A manual of the diseases of the heart : their pathology, diagnosis, prognosis and treatment

Front matter

The Library of the Wellcome Institute for the History of Medicine

MEDICAL SOCIETY \ OF ' LONDON DEPOSIT

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Preface

Notwithstanding the aumerous excellent works which have appeared in various parts of the civihsed world on the Diseases of the Heart, it seems to me that the time is not inopportune for the production of a small English manual on the same subject. As with all other topics connected with our profession, old views on cardiac maladies are continually undergoing revision and new ones are introduced to notice, though perhaps eventually destined to share the fate of their predecessors ; and my object is to exhibit the present phase of what cannot but be considered a very interesting field of inquiry. Besides these considerations, I have myself made some practical clinical investigations on matters connected with cardiac disease, and as I conceive it to be the duty of every one to contribute his stock of information, however small, I venture to lay my own humble experience, with some of the lessons it conveys, before my professional brethren.

R. H. SEMPLE.

8, TOBEINGTON SqTJAEE,

London.

DISEASES OF THE HEAET

Chapter I Introduction

AuDUAL, in editing the fourth edition of Laennec^'s ' Traits de i' Auscultation Mediate et des Maladies des Poumons et du CcBur/ in the year 1837, writes in a note: "In spite of many laborious researches the history of the diseases of the heart is far from being yet finished ; it still presents a great many doubts to be removed and many gaps to be filled up, and the time is not yet arrived when the diagnosis of these diseases can be regarded as being so easy and certain as that of the diseases of the lungs. Still, the continual progress which has been made from the time of Lancisi to that of Laennec, and from the latter to that of M. Bouillaud, must inspire us with hope for the future."

It is quite true that the whole history of the diseases of the heart is even now not yet completed, and that some of them are still enveloped in a certain amount of obscurity; that the relations existing between the physical and rational symptoms during life on the one hand, and the appearances found after death on the other, are not yet absolutely determined^ and that very many problems of treatment yet remain to be solved. Still, much more has been done in all these directions than Andral, in the preface referred to, appears willing to admit ; and it may be asserted, with tolerable truth, that the diagnosis of , cardiac diseases is at least as easy and certain as that of the diseases of the lungs; while, in reference to therapeutics, there can be no doubt that a very great advance has been manifest, not only in the introduction of new remedial measures, but also in the omission of many old ones which are now proved to be mischievous.

Andral, while he attributes great merit to the labours of Bouillaud, does very little, justice to the British investigators of cardiac diseases, especially the late Dr Hope and Dr C. J. B. Williams, although their researches were made before the period when Andral wrote. In fact, the elaborate and conclusive experiments made on the causes of the sounds of the heart by Dr Hope and Dr Williams, by the Dublin Committee in 1835, and by the London Committee in 1836, have thrown a complete flood of light upon the diagnosis of diseases of the organ, and have almost cast into the shade the brilliant investigations of Laennec himself, so far as cardiac auscultation is concerned. For the great Trench stethoscopist, while he explained very clearly the auscultatory phenomena of the rest of the chest, left the prsecordial region in a great measure to the labours of subsequent explorers. Although Laennec indicated the character of the sounds caused by the motions of the heart, he made no attempt to explain the mechanism by which they were produced ; and while to bim, moreover, is justly due the discovery of abnormal cardiac sounds, or murmurs [bruit de soufflet, iruit de rape, &c.), he was unable to account for their occurrence except upon the supposition that they denoted a spasm of the heart.

