deny that when the individual patient is
before us we are influenced directly by certain of the symptoms and signs,
without asking ourselves what their respective pathological meaning may
be. True bradycardia, the story of an unmistakable attack of angina pectoris,
a loud aortic diastolic murmur, the bruit de galop—these instantly give us
great concern before we have had time to translate them into the language
of morbid anatomy. Very naturally we attempt to carry this method too far,
and to reach a prognosis, as it were, by a short cut, by attaching a
prognostic value to each clinical phenomenon—palpitation, præcordial
oppression, faintness, lethal sensations, and so on. Now, quite irrespective
of the unscientific character of this proceeding, it is of little practical
service. Even when we have listened to an account from a middle-aged man
of an attack of angina pectoris, what can we tell him of his prospect of life
until we have learned whether he be guilty of excessive smoking or
drinking, whether he be gouty, whether he have lately strained his heart or
no? What I do regard as really valuable prognostically, in the way of a
simple clinical observation, is the determination of progressive symptoms
and signs. A man of 72 complains of oppression over the lower sternal
region as often as he climbs a hill. Twelve months later he comes and tells
us that he has had an attack of severe pain across the top of the chest during
the night. Another year passes, and he returns to say that now he cannot

hasten on the street without præcordial distress; and it is noted that the
second aortic sound, previously thick in character, is slightly blowing. By
the fourth year of observation the patient, having had influenza in the
interval, complains of an auto-audible murmur, and of actual pain in the
chest; there is now a fully-developed aortic diastolic murmur, and his ankles
swell occasionally. Prognosis was only too easy in this case, without inquiry
into either the cause or the lesion. A few months later true angina occurred,
and very shortly the patient died, after twenty-four hours' severe suffering.

Treatment.

Not the least advantage of the etiological standpoint of our survey of the
disorders and diseases of the heart and arteries in middle and advanced life
is the rational as well as hopeful line of treatment which it enables us to
pursue. On the whole, we can control morbific influences more easily than
we can alter pathological processes; and (what is of equal or even greater
importance) a knowledge of the causes of disease often enables us to
prevent what we could not possibly cure. For all that, the etiology of heart
disease furnishes us with but one set of many invaluable indications for
treatment. We must have also a clear mental picture of the pathological
anatomy of the conditions we would attempt to modify—for instance, of the
damage wrought by gout on the mitral valves and aortic arch, by syphilis on
the coronary arteries, by strain on the walls of the different cardiac
chambers. No less necessary is it for the practitioner to take into account,
before proceeding to prescribe, the clinical characters and course of the case
in hand. As I have said more than once already, a large proportion of the
distress, disabilities and dangers attending degeneration of the heart are due
to some additional or extrinsic disturbance—distension of the stomach,
constipation, worry or exertion—which alone, not the pathological
condition, calls for therapeutical attention.
It appears, then, that the whole natural history of the diseases and disorders
of the heart—and, I might add, of every individual case—has to be studied,
and the value of its different parts absolutely and relatively estimated,
before rational treatment can be ordered. How different will treatment be, if
ordered on these principles, from the routine procedure of prescribing a

