Read Ebook: The Lettsomian Lectures on Diseases and Disorders of the Heart and Arteries in Middle and Advanced Life [1900-1901] by Bruce J Mitchell John Mitchell

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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

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

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

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.

F. W. Beneke, 'Die Altersdisposition.'

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 it is found as large as it was at 45, and at the same time the haemoglobin 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.

Humphry, 'Old Age,' 1889, p. 23.

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. 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.

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.

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.

Leonard Hill, Allbutt's 'System of Me inc,' vol. xii; George Oliver, 'The Blood and Blood-Pressure,' p. 170, 1901.

Of the many cases of this kind that I have seen at all ages between 40 and 80 , 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.

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 , 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."

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 , 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, 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 praecordial 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.

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.

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.

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