A treatise on the diseases of the heart and great vessels, comprising a new view of the physiology of the heart's action, according to which the physical signs are explained

Front matter

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Preface

I cANNoT dismiss this work without expressing my great obligations to the gentlemen mentioned pages 11, 12 and 15, for the able assistance which they afforded me in the performance and attestation of the experiments.

To Dr. Forbes of Chichester, Dr. Charles Williams, and Dr. G. Julius of Richmond, whose intimate knowledge of diseases of the chest and of auscultation, requires no panegyric from me, I am likewise indebted for many valuable hints and suggestions in the plan and execution of the work.

To Dr. Lombard of Geneva, I have also to express my acknowledgments for the two remarkable cases xxx and xxx1.

J. i.

13, Lower Seymour Street, Portman Square, Nov. 25, 1831.

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Part I

ANATOMY AND PHYSIOLOGY OF THE HEART. Page Cuap. I.—Anatomy of the Heart,, .. .ds+..-.- nhewsil” | Cuap. II.—On the Action, of the Fidabheasdoaxcnelhedoun 10 ‘Sect. Experimental Researches on ‘the Action of A Ces CAT igeaca ee SRM hed WGN ROE 10 “Sect. I1/—Physiological Phenomena of the Heart's s CRONE A. Lai yidnadt arm N el OO nee Rea data lene 39 Sect. I11}+—Pathological Phenomena of the Heart’s LL TE Sg REOER, AE SOE NEP ERE ER Vv Mite titel OO PART II.

INFLAMMATORY AFFECTIONS OF THE HEART AND GREAT VESSELS.

Cap. I.—On Pericarditis... ...0.sessesee jretattuce £88 Sect. I.—Anatomical Characters of Pericarditis..... 84 Sect. 1].—Signs and Diagnosis of Pericarditis...... 96 Sect. I1].—Causes, Prognosis, and Treatment of Pe-

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Sect. [V.—Adhesion of the Bevioundituat Pe toed aha buudiome® Cuap. II.—Carditis, or Inflammation of the Muscular

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Cuap. II].—Inflammation of the Interior of the Heart and Arteries, and the Alterations of Structure con- SOGUOME OME. 06.5 oa oe wins ca iw wed eo wee ed He gle 138 Sect. I.—Anatomical Characters of Acute Arteritis.. 138 A 2 iV CONTENTS:

Page Sect. II;——Anatomical Characters of Chronic Arteritis, : and Diseases of the Coats of. Arteries connected

With, it..cssccos cows ben ons Jo gaicstiogs vi. 155 Sect. II].—Symptoms, Diagnosis, Prognosis and Treatmeit of Artéentisweet, vesoud bas .sa0giotss.1%. 168 PART III.

ORGANIC AFFECTIONS OF THE HEART AND

GREAT VESSELS.

Caar. 1.—Hypertrophy, of the Heart... ...0.0cecsceveccoo eles 176 Sect. I.—Anatomical Characters with Classification

and Nomenclature of Hypertrophy ............. 176 Sect. I].—Mode of Formation with the predisposing and exciting Causes of. Hypertrophy............8. 187

Sect. I1J.—Order of Succession in which the several —. Compartments of the Heart are. rendered Hypertrophous by an Obstacle before them in the Course of fie. Circulation . wusoh so oeGn Ue eet Cee eon 195

Sect. [V.—Pathological Effects of Hypertrophy, and Mode of their_ProductionwisY.3o iaamigailseL¥ . 201 Sect. V.—Signs and Diagnosis of Hypertrophy. .... 212 Sect. VI.—Progress, Terminations and Prognosis of Hypertrophyjaiscisks Io- tgs bee . PIAL 231 Sect. VII.—Treatment of Hypertrophy.........6.% 238 Cuap..1].—Dilatation of the Heart ............000% ‘248 Sect. I.—Anatomical Characters with Classification and Nomenclature of Dilatation. .......0...... 248 Sect. I1.—Mode of Formation, with the predisposing and exciting, Causes of Dilatation ...... wear Fl, 254 Sect. IIJ.—Pathological’ Effects of Dilatation and Mode of their Productions d. 36 ésemwant. Je eoilon 258 Sect. [V.—Signs and Diagnosis of Dilatation ...... 265 Sect. V.— Progress, Terminations and Prognosis. of Pitataton tt i oe he RL ae 277