little strychnine and digitalis for a man with oppression on exertion and a
systolic bruit at the base of his heart!
Let us begin this part of our subject with a brief consideration of preventive
treatment, founded on a knowledge of the cause at work.
Now, the first thing to strike us about these unfavourable influences is the
number of them that could be avoided or controlled successfully by simple
exercise of the will. The toxic effects of tobacco, alcohol, tea, &c. are due to
abuse, from thoughtlessness or ignorance, or from indisposition rather than
inability to exercise self-control. The abuse of tobacco appears to create so
much discomfort or even alarm, of a kind which the sufferer cannot fail to
refer to its cause, that the remedy is effected automatically, and no great
harm is done. We seldom have to do more than confirm the patient's
suspicions in this direction, and recommend temporary abstinence from the
cigarette or pipe and greater care in the future. With alcohol it is a different
matter. Alcoholism grows by what it feeds on, and our best efforts are often
vain. The present is hardly an occasion for dwelling on this subject—the
duty of the profession to their patients and friends in respect of the abuse of
alcohol. Still, I should not feel that I had discharged to the best of my
ability, or in full conformity with my strong convictions, the duties of the
honourable position which by your favour I occupy as Lettsomian Lecturer,
if I did not urge you to exercise more fully than is at present exercised your
personal influence to discourage habitual drinking. I believe (because I have
found) that many men who are not open to arguments of an abstract kind,
can be made to pause and reconsider their manner of living by having a
concrete presentment of their condition and its results placed before them—
in plain English, by being thoroughly frightened. "Heart disease" is a
powerful argument to employ with persons of this class, and it is one that is
also justified by the issues at stake. Of syphilis and the havoc that it works
on heart, aorta and the vascular system generally, but particularly within the
nervous system, I need not speak. The profession, as I have said, is not yet
sufficiently alive to it: what can the public be expected to do in the way of
prevention? Gout, corpulence and allied metabolic disorders, those fruitful
sources of cardio-vascular disorders and atheroma, call for temperance not
only in drinking but in eating. Whilst the question continues to be discussed
which particular articles of food ought to be avoided by gouty individuals,
let us all join in offering them one bit of advice of the value of which there

can be no doubt: whatever they eat, to eat little. Moderation in amount is,
speaking broadly, far more important than avoidance of the theoretical
antecedents of uric acid, whether meat, or milk, or sugar. Let me quote what
Dr. George Balfour, who has written so much and so well on disease of the
heart and its treatment, says on this subject:—"I know of no society that
inculcates, by precept or example, temperance in regard to food; yet there is
nothing ages a man or a woman so rapidly, there is nothing that shortens life
so certainly, and there is nothing that embitters the latter days of life so
much as over-indulgence in food. To those who can afford thus to transgress
—to the well-to-do—excess in food is a much more serious menace to
health and life than excess in drink, and it is specially so in respect of senile
affections of the heart, some of which have been distinctly recognised to
owe their origin to over-indulgence, while all are distinctly aggravated by
it."[15] With the observance of this simple and wholesome dietetic rule must
go attention to free elimination by all the excretory channels, and the
insurance of sufficient exercise and enjoyment of fresh air. If we wish to
impress this consideration on our own minds and give effect to it in our
practice, let us call to mind for a moment the number of cases that I have
submitted to you of atheroma of the aorta in stout matronly women of
sedentary and luxurious habits, in whom, indeed, this degeneration is quite
as common as in men.
I have already said so much on the subject of cardiac strain that it is
unnecessary and would be uninteresting to return to the question of the
prevention of it. We have seen how often it occurs in the middle-aged or old
subject by ill-considered attempts at athleticism. Moderation and due
respect for age are the true guides to the useful enjoyment of exercise after
40. As for the evil effects of nervous influences on the circulation, in
addition to anxiety, care, misfortune and grief, which are usually beyond
our control, nervous strain, as distinguished from simple hard intellectual
work, often must be relaxed if cardio-vascular damage is to be prevented. I
refer to the cases of persons in positions of great responsibility with heavy
complex prolonged duties, which they fail to overtake without exhaustion
consequent on high pressure and excitement.

