Ernst P. Boas

Hereditary disturbance of cholesterol metabolism; a factor in the genesis of atherosclerosis.

Abstract Serum cholesterol was found to be elevated over 300 mg. per 100 c.c. in seventy-one members (58 per cent) of a group of 122 patients with proved coronary atherosclerosis whose disease began under the age of 50 years. The average serum cholesterol for the entire group of 122 patients was 316 mg. per 100 c.c. (±7.49 S.D.m). The average serum cholesterol for the seventy-one patients who exhibited hypercholesterolemia was 365 mg. per 100 c.c., and the average among the remaining fifty-one patients was 250 mg. per 100 cubic centimeters. Arcus senilis was exhibited by twenty-two, xanthelasma by twelve, and xanthomatosis by three of the group. The great majority with these stigmata had elevated serum cholesterol levels. Hypercholesterolemia (serum cholesterol of 300 mg. per 100 c.c. or more) was found in all or most of the siblings of one-third of fifty families of patients with coronary acherosclerosis. In nine more families, one-half of the siblings exhibited hypercholesterolemia. This study lends support to previous clinical investigations and indicates that a disturbance in cholesterol metabolism is probably concerned in the genesis of some instances of coronary atherosclerosis. It also suggests that altered cholesterol metabolism may be the common denominator in most patients who have coronary artery disease and arcus senilis, or coronary artery disease and xanthelasma. One of the hereditary factors responsible for arteriosclerotic heart disease may reside in abnormal cholesterol metabolism. Since therapeutic measures for correcting this metabolic disturbance may reasonably be anticipated, further investigations paralleling the present one are desirable.

The epidemiology of atherosclerosis among a random sample of clothing workers of different ethnic origins in New York City

Abstract The prevalence of manifest atherosclerosis and associated conditions has been studied among a working population who were members of a Union representing the workers in the mens clothing industry in New York City. Of the total Union population of 33,000 men and women, a sample of 683 men and 592 women aged 40 and over was drawn at random; an additional, nonrandom group of family members, including 183 men and 272 women, was also examined. The majority of the participants belonged to two different ethnic groups,, and were first generation immigrants of Italian and Jewish origin; their social and economic status was otherwise comparable. The prevalence of manifest atherosclerosis in this population was established on the basis of well-defined diagnostic criteria. Manifest coronary heart disease was twice as frequent among Jewish than among Italian men but no ethnic difference could be discerned among the women; the sex difference in prevalence was well marked. In contrast, aortic atherosclerosis, diagnosed on the basis of roentgenorgraphic evidence of calcification in the thoracic and abdominal aorta, showed neither an ethnic nor a sex difference. Data on the prevalence of peripheral artery disease and calcifications in the arteries of the leg were also presented. Prevalence rates for hypertensive and rheumatic heart disease were also given. The reported data include information on relative weight, height, and other bodily characteristics, blood pressure and serum lipid levels, the prevalence of diabetes and the general state of health among this representative population sample and in the two main constituent ethnic groups. Jewish men and women were shown to have higher serum cholesterol levels than their Italian counterparts but serum phospholipid levels were similar in the two ethnic groups. Serum uric acid levels were higher in men than in women but similar in Italians and Jews. Systolic and diastolic blood pressure levels showed a rise with age but no ethnic difference. No ethnic difference was demonstrated in the prevalence of diabetes mellitus. An analysis of certain insurance records pertaining to this population group confirmed the evidence based on examination of the random population sample that coronary heart disease indeed occurred more commonly among Jewish than Italian men. The study provides an example of a comprehensive epidemiologic study of manifest atherosclerosis and should establish a basis for comparison with other much-needed surveys of this kind.

The epidemiology of atherosclerosis among a random sample of clothing workers of different ethnic origins in New York City. II. Associations between manifest atherosclerosis, serum lipid levels, blood pressure, overweight, and some other variables.