CONTENTS. Vv

9 Page Cuap, Il],.—Partial Dilatation or real’ Aneurism of the Heavinaoo. vaizatiA, Jo. etaon al, 2 1. B88 ei D9 285 Crap. 1V.—Softening of the Heart... cecverereee ees 287 Cuap. V.—Induration of the Heart....... WY Cirs ad £4 ODDS Cuar. VI.—Adipose and. Greasy Degenerations of the UCARGry fe OTe: 2. Nh Rb tare e a Gane 298 Cuap. VII.—Osseous, Cartilaginous and other accidental Productions of the muscular Substance of the Heart and of the Pericardigm « au 6553S RA “bldeh eH Oe « 301 Cuapr. VIII.—Atrophy of the Heatt, .....6..c0s0e0. 305 Cuap. [X.—Diseases of the Valves and Orifices of the Heart......0c0ca ar oe JKGOH, ot To. ydadongyH——.t, 307

Sect. ..—Anatomical: Characters, with predisposmg and exciting Causes, of Disease of the Valves... .. 307 Sect. I1.—Anatomical . Characters, and. Causes: of

Warty Vegetations:of the Valves (20) SP Ra 319 Sect. III.—Pathological Effects of Disease of the Valves, and Mode of their Production. .......... 324 Sect. [V.—Signs and. Diagnosis of Disease of the WV alyeS cows onenwaeinw nant een ves tops US 328 Sect. V.—Asthma from Disease of the Heart ....... 345 Sect. VI.—Treatment of Valvular Disease.......... 365 Cuap. X.—Aneurism of the Aorta........ 5.0.00... 386

Sect. [L—Classification, Nomenclature, Anatomical Characters. and Formation of Aneurisms of the

Barta ce ope 9 eV 9Q0 RIFE t ee han go eow ae 386 Sect. I].—Pathological Effects of Aneurisms of the

Aortasomieontibuouy Parisian? . SMOSe a Te. 403 Sect. IJ].—Signs. and dues of Aneurism of the

Sect. 1V.—Synopsis of the Piidedk in ausilivetoh with the General Signs, im reference to the several “varieties of Aneurisms of the Aorta.........00... 432 Sect. V.—Spontaneous Cure and Medical Treatment of Aneurism of the Aorta, and Treatment of Nerv1 CONTENTS.

PAB TY, IV: NERVOUS AFFECTIONS OF THE HEART.

Cuap. I.—Neuralgia of the Heart or Angina Pectoris.. Cuap. I].—Palpitation, particularly Nervous ........ SPA P.. LIL =-SyMCOPe ose re oon cence ts ta Pacoe he acuta tae8h%b"eta"SoEhye Me : PART V.

MISCELLANEOUS AFFECTIONS.

Cita p.\1+—Polypus of the: Hearty ss Cuap. I].—Displacements of the Heart ............ Cuap. Il].—Hydro-Pericardium .......0.......... Cuap. 1V.—Pneumo-Pericardium................. PART VI. (oT ee) Sa eer a boer MnO enol mep ay ters: SFC BOOP ICAL ADEN «oc soled eslalieiers eiviei te eaceote eases an ft oy oNFE pay fappteliaade Order ATE’ iy Be pla ALPHABETICAL INDEX, Pome ofan tA udned TE CASES.