I would not have dwelt so long upon the measures calculated to prevent
degeneration of the heart, were it not that they have to be employed with
equal strictness and perseverance in the treatment of cardio-vascular disease
when it is already established and our assistance is sought with anxiety. The
etiological indications have still to be respected faithfully; on this I need not
dwell. The next question is:—What can be done for the pathological
changes wrought on the arteries and the valves and walls of the heart? In
syphilitic lesions we do not hesitate to say that potassium iodide should be
given freely: it is a specific remedy of great value. Can the atheromatous
process be influenced with equal or with any success? It depends on
toxæmia and anæmia; the obvious indication is to purify and enrich the
blood. This, at least in respect of gout, glycosuria and corpulence, as we
have just seen, must be effected by a thorough reform in every department
of personal hygiene. Arsenic and moderate doses of iodides, combined with
an excess of alkalis, are calculated to promote the same end. Dr. Mott has
shown that atheroma, whether of valves or of vessels, can be traced in many
instances to disease of the vasa cordis and vasa vasorum. This carries us a
step forward in our quest for indications, but the practical conclusion
remains—that the healthy nutrition of the smaller arteries has to be restored
by attention to the blood and the use of specific remedies.
So much for valvular and vascular lesions. There remains to be discussed
the fulfilment of the greater indication for treatment: the one which directs
and governs the employment of the most important and successful of all the
measures comprised in cardiac therapeutics. This is the establishment and
maintenance of compensation. The nutrition and activity of the myocardium
can be increased and sustained by means of specific cardiac stimulants and
tonics, such as strychnine, ammonia and the digitalis group of drugs; by
hæmatinics, stomachics and laxatives to afford an abundant supply of
healthy blood; by insuring wholesome nervous influences, one of the
conditions of hypertrophy; and by the employment of the non-medicinal
measures now so extensively used to increase the vigour and benefit the
metabolism of the cardiac walls, particularly active and passive exercises
and baths. This is a comprehensive statement of the lines of treatment
calculated to benefit more or less all the kinds of cardiac degeneration
which I have had occasion to notice. Of the individual pathological
changes, and the rational treatment indicated for each from this point of

view, I will refer to three only which will serve to illustrate the
considerations which ought to guide us in practice.
In the subject of regular or irregular gout attention to the cause, that is, to
disordered metabolism of the body as a whole and of the cardiac and
arterial walls in particular, promotes, as we have seen, the recognised
conditions of compensation: the etiological and pathological indications are
here practically identical. In respect of exercise in detail, gentle walking on
the level should be ordered to begin with, that is, exercise short of
producing pain or oppression. The patient had better give up his regular
work for a time, and take advantage as fully as possible of the leisure to
enjoy the benefits of a healthy life in the fresh open air. Very shortly he will
be able to ride, play golf, shoot and cycle slowly. A course of treatment at
one of the best of our native spas or of the Continental watering-places
sometimes makes a new man of the sufferer from gouty heart. The Nauheim
treatment, whether taken there or in England, may also do real good. But it
must not be employed indiscriminately, as is so often done. The profession
ought to remember (what the public cannot and probably never will come to
understand) that pathological diagnosis must precede rational treatment,
which consists in applying a proper remedy to the individual case before us,
not in fitting every case to a specialised system or panacea—the essence of
quackery.
In planning the treatment of the dilated heart of the middle-aged man who
strained his circulation in youth and comes to us complaining of a
recurrence of præcordial distress and breathlessness, we have to remember
that there is left in the cardiac walls but a portion of that reserve of elasticity
and that reserve of muscular energy which they normally possess and
require to enable them to meet the stress of exertion. Let me remind you for
a moment that, of the provisions which the heart possesses against such an
emergency or other sudden or severe demand upon its capacity and activity,
one is extensibility of its tissues, by virtue of which it accommodates within
it the considerable increase in the charge of blood that is poured into it from
the active muscles, and the residues that accumulate within it from
insufficient discharge in the face of increased peripheral resistance. The
walls yield before the increased internal pressure acting on them both a
tergo and a fronte; the heart is over-distended, with a passing sense of
discomfort, dyspnœa and lividity; and when the muscular effort is ended the

