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

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 18887 (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 Murchison11 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 gout12; 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.