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Introduction

Doubts of the profession respecting the applicability of auscultation to the diseases of the heart, xi. These doubts not without foundation, xi. Sketch of the deficiences left by preceding writers: viz. Incorrect view of the action of the heart by Laennec, xii. Error of attributing the same symptoms to all its diseases andiscriminately, xii. This error partly corrected by MM. Bertin and Bowllaud, but their generalizations not perfectly accurate, xi. Errors in auscultation resulting from the incorrect view of the heart’s action, by Laennec, xiv. Murmurs and purring tremors of the heart and arteries independent of organic disease, attributed by Laennec to a wrong cause, xv. The more accurate doctrines contained in his first edition retracted in his second, xvi. Murmurs and purring tremor, from whatever cause, attributed by the writer to modifications in the motion of the blood, xvi. Diagnosis facilitated by this view, xvi. Researches of preceding Authors on the signs of Aneurism of the Aorta, pericarditis, and polypi in the heart, inconclusive, xvi. Treatment of diseases of the heart open for improvement, xvii. Neglected by Laennec, xviii. Too cursorily treated by Bertin and Bouillaud, xvii. Principles of the latter not always perfectly sound, xvii. Writer has therefore attended particularly to the treatment, xix. Reply to those who despair of improvex INTRODUCTION.

ment in treatment, xix. Direct improvements described, xx. Collateral improvements in reference to. apoplecy, xx. To disease of the heart imitating dyspepsia, .XXxi. To dyspeptic and nervous affections unitating disease of the heart, xxi. To asthma and dropsy, xxii. To rheumatism with pericarditis, xxii. To enlargement of the liver and abdominal dropsy, xxii. To all febrile and inflammatory affections connected with disease of the heart, xxii. Opinion of Senac as to the importance of studying diseases of the heart, xxiv. Plan of the work, xxv. Symptoms and morbid anatomy studied as cause and effect, xxv. Mode in which the cases were collected, xxvi.. At what hospitals, xxvu. Intentional repetitions adverted to, xxvii. Superfiuous minutie suppressed, xxix. Views respecting asthma, xxix. Comparative value of general and physical signs, xxx. —

PRECEDED by names so distinguished as those of Corvisart, Kreysig, Burns, Laennec, and Bertin, 1am sensible that I expose myself to the imputation of presumption, in offering to the profession a new treatise on the diseases of the heart and great vessels. I feel called upon, therefore, to explain, in a more circumstantial manner than I should otherwise have wished, the motives which have induced me to undertake this work, and the plan which 1] have pursued in its execution. Whether Lam justified in the attempt I can scarcely form an opinion. Iivery author contrives, I believe, to persuade bimself that the work which consumes his own midnight oil, is precisely the one that is wanted. It is for the reader to

INTRODUCTION. xi determine whether I labour under the delusion common to my brethren.

Notwithstanding the strong light diffused over the diseases of the heart by the researches of. the above-mentioned authors,—-notwithstanding the brilliant sunsbine emanating from the discovery of auscultation by Laennec,— a discovery, which, according to M. Bertin, “has, in a few years, more completely illumined the diagnosis of the diseases in question, than all the other modes of exploration had done for two centuries;” the great body of the profession still deny that the piercing ray has reached its destination, still doubt the utility of auscultation in reference to the primary organ of the circulation, still find the ordinary symptoms beset with their accustomed difficulties, still complaim, in short, that the obscurity which involves the diseases of which we speak, is scarcely less profound than ever :* and, while conflicting opinions are embarrassing the jadgment, and undermining the confidence of the patient investigator of truth, there is a general outcry for an additional mass of well attested evidence, which may bring the subject to some kind of a conclusion.

* A distinguished Frenchman recently said to me, ‘‘ Monsieur, je ne crois pas, pour vous dire la verité, que l’on puisse en faire le diagnostic—que sur la table du salon.”

Whee

Xl INTRODUCTION.

It rarely happens that a general. impression is wholly unfounded: nor is. it, if I mistake not, in the present instance... Authors. actually have not succeeded in completely redeeming this subject from its obscurity... Errors remained to be corrected, deficiencies. to be supplied, inconsistencies to be reconciled: the subject—a confused and _ incongruous mass, required to. be moulded and compacted into a symmetrical and harmonious whole, the parts of which, tewsh perfect in themselves, should, by their justness of proportion. and unity of design, afford relief and support. to each other.