elasticity corresponding with extensibility of the walls presently insures the
return of the chambers to their original dimensions. At the same time a
second provision comes into operation. Increased muscular activity is
developed in accurate proportion to the rise of internal pressure and secures
sufficient output from the heart. This, I repeat, is what occurs in the sound
heart. Now, in old parietal strain extensibility and the reserve of capacity of
the chambers which it insures are seriously exhausted; whilst the muscular
function is only maintained by means of hypertrophy, to which there is
necessarily a limit. In these cases of strain it is impossible to reduce the
original dilatation—that is permanent. But we may and ought to be able to
reduce the further dilatation, if any, that has been produced in connection
with recent failure of nutrition and fresh embarrassment. Therefore, whilst
we promote the nutrition of the elastic and muscular structures of the
myocardium on the general principles which I have just laid down, we must
be distinctly sparing of our demands on them. Everything approaching
effort must be forbidden at once and for a sufficient time to rest and
reinvigorate the cardiac tissues; whilst the nitrites or small doses of opium
will also give relief and restore confidence in attacks of palpitation and
anxiety. "Exercise, but not exertion," will be the broad rule to follow, at any
rate until it has been proved that greater effort can be made with safety and
actual advantage. But if præcordial embarrassment be the result of the
attempt, or of ordinary professional work, as occasionally happens, further
rest will have to be taken, that is, rest for hours or days, according to the
severity of the symptoms. I have already mentioned to you that middle-aged
patients with cardiac strain, dating from their youth, occasionally break
down in their work for months or even years. In such an event a thorough
change of air and scene should be combined with rest as a method of
treatment. A long voyage may prove invaluable, or foreign travel of an easy
and interesting kind. These not only rest the heart, but they divert the mind
and remove the curious nervousness or loss of courage which, as I have
said, is developed occasionally in these subjects, previously so vigorous and
confident.
Compare with this line of treatment that which is indicated in acute cardiac
strain after 40. The problem here is not how to deal with a chronically
dilated and hypertrophied heart, but with a heart which has just yielded
during effort, mainly in consequence of the nutritional impairment of its
walls. It is not simply strain of a heart that had begun to be somewhat

precariously nourished as a natural result of age; the probability is that the
heart was actually gouty in the comprehensive sense of the term, that is,
irritated by uric acid and embarrassed by flatulence, both mechanically and
reflexly; and, indeed, possibly it was damaged by the atheromatous process.
Rest is essential at first in the treatment of this type of case also; indeed, it
is automatically secured by the distress which accompanies attempts at
movement. But rest must not be carried too far, that is, it must not be of
greater degree or duration than is absolutely necessary as indicated by the
symptoms and signs, lest it aggravate the state of parietal mal-nutrition and
promote fresh gout. At the same time the diet must be controlled strictly or
even severely on the lines that I laid down for gout, lest the over-feeding
which accompanies rest as a matter of thoughtless routine should have the
same unfortunate effects. A course of treatment at some of the good home
or Continental spas, with special precautions, is distinctly useful in senile
strain, and the Nauheim methods have benefited more than one case of the
kind in my experience, the degree of dilatation diminishing whilst the
vigour of the heart increased. At the same time cardiac tonics of a medicinal
kind are administered judiciously.
I am on the point of passing from the subject of the nutrition of the
myocardium, when it occurs to me that some of you might very naturally
ask me: What about fatty degeneration and the treatment of it? This is a
question peculiarly interesting to me. I have not dwelt on fatty degeneration
of the heart in these lectures, and yet I have mentioned it again and again. I
have said that it is a result of alcoholism, of gouty atheroma of the
coronaries, of syphilitic arteritis in the same area, of Bright's disease, of
profound anæmia and of phosphorus poisoning; and that I believe it may
result from severe nervous strain of a harassing and depressing character;
and that in connection with each of these causes it has to be regarded and
treated differently. Nothing could well bring home more fully to us the
importance, indeed the necessity, of pursuing in practice the line of inquiry,
prognosis and treatment which I have advocated in these lectures—the
etiological one. Let me ask you also to listen to a confession of one of the
highest authorities on heart disease in this country. "It is absolutely
impossible," says Dr. George Balfour, "to diagnosticate fatty degeneration
of the heart; we may surmise its existence, but we can only be certain of its
presence when we see it post mortem"; and he quotes Fraentzel of Berlin in
support of his statement.[16] It must have occurred to many of you, as it has

