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

by J. Mitchell Bruce

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 1888[7] (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.