I proceed to glance briefly at the subjects where the principal defects appear to have resided ; and this I do, not only for the purpose of general guidance to the student, but also for that of pointing out where I have differed from preceding writers. In these differences, 1am anxious to offer my opinions, not as established facts, though I trust that they will be found grounded on careful observation, but simply as propositions to be admitted or rejected according to the test of general experience. J.am satisfied that, in our profession more especially, where there are few fived points to constitute the basis of an inductive process, nothing is more difficult to ascertain than a general. fact. Innovations, therefore, cannot be regarded with too much suspicion, cannot be scrutinized with

INTRODUCTION. Xi too much’ severity, cannot be received with too much Caution and reserve.

The most prominent error which reigns throughout the doctrines of Laennec, and which has prevailed in the schools ,since the first publication of Ins work, 1s, that he mistook the nature of the action of the heart. I trust that the view which I have ventured to substitute may be found more satisfactory ; and, as nearly a year and a half has elapsed since | first published my experiments and clinical observations relative to it: as my conclusions have, throughout that period, remained, so far as I can judge, uninvalidated; and as J have recently repeated the experiments with the same results, before a number of the most distinguished physiologists and _ pathologists of the metropolis ¥ I hope I shall not be considered’ precipitate in having taken the decisive step of modifying and explaining all the physical signs of disease of the heart according to the view in question” ; ~ Laennec and his predecessors have assigned to diseases of the heart a certain series of symptoms, which they conceived to be common to the whole; ‘but they had not analysed those symptoms and ascertained which were peculiar to, and pathognomic of, the several affections taken individually. MM. Bertin and Bouillaud,

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XIV INTRODUCTION.

both writers of high talent, made this attempt, and with partial success; but the spirit of generalization, (if I am correct in my own views;) carried them a grade too far. What observation leads me to regard as an inaccuracy, constitutes the hinge of their work—the pivot on which turns the principal train of their reasoning: namely, that the symptoms of a retarded circulation are, under all circumstances, the result of a mechanical obstacle to the course of the blood :—that when, for instance, they accompany hypertrophy or dilatation, they are not consequences of these affections, but of some co-existent mechanical obstacle, as a contracted valve, an aortic aneurism, &c. Ihave attempted to show, not only that hypertrophy and dilatation can, of themselves, respectively occasion the symptoms in question; but, that dhese symptoms are seldom produced in any very remarkable degree of severity by a mechanical obstacle, unless hypertrophy, dilatation, or softening of the heart is superadded.

It may naturally be supposed that the erroaction, led to corresponding errors in his doctrines ofauscultation. Yet these are, fortunately, not of such magnitude as might be expected. With one exception—that of considering loudness of the second sound: to be an indication of dilatation of the auricles, the errors are those of ot uf

H i f U ee f A INTRODUCTION. iz XV omission, and of incerrect explanation. The omissions are considerable and important. He was not aware of a fact noticed by the writer several years ago,.that bellows-murmurs are produced by regurgitation through the valves. This oversight alone naturally shook the confidence of many, and eventually of himself, in his theory of valvular murmurs. For, the lesion being found in one valve, when, according to that theory, it was expected in another, the inevitable conclusion was, that the theory was incorrect. At the same time, the cause of the murmur remamed doubtful. hoy The perplexity was further increased by the existence of murmurs independent of valvular disease, and accompanying both hypertrophy with dilatation, and a nervous’ action of the heart: without any organic lesion whatever. These murmurs Laennec attributed to a wrong cause: viz. to the sound of the muscular contraction, instead of to the modified motion of the fluid; which I presume to consider the true cause. Hence, he was unable to analyse and foresee the circumstances under which nervous murmurs should occur, and, consequently, to distinguish them from those occasioned by valvular disease.

