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[

ORGANIC HEART DISEASE.

SIE JAMES GRANT, M.D., F.R.C.P., (Lond.),
Consulting Physician, General Hospital, Ottawa.

(Reprinted from Montreal Medical Journal, December, 1897.)

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ORGANIC HEART DISEASE.

Sir .lAMi-a Grant, M.D., F.R.C.P., (Lond.),
Consulting Physician, General Hospital, Ottawa.

I thank you for the opportunity of making a few obsers ations on
the heart and organic cardiac diseiiso this evening. Foster says the
heart is a vtilvular pump, which works on mechanical principles, the
motive power of which is supplied by the contraction of its muscular
fibres. The frequency, force and character of the boat, with a given
quantity of blood ejected at each beat, ai'e the problems involved in
mechanical action. The vital problems are chiefly associated with
the correlation of the forces controlling the frequency, force and char-
acter of the beat. Cardiac impulse is found to be synchronous with
the systole of the ventricle, and is felt in the normal state on the fifth
costal interspace, about an inch below and a little to the median side
of the left nipple. To trace out the entire list of organic cardiac
diseases I feel confident is not the task assigned to me this evening,
but rather to confine my observations to a few lines of thought, as far
as the generalities of cardiac diseases are concerned. This centre of
circulating vital force, charmed into action during the stage of utero-
gestation and continuing into the seventies, eighties and nineties,
uninterrupted, is a subject attractive beyond expression, and wrapped
in the self-same mysterious agency, which guides and directs the pro-
cesses of vitality as a whole. The chief line of thought for this even-
ing's remarks will be as to the bearings of chronic heart disease on
the parturient system. The effect of two hearts operating at one and
the same time, in the same system, is a subject calculated to attract
attention, md chiefly on account of the exceedingly important issues
at stake. The physician in every day pi-actice and the physician
accoucheur, rarely in our larger centres, have an opportunity of fol-
lowing up consecutively, the entire manifestations of such abnormal
cardiac conditions. Such, however, is not the case in smaller centres,
where the entire rationale of such manifestations can be followed out
consecutively. First, then, what are the normal changes occurring in
the heart during pregnancy ? The first great question in cardiac
disease during the parturient period, was raised by the French school.
Whether the left ventricle of the lieart does or does not normally

1 Read before the Medical Society of Ottawa, Nov. 10th, 1897. ' ■■ ■.

hypertrophy during pregnancy. Larchor in 1825 and 182(5, while
serving as interne in tlie Paris Maternity Hospital, first directed atten-
tion to the fact that the left ventricle of the heart normally becomes
hypertrophied during pregnancy. He examined during three years
fully 1,'W hearts of patients who tlied at the hospital, the majority of
them of child-bed fever. The ages of the patients varied from 18 to
85 years. From his observations he concluded that the heart in the
human species is normally eidarged during the perio<l of gestation ;
that the enlargemeno affects almost exclusively the left ventricle ; the
left auricle ; the right side of the heart being little if at all changed,
and la.stly that it varies in amount, from a minimum of one-quarter of
the normal thickness of the ventricle to a maxinuim of one-third of
it ; that it constantly occurs and that it disappears but slowly during
the period of lactation. Larcher also iuclin(td to the belief, that
repeated pregnancies, within short periods, particularly if at the same
time they suckled their children, might give rise, even in a perfectly
sound heart, in all its openings, to permanent hypertrophy. It is now
a well recognized fact, that the pregnant condition modifies and
affects the conditions of the collective blood vascular system in a
most important manner, influencing thus very materially diseases of
the lungs, kidneys, etc., existing at one and the same time. Larcher's
views were first published in 1828, and a full record was addressed to
the Academy of Science, Paris, April 6th, 1857. This subject attracted
very considerable attention and investigation, at the hands of Drs.
Bean, Ducrest and Bizot, who fully endorsed tlie views of Dr. Larcher
and give the mean thickness of the left ventricle as averaging from
1.0 per cent, to 1.5 per cent, and 1| per cent. Dr. Blot did not con-
fine his observations to measurements of thickness alone of the walls,
but by an examination of 12 hearts of women who died during preg-
nancy, in the lying-in-period, he found the average weight to be 9
ounces 38 grains troy weight, whereas the average weight of the
healthy heart of young women is about 7 ounces 120 grains troy
weight. It would thus appear, according to Mr. Blot, that the heart
of the pregnant female gains in weight fully r^uring pregnancy, and
that the hypei-trophy js confined almost entirely to the left ventricle.
Dr. Fritsch the great German authority (Archives of Gyncecoiogy) is
inclined to doubt the statements of the French authorities and to
explain a considerable amount of the increased dullness, by upward
and forward displacement of the heart, ti-om the pushing of the dia-
phragm, and also inclines to the belief, that the statements of the
French authorities as to increased nmscular tissue, in the left ventricle
during pregnancy, are considerably overdrawn. Fritsch although