" It appears to me," he says, " that the positive and negative facts which I have just adduced all tend to prove that the bruit de souffiet is produced by a simple spasm, and does not indicate any lesion of the heart or arteries." ^ He was, however, very near to the discovery of the valvular origin of the murmurs, when he states that " the bruit de sovfflet exists pretty constantly in the hearts of persons who are affected with narrowing of the orifices of this organ ; " but he goes on, somewhat erroneously, to state that " it is also pretty frequently met with in persons affected with hypertrophy or dilatation ; but it is found still more frequently as well in the heart as in the arteries of persons who have no lesion of these organs, and who are attacked by very different affections.'' ^

The progress made in our knowledge and practice, in reference to cardiac diseases in the present day, is still more strikingly displayed by the perusal of the single short chapter devoted by Laennec 1 ' Traite de rAuscultation Mediate,' vol. iii, p. 84, 1837. » Op. cit., p. 92.

to the treatment of the organic affections of the heart. " Of all the organic affections of the heart," he writes, " simple hypertrophy or combined with dilatation appears to me the most susceptible of cure. By applying, courageously and perseveringly, to the treatment of hypertrophy the method advised by Yalsalva and Albertini for aneurism of the arteries, we may promise to ourselves much more frequent and complete success, especially if we begin to employ it at a period when the disease has not yet produced serious general symptoms The treatment ought to be pursued in an energetic manner, especially at first We must begin, therefore,

by bleeding the patient as copiously as he can bear without fainting, and the bleeding must be repeated every two, four, or eight days, at the latest, until the palpitations have ceased, and the heart no longer gives more than a moderate impulse under the stethoscope." ^

Laennec goes on to advise that the patient must reduce his diet by at least one half, and after about two months of bleeding and low diet, if he no longer suffers from palpitation, or presents a strong cardiac impulse, then the bleeding may be practised at more distant intervals, and the seventy of the regimen may be in some measure relaxed. But he adds that the same measures must be resorted to, and with equal rigour, if the impulse of the heart should afterwards increase.

The influence of these doctrines and of those of Bouillaud, who carried out the system of sanguineous depletion to a still greater extent, especially in recent cardiac affections, was, as I cannot help thinking, exceedingly injurious ; and I can perfectly well recollect seeing cases in France where this vigorous antiphlogistic treatment was resorted to in instances of supposed diseases of the heart, but where none really existed. Even where such , disease did exist, it is more than doubtful whether any benefit ever resulted from this treatment,, and the success said to attend the plan must be referred, perhaps, rather to the enthusiastic and coloured statements of the practitioners of the period than to the actual relief afforded to the patients.

Among many such cases I well recollect attending a young French lady, more than twenty years ago, who had been almost brought to the grave by continued bleedings for supposed disease of the heart, attended by a feeling of fulness in the head, and who, in fact, asked me to prescribe further bleeding, as the symptoms had

^ Op. cit., p. m.

not subsided. But as I could detect no evidence of cardiac disease, and indeed found no signs of congestion anywhere, I attributed the persistence of the symptoms to the treatment and not to disease, and pursued a totally different plan, ordering wine, iron and quinine, and with the very best results, for the, lady completely recovered, and subsequently married ; and on a recent visit to this country she called upon me to express her gratitude for the change of treatment which had been so opportunely adopted, and which perhaps saved her from an infinity of suffering, if not from death itself. In the present day, probably, such a case would not be thought of much interest, but it illustrates well enough the point to which I am referring, namely, the injurious influence of the doctrines taught by some of the most distinguished writers on cardiac disease in the earlier half of the present century.

It is now well known that bleedings and low diet increase the palpitations of the heart, and the very symptoms which led Laennec and Bouillaud, and their followers, to persevere in the depletory system, afl^ord the strongest indications to the practitioners of the present day in Great Britain to discontinue it, if it has been commenced, or to abandon it altogether. In many cases treated by excessive depletion the patients have no doubt survived, but who shall say how many have sunk under it ?

Dr Hope, whose classical 'Treatise on Diseases of the Heart ^ has been of invaluable service to the progress of cardiac pathology and diagnosis, very properly condemns the treatment recommended by Laennec, although he admits that he himself has invariably found the greatest benefit to be derived, in the early stages of hypertrophy of the heart, from sparing abstractions of blood at intervals of two or three weeks or more. " I have constantly noticed," he writes, " that when from the severity of the dyspnoea and palpitation, in the advanced stages of the complaint, the practitioner was induced, or thought himself compelled, to resort to frequent bleedings at short intervals, the patient, though perhaps temporarily reheved, progressively declined from that moment, dropsy increasing, and the paroxysms recurring more frequently and with greater violence, until they eventually terminated in his destruction.-" ^ Dr Hope's own plan of treating hypertrophy of the heart consisted in the abstraction of blood to the amount of four, six, or eight ounces, every two, three, four, or six weeks, according to the age and ' ' Treatise on Diseases of the Heart,' Fourth Edition, p. 26i, 18G9.

