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

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.

      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