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Are Those of Longcope', Allbutt23, and Reid45. 662 Negroes Who Had Syphilis

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Are Those of Longcope', Allbutt23, and Reid45. 662 Negroes Who Had Syphilis 656 Ti, CANADIN MEDICAL ASsOcIATIoN JOURNAL [Nov. 1930 SYPHILIS OF THE AORTA AND HEART* A CLINICAL STUDY BY SAMUEL S. RIVEN, M.D., Ann Arbor, Mich., and J. FEIGENBAUM, M.D., Montreal THIS article presents a summary of the clinical can be demonstrated microscopically in findings in a series of 74 patients with practically 100 per cent of the cases syphilitic cardiovascular disease observed at Very different is the case in the syphilitic female. the University Hospital, Arn Arbor, between In a large proportion of such, no characteristic July, 1925 and July, 1927. Seven of these gross or microscopic syphilitic lesions can be patients were subjected to autopsy. In the found in either aorta or heart." remaining instances the diagnosis was made on Racial incidence.-Sixty-four of the patients the history, and the clinical and laboratory here reported belonged-to the white race and findings. No doubtful cases were included. 10 to the coloured r4k. The proportion in The clinical diagnoses are summarized in Table I. Scott's series between white and coloured in- There is an extensive literature dealing with dividuals was 34 to 41. Paullin found evidence this subject. Among the more important studies of cardiovascular syphilis in 39 per cent of are those of Longcope', Allbutt23, and Reid45. 662 negroes who had syphilis. This percentage We have compared our data with the findings is apparently not any greater than occurs in of these and various other authors. the white population with syphilis. No definite conclusion can be drawn regarding the pre- TABLE I. disposition of negroes to syphilis of the circulatory Clinical Diagnosis No. of Cases apparatus, because the figures from various parts Aortic insufficiency without of the country vary with the proportion of aneurysm.................... 35 47 Syphilitic aortitis without aneurysm negroes in the total population. or aortic insufficiency.......... 14 19 Age incidence.-The relationship of cardio- Aneurysm........................ 13 18 Aneurysm and aortic insufficiency. 9 11 vascular syphilis to age is given in Table II. Syphilitic myocarditis............ 3 4 TABLE II. 74 100 Ages No. of Cases Per Cent ETIOLOGICAL CONSIDERATIONS Authors' Longcope's Authors' Longcope's Series Series Series Series Relationship of sex to the incidence of cardio- 20-30 0 19 0 30.1 vascular syphilis.-Of the total number of 31-40 7 13 9 20.6 patients, 64 were males and 10 were females, 41-50 33 19 45 30.1 51-60 23 7 31 11.1 an incidence of 6.4 to 1 in favour of males. 61- 1 1 5 -15 8.0 In cases on which autopsy. was performed Reid4 found a ratio of 3 to 1; Scott6 6 to 1, and Clawson 74 63 100 99.9 and Bell7 4.7 to 1; while in clinical cases Reid By far the largest number of our cases fell found a ratio of 11 fo 1 (out patients), and Paullin8 into the fifth and sixth decades, while the majority 4 to 1. One might expect to find a greater of Longcope's cases were found in the third and preponderance of males in autopsied than in fifth decades, with- an equal number in each of clinical cases, for according to Warthin9 "Sy- these age groups. A comparison of the two philitic lesions in the aorta and heart of the male series reveals a rather striking difference in the third, fifth, and sixth decades, with the greatest *From the Department of Internal Medicine, Uni- versity Hospital, University of Michigan, Ann Arbor, discrepancy in the third. As will be noted, Michigan. almost one-third of Longcope's patients were Nov. 1930] RIVEN AND FEIGENBAUM: SYPHILIS OF THE AORTA AND HEART 657 between 20 and 70 years of age, while none of some complaint, or the symptom which urged our patients fell within that age period. Also, him to seek medical advice. Although it was while one-half of Longcope's patients were difficult to be certain of the presenting symptom between 20 and 40 years old we found a much in every instance, it was obtainable in the ma- smaller percentage in this group. In fact, 67 jority of patients. The most frequent was per cent of the patients were between 40 and 55 dyspncea on exertion, in 44 patients, or 59 per years old. The average age of all patients was cent of the total number. Next in order of 50 years, with extremes of 32 and 74 years. frequency was pain in the chest, arms or abdomen, Most authors place the commonest age inci- in 19 patients, or 25 per cent. Palpitation was dence of syphilitic heart disease between 40 the chief complaint in 2 patients; "swelling of and 50 years. Reid gives the average age as the ankles" in 2 instances, and "nervousness" 44 years, with age limits between 21 and 73 years. in 2 others. Of the 3 