strength of the patient, so as merely to keep down palpitation, dyspnoja, and strong impulse of the heart. But although this plan was recommended, and no doubt adopted, only about thirty years ago, there are very few practitioners of the present day who would consider it either safe or judicious.

Although Dr Hope recommends only the cautious abstraction of blood in hypertrophy of the heart, he is by no means sparing of this mode of depletion in the acute affections of that organ. In the treatment of acute pericarditis and endocarditis he advises that the antiphlogistic treatment, in as energetic a form as circumstances will allow, should be employed with the utmost promptitude. If the attack is recent, and tlie patient^s strength will admit, he recommends that blood should, in the first place, be drawn freely from a large incision in the arm of the patient in the erect position, so as to bring him to the verge of syncope. From five and twenty to forty leeches, according to strength, should then be applied to the prsecordial region as soon as the faintness from the venesection disappears and reaction commences. " Unless," he writes, "the pain be completely subdued by these measures, the leeching, and in some cases the general bleeding also, may be repeated two, three, or more times, according to the strength, at intervals of from eight to twelve hours ; or, what is a better rule, as soon as the pulse and the action of the heart denote a commencement of reaction. It is not, however, in every case," he continues, " that so active a treatment is required. I have seen a single, prompt, and abundant application of leeches, or a cupping, at once subdue every formidable symptom."^ Tlie last sentence probably contains the true rule of treatment in such cases, for it is quite conceivable, although not perhaps capable of demonstrative proof, that at the very outset of an acute inflammation, the removal of a certain quantity of blood may so affect the general circulation, and, through it, the nervous system, as to nip the incipient disease, as it were, in the bud.

Bouillaud, writing in 1835, announces as a happy discovery his method of bleeding copiously and frequently in pericarditis ; and he declares that this kind of treatment has been so successful in his hands that recovery has become the rule in such cases and death the exception, while, according to his predecessor and fellowcountryman, Corvisart, death was the rule and recovery the exception. " As a general rule," he writes in his chapter on the Treat-

6 INTRODUCTION

ment of Pericarditis, "in a subject in the prime of life, three or four bleedings from the arm, in the first three or four days, assisted by the application of twenty-five to thirty leeches, or of cupping-glasses, repeated two or three times, will be sufficient to cure the disease."^

There is no physician of our age and country whose opinions have justly commanded more respect and deference, in relation to diseases of the heart, than the late Dr Latham, and in his deeply thoughtful and excellent lectures on subjects connected with Clinical Medicine he thus discourses on the treatment of the acute diseases of the heart. " Bloodletting," he writes, " and mercury, and opium, are your remedies for these dis'eases of the heart ; and so they are for

acute rheumatism, irrespective of inflammation of the heart

Bleeding, mercury, opium., the very remedies you used in acute rheumatism, are, I say, still your main reliance, when inflammation

attacks the heart With respect to venesection, if in acute

rheumatism any of those symptoms referable to the heart are present which have been already mentioned, auscultatory or non-auscultatory, and especially if they have arisen under your own observation, or though not under your own observation, if they be now present, and you have reason to believe that they have recently arisen, then, should the pulse be found to have even a notable degree of that hardness which is deemed inflammatory, blood must be taken from the arm. Should there be any doubt about venesection, any misgiving whether the inflammatory hardness of the pulse is quite enough to require it, let it be employed nevertheless. There is greater hazard in omitting it wrongfully than in practising it wrongfully.''2

