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* * * * *
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 Glycosuria 22
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 Nervous Strain 29
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]
[1] F. W. Beneke, 'Die Altersdisposition.'
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.
[2] Humphry, 'Old Age,' 1889, p. 23.
[3] _Op. cit._, p. 48.
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.
[4] Humphry, 'Old Age,' 1889, p. 15.
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.
[5] Leonard Hill, Allbutt's 'System of Me inc,' vol. xii; George
Oliver, 'The Blood and Blood-Pressure,' p. 170, 1901.
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.
[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.
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.