Abstract The prevalence of various manifestations of atherosclerosis was measured among a random sample of clothing workers, aged 40 and over, of Italian and Jewish extraction, who were comparable with regard to working conditions, socioeconomic status, and dietary intake of calories and fat. The over-all prevalence rate of coronary heart disease among Italian men appeared to be influenced by serum cholesterol, blood pressure, and body weight levels since the frequency of the disease was consistently greater at higher than at lower levels of these three variables. By contrast, among Jewish men who, as a group, showed evidence of coronary disease more frequently than Italian men, these variables exerted no appreciable effect upon the prevalence of the disease. The sample included too few women with coronary disease for a similar analysis. The prevalence of roentgenographic evidence of aortic calcifications appeared similarly more susceptible to the influence of the three variables in question among Italians than Jews in both sexes. Data relating the prevalence of manifest atherosclerosis to the serum cholesterol-phospholipid and ratio and serum acid levels were also presented. Aortic calcifications were more commonly seen in the presence than in the absence of manifest coronary disease; further interrelations between manifest coronary, aortic and peripheral arterial disease were also made. Comparison of Italian and Jewish men with and without coronary disease in terms of some more obvious possible atherogenic factors failed to delineate a “profile” which might help in characterizing the affected men. These findings indicated primarily that the predisposition to the development of coronary heart disease of Jewish, as compared with Italian, men in this population segment is largely unexplained by any of the factors studied in these investigations. Presently undefined factors appear to be of considerable quantitative importance in determining the prevalence of coronary disease among certain predisposed groups and require further study, particularly by epidemiologic methods.

Extracardiac determinants of the site and radiation of pain in angina pectoris with special reference to shoulder pain

Abstract An affection of the shoulder characterized by pain, muscle spasm, and limitation of motion occurs commonly in patients with angina pectoris. With rare exceptions the left shoulder is involved when there is left-sided radiation of anginal pain; the right shoulder when there is right-sided radiation. This shoulder pain is continuous, is not exaggerated by factors that usually induce anginal pain, but is often aggravated by sudden progress of the heart lesion, such as coronary thrombosis or acute left ventricular failure. Such shoulder pain does not call for bed rest and treatment of the heart, but is relieved by local physiotherapeutic measures. At times the Libman maneuver-firm pressure on the homolateral brachial plexus-brings about instant relief of this pain and limitation of motion. The mechanism of this shoulder pain remains obscure. Certain analogies suggest that the radiation of the anginal pain to the shoulder superimposed on a local slightly painful affection of the shoulder may by summation induce this painful disablement. However, the many other trophic and sensory disturbances that may occur in the left upper extremity in patients with angina pectoris, suggest rather that the chief factor lies in some reciprocal relationship between afferent impulses from the heart and sensitization of the neurones whose fibers go to make up the brachial plexus. The site and radiation of anginal pain may be determined by extracardiac lesions, such as abscesses of the teeth or spondylitis. In such cases the anginal pain may be experienced only or chiefly in the area sensitized by somatic disease. Conversely in the presence of peptic ulcer or of gall bladder disease the pain arising in the ulcer or in the gall bladder may follow the anginal radiation. Fitz-Hugh and Wolferths observation is confirmed that there are patients with gall bladder disease, with reference of the pain to the precordium and T-wave changes in the electrocardiogram, in whom operative removal of the gall bladder is follwed by disappearance of precordial pain and a return to normal of the electrocardiogram.

The natural history of coronary artery disease of long duration

Abstract The clinical course of 124 patients who had been under observation for coronary artery disease for at least 10 years is described and graphically portrayed. The average duration of cardiac symptoms was 13.6 years. Patients whose illness began with simple angina pectoris had a better prognosis than those in whom it was initiated by a myocardial infarct. Fifteen patients who never had hypertension developed cardiac enlargement. Sixty-five per cent of the patients were without symptoms for 1 or more years, and 72 per cent followed their usual occupations during most of their illness. The study emphasizes the unpredictable, variegated course of coronary artery disease and the frequent modifications of symptomatology in patients with this disorder.

VITAMIN E IN HEART DISEASE

Excerpt Enthusiastic reports1, 2on the value of vitamin E (alpha-tocopherol) in the treatment of certain forms of heart disease warrant further trial with this substance. Cardiac failure has been r...