This advice was ofi'ered to the profession in 184-5, and it would be easy to quote opinions almost exactly similar in their nature, from most, if not all, of the clinical teachers of that and preceding periods ; and many, like myself, can very well recollect that these doctrines were taught and acted upon in the medical schools of London and elsewhere within the last thirty years. For my own part I can perfectly well remember, as clinical clerk in a London hospital, having, under the directions of my teachers, drawn a large quantity of blood from patients presenting symptoms of acute cardiac disease ; and when afterwards, practising in a large parochial district and in

1 ' Traite Clinique des Maladies du Coeur,' Paris 1835, p. 480. * 'Lectures on Clinical Medicine/ by P. M. Latham, M.D. 1845, vol. i, p. 248.

private cases, I carried out the same kind of treatment on my own responsibility. But I must honestly admit that although I then believed, and do still believe, in the efficacy of bloodletting occasionally employed in certain acute inflammatory and congestive diseases, I never found any very beneficial effects to ensue from this measure in either the acute or chronic diseases of the heart, although, as 1 have previously remarked, when commenting on a passage from Dr Hope, I think it probable that if some blood could be drawn at the very outset of an acute cardiac inflammation, it might cut it short altogether. When acting on the principles formerly prevailing as to the efi'ect of bleeding in diminishing the fibrine of the blood, I bled patients over and over again in acute rheumatism, and was astonished to find, in opposition to the then existing doctrines, that the relative amount of fibrine was in no way diminished, but in many cases was actually increased by this treatment, while the rheumatic affection was scarcely ever improved. As to the venesection obviating the supervention or arresting the progress of pericarditis or endocarditis, I can truly state that, as far as I could observe, it had no perceptible effect in that direction at^all, for cardiac disease often supervened in the cases where bleeding was freely practised, and the inflammation of the membranes of the heart pursued its course although the bleeding was continued.

I am not prepared, however, to state that the treatment by venesection did positive harm in any of the cases in which I practised it, or saw it practised, in this country. The doctrines of Bouillaud, and his merciless evacuations of blood coup sur coup, were never in much favour in Great Britain, and, in the cases I witnessed, the abstraction of blood was practised with a certain amount of moderation and with a definite object. I do not recollect a single fatal case of cardiac inflammation where the result could be considered due to excessive depletion. In many of the cases, however, the persistence of abnormal sounds in the cardiac region after recovery proved that the valves had been permanently affected or that the heart was otherwise damaged.

Most of the patients I have lost sight of, as generally happens with hospital and parochial cases, but several others, whom I attended in private practice, are still living and enjoying good health and engaged in the active pursuits of life, although in some I have since convinced myself that the morbid indications remained and in all they probably exist. Whether such patients would have escaped cardiac complications if they had not been bled is by no means clear, for multitudes of cases of cardiac complications occur where no bleeding has been practised ; but I think it may be stated generally that if any one should repeatedly employ venesection in acute rheumatism or in acute disease of the heart, in the hope of preventing or putting an end to fibrinous effusion in the pericardium or on the valves, he will not only fail in his object, but will probably do much more harm than good, and will exhaust the patient instead of curing the disease.

The change of opinion as to the treatment of the acute diseases of the heart may be very well traced in examining the writings of the late Dr Todd, whose clinical teachings, opposed, as they often were, to the views generally entertained by his contemporaries, were always marked by boldness, independence, and originality, although it must be admitted that some of his theories were pushed too far, and that the practice founded upon them has, in many instances, been carried to a dangerous extreme. It was no doubt useless, if not injurious, to draw away large quantities of blood in the hope of curing acute rheumatism or of obviating inflammation of the cardiac structures, but it by no means follows, therefore, that all inflammatory and congestive diseases and all fevers should be treated by the administration of enormous doses of alcohol, and yet it may be stated, without much exaggeration, that such appeared to be the tendency of Dr Todd^s practice, especially in the later years of his life.