Several minor phenomena likewise, as the

‘purring tremor, and the arterial thrill and bellows-murmur, he was, in consequence of the

Xvi INTRODUCTION.

confusion created by the error in question, equally unable to explain. Hence, he vaguely attributed them to some unknown ‘modification of the nervous action.”

It cannot be a subject of surprise that, saith the above opinions, acquired chiefly during the latter period of his life, he should have retracted, in his second edition, the much more accurate doctrines respecting bellows-murmur as a sign of valvular disease, which he had advanced in his first ;—transmitting to his disciples the confusion which reigned in his own mind, but which, like the storm that, in tropic climes, is the precursor of the purest, brightest weather, must, sooner or later, had his life been spared, have rolled away before the irresistible force of his purifying and enlightening genius.

The murmurs attending valvular disease, hypertrophy with dilatation, nervous action of the heart, reaction from loss of blood, (pericarditis;

vand_ adhesion of the per icardian; also the allied phenomena of purring tremor, arterial thrill, throb, and murmur, I have attributed to modifications in the motion of the blood, and ex-

plained according to the laws of hydraulics and — acoustics. In this way, not only may organic diseases of the heart be readily and certainly distinguished from nervous and other affections wearing their aspect, but, with attention to certain rules which I have offered respecting the

INTRODUCTION. KVI situations where valvular sounds are to be explored, and to certain corroborations derived from general symptoms, the particular valve diseased may in general be detected with precision. Such, at least, are the conclusions to which I have been brought by a very considerable number of cases, a small proportion of which are appended to this volume.

The investigations of Laennec on aneurism of the aorta, were limited and imconclusive: accordingly, he remarks that, “of all the severe lesions of the thoracic organs, three alone remain without pathognomonic signs to a practitioner expertin auscultation and percussion,—namely, aneurism of the aorta, pericarditis,,and polypi in the heart previous to death.” It hope that my attempts to throw light on these subjects, may not be found entirely fruitless. The article on aneurism is the substance, with considerable additions, of a series of essays published in the Lond. Med. Gaz. Aug. 22, 1829, and is founded on nearly forty cases in which the diagnosis was verified by post-mortem examination.

The treatment of diseases of the heart offers a spacious field for improvement. Previous to the discovery of auscultation, these maladies could seldom be detected before they were so far advanced as to be incurable; and then was not the time to judge of the efficacy of remedies. Laennec, absorbed in his investigation of the

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XVI INTRODUCTION.

diagnosis, paid comparatively little attention, to the treatment. His first edition scarcely alluded to it: in the second it is ouly cursorily treated. Bertin and Bouillaud are not more satisfactory, —giving a bold outline of leading principles, such as might be struck out by generalization in the closet, but seldom descending into those detailed delineations of therapentic measures, which are essential to the practitioner at the bedside. |

Nor. are these principles always, perhaps, perfectly sound. Their habit of attributing the symptoms of a retarded circulation, under all circumstances, to one cause only,—a mechanical obstacle, gives a wrong bias to the mind ; and that of eutwining inflammation with the cause of almost every organic lesion of the heart or great vessels, is replete with danger to the inexperienced. practitioner. While I feel bound to say this, (for it is the duty of a writer to point out the path which is insecure, no less than that which is safe,) let me not be supposed _to detract from the singular merits. of these authors; let me offer my tribute of admiration to the talent which shines through every page of their elegant and scientific work, and.-acknowledge the extensive obligations that owe it in the execution of my own.

Conscious of the gap that was presented in the treatment of diseases of the heart, I have

INTRODUCTION. XIX devoted more attention to this, than to any other department of the subject: availing myself, in particular, of the wide and favourable sphere for observation, afforded by a long residence as House Physician and Surgeon successively, in the Royal Infirmary of Edinburgh; where living, literally, | may say, as well as figuratively, at the bed-side of the patient, I had an opportunity of closely watching every habitude and phasis of the disease—every operation and effect of remedies. The result of these researches were submitted in a memoire to the Royal Medical Society of Edinburgh, in the year 1824-5, Many think that the expectation of effecting an improvement in the treatment of diseases of the heart, is chimerical: and they think so because, not being accustoined to recognise the diseases in question before they haveattained an advanced stage, they are pre-occupied with the old and popular idea of their incurability. To such it “might, perhaps, be a sufficiently philosophical! answer to reply, that an improved knowledge of the nature and causes of a disease, must alone necessarily lead to an improvement in “the treatment; and that therapeutic weapons ‘are dangerous when wielded in the dark. But here we may go much farther: we may say that, by the improved means of diagnosis, the maladies “under consideration may be recognised, not only in’ their advanced, but in their incinient

