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

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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.

      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.

      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.

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