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

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.