XX INTRODUCTION.

stages, and even when so slight as to constitute little more than a tendency. We may say on the grounds of incontestible experience, that, in their early stages, they are, in a large proportion of instances, susceptible of a perfect cure; and that, when not, they may, in general, be so far counteracted as not materially, and _ sometimes not at all, to curtail the existence of the patient. We may, accordingly, predict that the term ‘“‘ disease of the heart,” which at present sounds like a death-knell when uttered by the physician, will hereafter become by familiarity not more alarming than the term asthma, under which it is frequently disguised.

Such are the direct practical improvements to be expected from a_ better knowledge. of diseases of the heart. But there are collateral ones of no less magnitude. It has been stated by M. Richeraud, repeated by Bertin, and echoed by all who are conversant with this class of maladies, that ‘“ hypertrophic enlargement of the heart is more closely allied to apoplexy and palsy than the apoplectic constitution itself.*

Should the hypertrophy be recognised, its effects on the brain may be counteracted by — judicious treatment: should it be overlooked

* This constitution consists, according to the popular idea, in a broad, robust frame, full habit, and florid complexion. It is in general attended with an unusual size and thickness of the heart.

INTRODUCTION. - XXI the patient, with a view to reducing his apoplectic fulness of habit, is ordered smart exercise, which, by increasing the action of the heart, already too powerful, causes a preternatural determination of blood to the brain and induces the apoplectic or paralytic seizure. _ According to evidence hereafter to be adduced, the majority of those who are prematurely cut off by apoplexy in the apparent enjoyment of good health, sink under the circumstances described.

Again, there are few more common = and certain exciting causes of palpitation and difficulty of breathing in disease of the heart, than derangement of the stomach. What happens to the patient in this case? Tracing the attack, in perhaps every instance, to a dyspeptic fit, he naturally concludes that the latter is the cause: that it is “all indigestion.” “ Good air, and plenty of exercise” are the remedies recommended: the result is an apoplectic seizure. The circumstance that before the introduction of the new mode of exploring diseases of the heart, they could rarely be detected in their early stages, contributed to the error in question. For, as patients frequently recover from the early stages, the recovery was regarded by those who assumed this class of diseases to be incurable, as a proof that the affection was merely dyspeptic. Hence dyspepsia acquired the reputation of producing certain symptoms, particularly in the head, which are in realitv

XXI INTRODUCTION.

foreign to it, being exclusively the results of a co-existent disease of the heart. si

‘There prevails another error, the converse of the above—that of mistaking nervous, or really dyspeptic palpitation, for disease of the heart. The frequency of cases of this kind, especially amongst men of studious habits, (and more particularly, I have noticed, among those of my own profession,) is truly surprising; and, as it has always been considered difficult, and by many impossible, to distinguish the two affections, the alarm created is sometimes distressing. Having thought this subject of so much importance as to demand a separate article, I shall here only say, that, so far as my own experience enables me to judge, the discrimination may be made with ease and certainty.

An immense proportion of asthmas—and of the most dangerous and distressing cases, result from disease of the heart: the same may be said of dropsies, especially those that are universal. If the cause be overlooked, the asthmatic is harassed with a farrago of inappropriate and unavailing, not to say pernicious remedies; and the hydropic is treated with dangerous activity; or for imaginary affections of the liver, the lungs, or the kidnies. On the other hand, if the cause be detected in the incipient stage, by precautionary measures both the one effect and the other may in general be prevented.