Kitabı oku: «The Lettsomian Lectures on Diseases and Disorders of the Heart and Arteries in Middle and Advanced Life [1900-1901]», sayfa 2

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.

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.