julhoring partially to the vit-w that there is normally some cnlarge-
iu(!nt durinj^f projfiuiiicy, is somewhat skeptical as to eccentric hyper-
trophy of the muscular tissue of the left heart, and inclines to the
belief that a passive dilatation of the orj^an, of a slight amount, is
sufficient to account for the necessities of the case. This same author-
ity makes a statement somewhat contradictory, that in jjeneral the
hearts of lying-in-women, on post-mortem examination, appear larger,
yet one would recjuire to take accurate weights and measurements of
them. In my huudile opinion, conclusions accurate in characte* can-
not be arrived at, without both weight and measurement, such as the
French authorities Iiave most carefullv T^"vformed. Herman Loblcin
meets Blot's deductions from the incrt^ased weights of hearts of preg-
nant woujen, by the results of an examination of the hearts of 9
women who had ilied in tin- Gyuieeological t'linicpit^ at Berlin, during
tlie previous year. ])eath in these eases was due to rupture of the
uterus, or some other acute cause, terminating life witliin a few days
after delivery. The average weight of these hearts, he found to be
247 grms ; while according to Blot, the weight of the heart of the
pregnant female, is to that of the non-pregnant female, as 290.95 to 220
23 grins. He argued tliat the average weight of the hearts of preg-
nant females would be found not greater than the average weight of
hearts of non-pregnant females. He argues that authors in maintain-
ing the existence of hypertrophy of the left heart, have clinically
bestowed too exclusive attention to the cardiac dullness, which from
the upward displacement of the heart in t'le course of the pregnancy
is specially liable to mislead, and have not noticed whether the cardiac
impulse was found to be intensifietl, the first .sound at the apex spec-
ially loud, tlie .second aortic sound accentuated, the radial pulse hard
and difficult t': compress, or whether the open beat was thrown out-
wards and downwards, from its normal situation. ])()ul)tless (says
Loblein) the absence of all clinical .symptoms, by which we recognize
tlie hypertrophy of the cardiac nuiscle, is the rule at the end of the
normal pregnancy ; its occurrence on the other hand he considers the
exception. Still notwithstanding the strong negative statements of
Loblein, Professor Angus Macdonald of Edinburgh says he cannot
help feeling convinced that in the latter months of pregnancy in the
case of women with normally sized hearts, there is a certain amount
of such hypertrophy. Peacock in his tables of the weight of the
healthy hearts of females dying between the ages of 20 and 55 years,
fai^ours the doctrine of there being a certain degree of hypertrophy
in the heeirts of parturient females. CoUvSidering the entire circum-
stances, a certain amount of cardiac hypertrophy, is very likely, by

the existence of greater work for tlie heart to perforin during prejj;-
nancy, and more particuhirly as there is an undoubted arterial tension
in tlie latter months of pregnancy, as has been ably demonstrated by
the sphygiuograph in the hands of Mahomed, Meyburg, Marey, and Blot
(Archives of Gynmcoloqy). What stronger evidence could we desire
as proof of exulted venous tension, than the various varicosities during
pregnancy, which point to abnormally high tension during the par-
turient period. The abnormal demand for blood at that time, and the
circulation in the heart in a given period, gives rise to a demand for
increased cardiac force, as the result of which, an hypertrophic cardiac
condition, such as aV)ly defined, might very naturally follow. After
careful analysis of the literature on this subject I am disposed to
accept the opinion, that we have reason to believe, that in the left ven-
tricle during pregnancy, there is a certain degree of increase in its capa-
city, associated with a variable amount of muscular hypertrophy in its
walls. The parturient state is one marked by well defined .systemic
changes, and in the development and progress of such it is well to
note the part played by cardiac action, when any abnormality is
known to exist. The successful issue in a case of pregnancy depends
much on watchfulness through the entire period of uterogestation,
and it becomes even uch more so if any line of diseased action is
known to exist. The correlf.Lion of the forces as to the mutual bear-
ings of cardiac disease and pregnancy are all inlportant. Hecker
{Leipslg Clinic 18G0) states, that the danger to women who suffer from
valvular lesions, determined by pregnancy and parturition, is capable
of developing itself in two directions. First, during the latter months
of pregnancy, the thoracic space is narrowed, and the lungs, em-
barrassed by cardiac lesion, frequently become functionally unable
through serous effusion, and life's activity closed ; or the heart becomes
so used up by the exertions of labour, that its disturbed mechanism
comes to an end. Hecker, Dohrn and Fabiu.: (of Leipsig) incline to the
belief, that while the perpendicular axis of the thoracic cavity is
diminished during the latter months of pregnancy, and likewise its
an tero- posterior axis, at the lower part of the cavity, the tranverse
diameter is at the same time much increased, so that as a whole, the
cavity is not at all oi very triflingly diminished, except some patholo.
gical condition is present, such as abdominal or chest dropsy. The
important fact is that the general belief of the profession inclines to
the idea that the diminution in vital capacity of the lung's condition
by normal pregnancy is very immaterial indeed.

Of the many authors who have written on this subject by far the
most original and important observations have been made by Prof.