occurred to me, how seldom we diagnose fatty degeneration of the heart
until after sudden death. How can we be expected to do so if we trust only
to signs and symptoms, and overlook that which is the key to the diagnosis
—the discovery of the cause that is at work?
I have now sketched very broadly the rational treatment of these disorders
and diseases as far as the object of it is to prevent the occurrence or the
extension of them, and to promote compensation of the disabilities which
they produce. It remains for me to notice, also very briefly, the management
of cardio-vascular degenerations when the heart fails, or when it appears to
fail, and distress and danger demand more direct and immediate attention. I
have said "when the heart appears to fail" of set purpose. I am anxious to
direct your attention, if it be but for a moment, to the fact that in many
instances where præcordial oppression, pain, palpitation and faintness, with
frequent small irregular pulse, are significant of serious disturbance of the
action of the heart, there is no failure of the myocardium in the proper sense
of the term, but only embarrassment of a temporary character. Do not
conclude from this that I regard the disturbance of the heart as of little
account. I have called it serious, for indeed the patient may perish of it.
What I wish to maintain is that in cardiac degeneration of any kind, in
chronic cardiac dilatation, and in the enlarged heart of Bright's disease and
of emphysema, just as in ordinary valvular disease, attacks of distress,
alarming both to patient and doctor, often occur which call for nothing more
in the way of treatment than attention to some intercurrent influence—an
indigestible meal, loaded bowels, a nervous shock, a thoughtless effort, a
passing hardship or nervous strain. Digitalis and its allies, strychnine,
alcohol, nitrites, iodides and the rest are out of place in such an event.
Complete rest in bed, a carminative draught, calomel and saline purgatives,
spare and highly digestible diet, reassurance and a little time are quite
sufficient means of treatment.
When true failure occurs, manifested by the familiar phenomena of residual
dilatation of the heart, mechanical congestion and dropsy, a different set of
measures are demanded. Now is the time to attend with expedition, energy
and completeness to the fulfilment of the three great therapeutical
indications for the treatment of cardiac failure: to reduce the peripheral
resistance; to increase the vigour of ventricular contraction and rehabilitate
hypertrophy; and to remove arrears of work in the form of residual blood in

the cardiac chambers, mechanical congestion of the veins and viscera, and
dropsy of the integuments and serous sacs. Bodily rest; a light, solid diet,
and a definite allowance of alcohol, if required; active purgation with
mercurials, salines and jalap; and the exhibition of sufficiently large doses
of digitalis or one of its congeners, in combination with saline and other
diuretics—these are the means calculated to attain the desired objects. You
will not expect me to enter into the many details of the management of
cardiac failure. It is not different in any important respect in the man of
middle or advanced age with cardiac degeneration from what it is in an
ordinary case of chronic valvular disease. Only on a few points do I desire
to dwell. First, that we must not be afraid to purge these patients, if
necessary, every morning. Secondly, that when the appetite flags and
flatulence occurs, instead of slops a blue pill or a dose of calomel should be
given, and light solids persevered with. Third, that digitalis must be given
freely, the dose of the tincture, for instance, being raised to 15 or even 20
minims every four hours, if smaller doses, such as 7½ or 10 minims, fail.
Unquestionably there is a disposition on the part of some practitioners to
pause or retrace their steps in the dosage of this invaluable drug, alarmed by
the irregularity, frequency and smallness of the pulse. All these characters
of the pulse call for more digitalis, not for less. In this connection let me
also say that the most ready and accurate, because measurable, evidence of
the action of digitalis in cardiac failure is strangely disregarded in ordinary
practice—I mean the volume of the renal secretion. We may be in difficulty,
and we may differ with each other, as to the tension of the patient's pulse
and the use of continuing or modifying the digitalis treatment, when all that
we have to do is to ascertain the exact degree of diuresis. Fourth, that
nocturnal restlessness and sleeplessness are to be met unhesitatingly with
permission to spend the night in an easy chair by the bedside. Fifth, that,
according to my experience, acupuncture and drainage succeed perfectly in
these senile cases with dropsy, as much as 10 pints or more of serum
escaping in the course of 24 hours, to the complete and often lasting relief
of the circulation.
And now I must bring these lectures to a close. In doing so I feel that I have
not only to thank you, Sir, and the Fellows of the Medical Society and our
visitors for the favour with which I have been received and the patience
with which you have listened to me, but at the same time to apologise for
the many defects, both in matter and in form, of what I have presented to