remaining patients, one Allbutt2 gives the age period of greatest incidence presented as his chief difficulty "painful heels", as 35 to 50. Benary (quoted by Allbutt in the another dizziness, and the third hoarseness. It above reference) gives the average age as 48.6 will be seen that 84 per cent of the patients with years. Brooks11 in a study of 200 cases found syphilitic cardiovascular disease had as their the average age in women to be 38 years, and in presenting symptom either dyspnoea on exertion men 44 years. Scott sets the average age at or pain. The duration of the chief complaint about 40 years, with limits of 29 and 76 years. varied between 2 weeks and 16 years. In about The mean of Coombs'10 cases was only 35 years. three-quarters of the cases, however, the chief In 80 per cent of Paullin's patients, the disease complaint had been present between 2 weeks was seen before the fiftieth year. This author and 2 years before the patient came to the points to the fact that syphilitic aortitis can hospital. occur in adolescence, one of his patients being Dyspncea.-Dyspncea on exertion as a feature 17 years old and another 22 years old. at, some time during the patient's illness, and not necessarily as a presenting symptom, occurred SYMPTOMS in 67 patients or 90 per cent. Longcope found The interval between primary syphilitic infection dyspnoea to be one of the first symptoms in and onset of symptoms.-This information was about one-half of his cases, and Reid found available in only 39 of the cases. The shortest it in two-thirds of his series. lapse of time between the infection and the Paroxysmal dyspnwa.-Paroxysmal dyspncea development of symptoms was 6 years, the. appeared in 13, or 17 per cent, of our cases, and longest 49 years; the average interval was 24 in 9, or 14 per cent, of Longcope's patients. In years. An interval of 6 to 20 years elapsed Scott's experience, only few cases of syphilitic between the primary infection and clinical aortitis without aortic insufficiency presented disease in one-third of the cases and a period of typical paroxysmal nocturnal dyspncea. Keefer 21 to 30 years in half of the cases. So that in and Resnik"2 also found this symptom to be very five-sixths of the 39 cases, symptoms appeared common in aortitis with aortic insufficiency; of between 6 and 30 years following the infection. their 28 patients 25, or 89 per cent, had From his studies, Longcope concluded that the paroxysmal dyspncea. In another series of 24 average interval between infection and the patients with uncomplicated syphilitic aortitis, occurrence of symptoms was 16 years, the limits collected by Keefer and Resnik, not one being 3 and 35 years. Coombs found this complained of paroxysms of dyspncea. So far lapse of time to be- about 20 years., Scott ob- as the high incidence of paroxysmal dyspncea served the interval between infection and death in cases with aortic insufficiency is concern- in 34 male patients to range from 5 to 44 years, ed our experience has been different from the average being 20 years. It is worthy of note that of the last mentioned authors. Only here that many authors have reported syphilitic 9 of our 42 patients with aortic insufficiency had infection of the heart and aorta during the paroxysmal dyspncea. Moreover, of the total secondary stage. Valda (quoted by Allbutt) number of 13 cases with paroxysms of dyspncea, reported a case of infection of the mediastinal 4 had aortitis without aortic insufficiency. glands while the chancre was still present. Longcope, who was one of the first of American Presenting symptom.--By "presenting symp- authors to call attention to the occurrence of tom?' we mean the patient's chief or most trouble- paroxysmal dyspneea in syphilitic aortitis, '658T6E8 CANN:A.DI MsncAL ASsoCLATION JOURNAL[[Nov. 1930 attributed the attacks of shortness of breath to were unable to find any definite data regarding. reflex stimuli from the root of the aorta. the relative frequency of cardiac enlargement in Allbutt's explanation of this phenomenon is that syphilitic heart disease, as determined by clinical it is due to an irritation of the recurrent laryngeal means. However, reference is made to the nerve with consequent laryngeal spasm.. Keefer weight of the heart in certain pathological studies and Resnik offered no explanation of the on cardiovascular syphilis. Scott and Saphir" paroxysms of dyspncea, but maintained that state that the majority of hearts with syphilitic they occurred generally in patients with very aortic insufficiency weighed about 500 grams, large hearts. Twelve of our 13 patients with and Clawson and Bell give the average size of attacks of dyspncea had huge hearts, while the the heart in syphilitic aortitis as 620 grams for 13th had an aneurysm with a heart of normal men and 400 'grams for women.
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