Cardiac hypertrophy caused by glycogen storage disease in a fifteen-year-old boy

Abstract Evidence is presented which suggests that some cases of idiopathic hypertrophy of the heart, described in the older literature, represent end stages of glycogenosis of the heart, and that our first case represents a transition between the infantile, fully developed picture of massive glycogen deposition, and the end stage, with only reactive inflammation, degeneration, and fibrosis.

Some modes of infection in rheumatic fever

Abstract We have tried to show, both from our experience and from a survey of the literature, that rheumatic fever has many of the characteristics of other infectious diseases with a low degree of contagiousness, but that at times, and under special circumstances, it may assume epidemic proportions. We have pointed out the importance of the lungs as a source of reactivation or as a portal of entry of rheumatic infection, and have drawn attention to the close connection that exists at times between bronchopneumonia and rheumatic carditis. We have tried to reemphasize the importance of regarding rheumatic fever as a generalized systemic infection of great chronicity, and consequently the inadequacy of directing the attention too exclusively to one organ, such as the heart or the tonsils. We have shown the relatively minor role played by the tonsils as sources of reinfection. Finally, we have tried to indicate the inadequacy of present methods for after-care of children with rheumatic heart disease and the harmfulness of the ordinary form of prolonged general hospital care. The problem of the rheumatic child can be met only by providing some form of extended sanatorium treatment in an effort completely to eradicate the rheumatic virus from the infected individual.

Clinical studies of gitalin and of digitalis in the treatment of auricular fibrillation

Abstract A comparative study of the actions of gitalin and digitalis was made in thirty-six ambulant patients with auricular fibrillation. Gitalin acts like digitalis in slowing the ventricular rate and relieving congestive heart failure in patients with auricular fibrillation. Gitalin parallels digitalis in its effect on the R-T transition and T-waves of the electrocardiogram. Gitalin has a persistence of action at least as long as digitalis. Rapid administration of gitalin in eight patients produced prompt and effective slowing of ventricular rates and clinical improvement without the development of toxic symptoms. The average daily maintenance dose of gitalin was 1 110 grain; of digitalis, 2 1 4 grains, or 1 1 2 cat units. Clinically, 1 160 grain of gitalin is equivalent to 1 cat unit of digitalis leaves. The daily maintenance dosages of both drugs show considerable variations in different individuals. Toxic reactions to gitalin are the same as to digitalis. They are neither more nor less frequent. With careful administration they should be rare with either drug. Our studies indicate that digitalis can slow ventricular rates in auricular fibrillation in the absence of heart failure, which is contrary to the contention that slowing of the ventricular rate in auricular fibrillation is effected by digitalis only in the presence of heart failure.

The ventricular rate in auricular fibrillation studies with the cardiotachometer

Abstract The ventricular rate of patients with auricular fibrillation has been studied by means of the cardiotachometer. It has been shown that the ventricular rate is variable, that it accelerates in response to the slightest exertion or emotion, and that it slows during rest and particularly during sleep. All the evidence indicates that the ventricular rate in these patients is under control of the cardiac nerves and that alterations in rate are governed by neurogenically determined changes in conductivity of the specific conducting tissue of the heart. The changes in ventricular rate arise, apparently, in response to the varying physiological needs of the body just as in health, but the reaction is not so well regulated and is often excessive. Patients with auricular fibrillation may be classed in two groups: those with labile and those with stable ventricular rates. The former are high-strung and nervous and correspond to patients with neurocirculatory asthenia. Their ventricular rates tend to be rapid, and quantities of digitalis in excess of the body-weight dose are required to keep the ventricular action slow and stable. In addition it would seem that sedative and psychotherapeutic treatment should assist materially in slowing the ventricles. In the stable group the ventricles do not exhibit such an exaggerated response to physical and emotional stimuli and can readily be kept under control by the usual methods of digitalis therapy. The value of rest and sleep in the treatment of patients with auricular fibrillation, a fact well known, is forcefully demonstrated by actual count of the number of heartbeats by means of the cardiotachometer.