you. It is a fortunate circumstance for me that, whilst the subject was so
large and so difficult, the mode of treatment of it commonly associated with
the Lettsomian Lectures and your kind forbearance have enabled me to
conceal my shortcomings by free selection of less severely scientific topics,
and the employment of an easy style. At the same time, may I claim a little
of your favourable consideration for the aspect in which I have regarded the
disorders and diseases of the heart and arteries in middle and advanced life?
I should be satisfied with the results of my efforts on this occasion,
whatever may be thought of their form, if I have succeeded in convincing
you of the practical advantage of regarding these complaints from the side
of their causes as well as of their pathological anatomy.

Harrison and Sons, Printers in Ordinary to His Majesty, St. Martin's Lane.

INDEX.

Acute disease and cardio-vascular degeneration; 39

Alcohol and cardiac disease; 9, 18

Alcoholism, Heart in, Course of; 20

Alcoholism, Heart in, Pathology of; 3, 19, 20

Alcoholism, Heart in, Prognosis of; 36

Alcoholism, Heart in, Symptoms and signs of; 13

Alcoholism, Heart in, Treatment of; 42

Angina pectoris; 17, 21, 24

Angina pectoris, false; 35

Angina pectoris, Prognosis of; 40

Angina pectoris, Significance of; 35

Arteries, The, at 20 to 45; 3

Arteries, The, at 45 to 65; 3, 4

Arteries, The, at 65 to 75; 4

Arteries, Degeneration of, and Gout; 7

Arteries, Diseases of, after 40, causes of; 6

Arteries, Soundness of, after 40; 5

Atheroma and Gout; 7

Atheroma, Treatment of; 44

Beneke, Professor, on the normal Arteries after 40; 3

Beneke, Professor, on the normal Heart after 40; 3

Bright's disease and cardio-vascular disease; 11, 29

Bruit de galop; 35

Causes of cardio-vascular disease; 9

Coffee and cardiac disorders; 9

Compensation, Maintenance of; 44

Cycling and cardiac strain; 6

Diabetes and cardio-vascular disease; 10

Diagnosis, Differential, of cardio-vascular disease; 3

Emphysema and cardio-vascular disease; 11

Exercise, Abuse of, and cardio-vascular disease; 8, 26

Exercise, after 40, Uses of; 45

Failure of Heart, Treatment of; 48

Failure of Heart, with Digitalis; 49

Failure of Heart, with Drainage; 49

Failure of Heart, with Purgatives; 49

Faintness, significance of; 35

Fatty degeneration, Diagnosis of; 47

Fatty degeneration, Treatment of; 47

Fevers, Acute specific, and cardio-vascular disease; 11

Glycosuria and Heart Disease; 22

Glycosuria and Heart Disease, Prognosis of; 36

Glycosuria and Heart Disease, Symptoms and Signs of; 22

Golf and cardiac strain; 7

Gout and Atheroma; 7

Gout and cardiac strain; 7

Gout as a cause of cardio-vascular disease; 9

Gout and Heart Disease; 20

Gout and Heart Disease, Prognosis of; 36

Gout and Heart Disease, Symptoms and signs of; 20

Gout and Heart Disease, Treatment of; 42, 45

Gout, Irregular; 10

Gouty Heart; 20

Heart, The, at 20 to 45; 3

Heart, at 45 to 65; 4

Heart, at 65 to 75; 4

Heart of the business man; 12

Heart, Disorder of, after 40, Causes of; 6

Heart, Failure of, Treatment of; 48

Heart, Family; 14

Heart, normal, The, after 40; 3

Heart, Soldier's, The; 12

Heart, Strain of; 6

Heart, Strain of, after 40; 6

Heart, Strain of, in Gout; 7