In Dr Todd's Gulstonian lectures delivered in 1843, this physician recommends that the utmost vigilance should be exercised in detecting the first indications of acute cardiac disease in cases of acute rheumatism ; and if any abnormal sounds should be discovered, then the practitioner should have immediate recourse to local bleeding over the cardiac region. A large number of leeches should be at once applied, or a good quantity of blood should be taken by cupping. " I have no doubt," he writes, " that by prompt practice of this kind inflammation of the heart may be checked at its commencement, and as this is the time when the interference of art may be the most efficacious, it is plain how much the future comfort of the patient depends on the vigilance and sagacity of his medical attendant at this juncture."^

1 ' Practical Remarks on Gout, Rlieuraatic Fever, and Chronic Rheumatism of the Joints,' by R. B. Todd, M.D., F.R.S., p. 197.

i

Dr Todd immediately adds^ in opposition to the views of Bouillaud, Hope, Latham^ and others, that his experience leads him to value very lightly the efficacy of general bleeding in inflammation of the heart. He says, " I have never seen an instance in which it unequivocally did goocl,^' and he proceeds to show that many of Bouillaud's cases, as recorded by that physician himself, by no means bear out the views which he inculcates, and that, under the large bleedings practised, the patients suffered repeated relapses or their convalescence was very much protracted.

In a subsequent course of clinical lectures on certain acute diseases, pubhshed in 1860, Dr Todd goes a step further, and condemns the abstraction of blood altogether. In this work, which contains a great amount of sound reasoning, he remarks that two objects are to be kept in view in the treatment of the cardiac aff'ections accompanying rheumatism, namely, to check the morbid process completely, or to restrain it from producing such changes as may prove destructive to the heart; and secondly, to obviate liquid effusions which may distend the pericardium and compress the heart, and so become seriously detrimental to life. With regard to the first point, Dr Todd thinks it clear that bleeding has no power to stop or prevent the formation of the fibrinous concretions which are apt to collect on the valves. He not unaptly regards these concretions as being formed, in a great measure, mechanically, and thinks that they would form around or upon any opposing material, just as fibrine will coagulate round a bunch of twigs by which blood is beaten as it flows from a vein. If such is the mode, therefore, in which plastic concretions are developed on and in the heart in inflammations of that organ, the object of the practitioner ought to be to prevent the development of the altered state of nutrition vMdx precedes the fibrinous formation, and bleeding will not effect this object any more than it will do the same thing in rheumatism. Again, Dr Todd asks whether bleeding will alter the state of the blood which is favorable to the formation of plastic deposits, and he answers the question in the negative. Bleeding, in fact, as is proved by experiments, considerably diminishes the red particles, augments very much the proportion of water, and affects the fibrine very little. He quotes Dr (now Sir Eobert) Christison, who has shown that the amount of fibrine increased under bleeding, and Dr Beale, who showed the same fact in the blood of a dog bled on four successive days ; and I have before observed (p. 7) that I have often noticed the same fact myself.

" If, then/' Dr Todd concludes, " bleeding will not stop the inflammatory state which creates the undue determination of the blood to the pericardial and endocardial surfaces, and if it will not prevent the plastic formations, but rather favours them, surely it is not the remedy for pericarditis and endocarditis. And if the effects of venesection be — as beyond all doubt they are — to diminish all the solids of the blood but the fibrine, and to augment the water, surely the employment of this treatment is fraught with the greatest danger of creating liquid effusions into the serous and synovial sacs, which are so exposed to the action of the rheumatic matter. These are the theoretical grounds on which I object to the practice of bleeding, whether local or general, for the cardiac affections of rheumatic fever, and my experience confirms me in the belief that the practice of bleeding is altogether unsatisfactory in its remedial results and prejudicial in its consequences. I have likewise learned by experience that the practice of abstaining from this mode of treatment is perfectly safe, and tends to the best results." ^

I consider these remarks exceedingly valuable, and I regard the arguments as conclusive against the practice of large bleedings, at least, in rheumatism and acute diseases of the heart, and I think that the general experience of medical practitioners in the present day will confirm the views thus lucidly expressed.

The foregoing remarks are only historical, and the whole question of the treatment of cardiac disease will be discussed in its proper place.

^ ' Clinical Lectures on Certain Acute Diseases,' by R. B. Todd, M.D., E.R.S., pp. 68, 71.