A hundred years ago: “Weak hearts” in general practice
By Gordon Lambert, M.D.
By Gordon Lambert, M.D.
Extracted from the November 1907 issue of The Practitioner
The general practitioner is frequently called upon to treat patients, who have been told by former medical attendants, or have decided for themselves, that they suffer from "weakness" of the heart. In a large proportion of such cases there is considerable truth in the statement, but both time and patience are often needed for forming an accurate opinion as to the nature and cause of the heart's weakness. The difficulties presented are not slight, and too often the task of arriving at a definite decision, the only possible guide to rational treatment, is abandoned at the very outset.
1. The Alcoholic.– The abuse of alcohol produces morbid conditions of the heart with sufficient frequency to warrant separate grouping of alcoholic weak hearts. The signs and symptoms, presented by the alcoholic weak heart, differ less in character than in degree from those already described for the anaemic heart. This clinical resemblance of the two groups is readily explained by the fact that they have to some extent a common pathogenesis. In both groups the myocardium suffers impairment of functional activity owing to abnormal nutrition, which tends in both instances to produce fatty degeneration. Excessive ingestion of alcohol leads to widespread deposition of fat in the body, familiar to us as the obesity of alcoholics. Not only is the sub-cutaneous fat increased, but there is an increased deposit of epicardial fat. This fatty infiltration penetrates the heart substance, causing secondary degeneration of the muscular fibres by mechanical compression. It is probable, however, that the degeneration results in greater measure, from a more direct action of the alcohol upon the cardiac muscle cells, from its shielding of the protoplasm from oxidation, combined with the injurious effects of toxic impurities contained in it.* Moreover, the influence of alcohol in the production of atheroma and arterio-sclerosis must not be forgotten. The aorta and coronary arteries suffer early and with marked frequency.
The alcoholic has a "flabby" heart in a "flabby" body. The heart's impulse is diffuse and feeble, the apex beat is often displaced outwards, less by hypertrophy than by dilatation. The dilated right ventricle may thrust back the left ventricle and the impulse of the former may be mistaken for that of the latter. The first sound is not infrequently short and sharp, but both sounds are often heard indistinctly through the thick covering of the chest wall. Slight exertion is sufficient to cause dyspnoea, praecordial distress, intermittent and irregular action of the heart. More severe exertion, such as running to catch a train, may produce either fatal syncope or permanent dilatation of the heart. Chronic alcoholics, however, are seldom energetic persons, and fatal syncope overcomes them more commonly during an attack of delirium tremens.
2. The Athletic (or Strained).– This group includes cases in which strain of the heart has been caused by physical exertion too severe, or too prolonged, for the strength of the individual. The best examples of this form of heart weakness occur in athletic school boys, and in young soldiers, in whom the "irritable heart" is induced by prolonged marches. In a paper published on the subject,1 Dr. Arthur Lambert, of Harrow, presented the results of his observation of this affection in public school boys. He stated his belief that the progression from physiological to pathological dilatation of the heart is not gradual, that the transition is abrupt. "The boy is accustomed to extreme breathlessness, but when acute dilatation befalls him he recognises its onset as a sudden evil. He ‘felt a sudden pain in his chest and couldn't go on.'" This sudden onset is usually associated with increased frequency and irregularity, in rhythm and volume, of the pulse. The increased frequency and irregularity of the heart's action may persist for an indefinite period; the disorder of action may permanently remain in some cases. The first sound of the heart, in many cases, is short, slapping and accentuated. Percussion dullness to the right of sternum is not infrequently increased and the pulmonary second sound accentuated. The face may be pallid and the lips blue.
In the paper referred to above, stress is laid on "the tendency of all these cases to recurrent dilatation of the heart, whatever may have been the method of their production." Premature return to active exercise is followed by recurrence, frequently with augmentation, of the symptoms. Chronic hypertrophy and dilatation are among the possible results enumerated. In the discussion of the pathology of heart strain, it is suggested that fibrous hyperplasia may play an important part in the later stages.
In an instructive article, recently published by an American physician, Dr. Woods Hutchinson, on "Exercise and its Dangers," occurs the following statement, "every physician who has practised in or near a university town can point to a dozen athletic young men, who have been seriously injured by muscular exercise. Particularly is this true of overstraining and hypertrophic disease of the heart muscle. A recent study, by the school physician, of the boys in training at a western academy showed that over sixty per cent had cardiac murmurs." It is further pointed out that "the large heart of the athlete often contains inflammatory exudates; to put it roughly, is swollen from congestion. Second, that this large heart, whether normal or diseased, after the contest is over, and training is relaxed, begins to shrink again. This shrinking is brought about by a fatty degeneration and absorption of both the inflammatory exudates, and the surplus muscle-fibres, and, if it goes a step too far, may become one of our most insidious and dangerous cardiac diseases, fatty degeneration of the heart."
* Both fatty infiltration and fatty degeneration, however, are present in the fatty hearts of those who suffer from the diathesis of obesity, though, in some cases, alcoholism plays no part.