High arterial tension from nervous strain; 8

Influenza and cardio-vascular disease; 11

Lead and cardiac disorder; 9

Metabolism, Disturbances of, and cardio-vascular disease; 9

Murmur, Aortic Diastolic, Significance of; 33

Murmur, Systolic Diastolic; 33

Murmur, Endocardial Diastolic; 33

Murmur, Mitral, Presystolic Diastolic; 33

Murmur, Mitral, Systolic; 33

Nauheim treatment; 45

Nervous influences a cause of cardio-vascular disease; 8

Nervous Strain and Heart Disease; 29

Nervous Strain and Heart Disease, Prevention of; 43

Nervous Strain and Heart Disease, Prognosis of; 39

Nervous Strain and Heart Disease, Symptoms and signs of; 29

Obesity and cardio-vascular disease; 10, 22

Obesity and Heart Disease, Symptoms and signs; 22

Old Age, Normal arteries in; 5

Old Age, heart in; 5

Operations in cardio-vascular degeneration; 39

Palpitation, Significance of; 35

Physical stress, a cause of cardio-vascular disease; 6

Prognosis, Elements of; 36, 40

Pseudo-angina pectoris; 35

Rowing and cardiac strain; 7

Running and cardiac strain; 7

Sound, First, reduplicated; 34

Sound, Second, accentuated; 34

Strain of Heart after 40, Prevention of; 45

Strain of Heart after 40, Prognosis of; 38

Strain of Heart after 40, Symptoms and signs of; 23

Strain of Heart after 40, Treatment of; 46

Strain of Heart before 40, Prognosis of; 38

Strain of Heart before 40, Symptoms and signs of; 25

Strain of Heart before 40, Treatment of; 45

Syphilis, a cause of cardio-vascular disease; 10

Syphilitic Heart Disease, Prognosis of; 37

Syphilitic Heart Disease, Symptoms and signs of; 28

Syphilitic Heart Disease, Treatment of; 44

Tea and cardiac disorder; 9

Tension, High, Significance of; 35

Tobacco Heart; 9, 15

Tobacco Heart, Prognosis of; 36

Tobacco Heart, Symptoms and signs of; 15

Tobacco Heart, Treatment of; 42

Treatment of cardiac disease, Preventive; 42

Treatment of cardiac disease, Principles of; 41

FOOTNOTES:
[1] F. W. Beneke, 'Die Altersdisposition.'
[2] Humphry, 'Old Age,' 1889, p. 23.
[3] Op. cit., p. 48.
[4] Humphry, 'Old Age,' 1889, p. 15.
[5] Leonard Hill, Allbutt's 'System of Me inc,' vol. xii; George Oliver, 'The
Blood and Blood-Pressure,' p. 170, 1901.
[6] A medical friend who has suffered from tobacco heart assures me that at one
period he could distinguish the contractions of the auricles and ventricles.
[7] Maguire, 'Trans. Clin. Soc. of London,' vol. xx, p. 235.
[8] Mott, "Cardio-Vascular Nutrition and its Relation to Sudden Death,"
Practitioner, xli, p. 161.
[9] Mott, 'The Croonian Lectures on the Degeneration of the Neurone,' p. 110,
1900.
[10] Dyce Duckworth, 'A Treatise on Gout,' 1889, p. 108.

[11] Murchison, 'Clinical Lectures on Diseases of the Liver,' 3rd edition, 1885, p.
637.
[12] Cf. Clifford Allbutt, "Selections from the Lane Lectures," Philadelphia Med.
Journ., January 27th, 1900.
[13] Mott, Practitioner, loc. cit., p. 169.
[14] Clifford Allbutt, 'System of Medicine,' v, p. 843.
[15] G. W. Balfour, 'The Senile Heart,' p. 236, 1894.
[16] Balfour, op. cit., p. 249.

Transcriber's note:

Minor typographical errors have been corrected without note. Irregularities and
inconsistencies in the text have been retained as printed.

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