Spiogelherg in 1871-72 (Medical Union — Lecturo l)y Peter, Hospital
do la Charit6, Nov. 1871). "I wisli to speak to-day of facts of which
" the authors of treatises on diseases of the lieart, have left in the
" shaile, and which authors of treatises of obstetrics seem to nie to
" have entirely forgotten ; tho.se facts are tht; pulmonary accidents to
" which pregnancy exposes women ati'ected with ili.seaaes of the heart."
He recommends the greatest care as to movements and exposure, sup-
posing a patient with heart disease becomes pregnant, the avoidance
of pregnancy in -future, and avoidance of lactation in all cases as well
t' escape any abnormal strain on the heart. Fritsch deni'-.-i the cor-
reciuK^ss of Spiegelberg's views relative to diminished aortic tension.
He is of opinion that the sudden accidents that arise fron> heart
disease during child-bed, are due to defective cardiac compen.saticm,
being unable to meet the conditions introduced by the suddenly altered
relative pressure, although he disagrees with Spiegelberg as to the
manner in which it acts. The healthy heart can meet these extra
requirements but the diseased organ suffers from imperfect power of
accommodation to the demands upon it. Valvular lesions are very
apt to be altered for the worse during pregnancy, of which we have
evidence in the readiness Arith which pregnant women with unsound
hearts, suffer from puerperal endocarditis. An important conclusion
arrived at by Spiegelberg is, that the placental circulation is capable
of giving little obstruction to the general circulation, but may operate
injuriously with other evil influences, such as compression of the
chest, bronchitis, pneumonia or pleurisy, in aggravating the evil effects
of even a slightly dilated right ventricle. Of fifteen cases of labour,
complicated with heart disease which he treated, only one of the
patients died during delivery from pulmonary oedema. He comes to
the conclusion that in most cases of heart disease death does not take
place during delivery. From all the facts I have been able to bring
before you this evening it is evident that pregnancy is likely to intro-
duce serious complications in the condition of a patient suffering from
chi'onic heart disease, except the lesion is not of very recent origin,
which is a very extenuating circumstance.

Professor J. H. Musser of the University of Pennsylvania, in his
recent address before the British Medical Association, Montreal, called
attention to one of the most interesting and attractive points in car-
diac disease, namely the disappearance of endocardial murmurs of
organic origin. It is the permanency usually of organic heart disease
which serves to distinguish between the murmurs of anaemia, or of
incompetency from dilatation. It has however become a well recog-
nized fact, that organic murmurs often appear and disappear from
various circumstances, such as change of position and rest.

Evon tiomporary disappoaranco of the niurmur is believed to be duo
to tlie extreme dilatation, and conse(|uent debility ot" the heart nmsclo.
Aortic iiiurniurs rarely ilisappear under such circumstances.

It is to this chiss of cases of heart disease, without njurmur, that
Fiig{?e applied the term " Santly desert of cardiac pathology. " That
the murmur of mitral obstruction may be temporary or permanent,
the clii authorities on cardiac disease favour this view, ami Osier
adverts o the disappearance of nnn-mur with rupture of compensation.
Di'. Gee favours the idea that even in aortic regurgitation in which
organic murmur is the most peristent, the sound producing power
may disappcuir when the heart falls into a state of systole. There are
also various pathological conditions which govern valvular ImMuatic
action, all of which render the subject most attractive. The sound
produced by even miti'al regurgitation, has been'known to be wanting,
disappearing suddenly in ihe most unexpected manner. Such nuir-
luurs tlisappearing are usually inorganic. Walsh has {)ointed out the
<lisappearance of this murnuir in chorea. The irregularities in mitral
regurgitation so far noted, are connected with some organic heart con-
<lition, and modified or otherwise by the peculiar circumstances of the
case.

The disappearance of endocardial murmurs cannot be observed too
cautiously, in forming an opinion as to the existence or non-existence
of organic disease. Sansom (British Medical Journal, Oct. 1(5, 1897)
states that the signs of structural disease of the heart have borne no
proportion to the degree of cardiac tumult, and that in every such
case there should be a careful investigation of the nervous .system,
more specially in its relation with the cardiac reflex. The most
fre(|uent form thought to be almost entirely nervous is tachycardia,
which 1 have found usually paroxysmal in c'.iaracter. I wish to refer
briefly to tlu; mountain cure of heart ilisease. In March, 1887, at
Leeds, Dr. Clifford Allbutt called attention to the growing practice of
recommending exercise rather than perfect rest, in some cases of heart
disease, and described the German plan of graduated exercise by
ascending hills, known as the mountain cure. Dr. Allbutt remarked
that ,cases for this treatment must be very carefully selected, as such
treatment should be avoided in cases of aortic regurgitation or atrophic
conditions of the heart.

In conclusion let me say, there is an impression with the public,
that disease of the heart usually means sudden death, to the person
so afflicted. Such however, has not been my experiene*:, and the
following case, I now cite as an illustration of that fact.

J. S., aged 36 yeoi's, of robust habit of body, active, energetic and

able to omlure almost any (lejrroe of physical exertion, heiiifi; known as
an expert skuller, of healthy parentage, and no tendency in family to
hereditary disease. Thirty-four years ago the late Dr. C'amphell of
Montreal, diagnosed cardiac disease in this case. From 1880 to 1892,
he had perioilic attacks of acute rheumatism and erysipelas, chieHy of
the scalp and legs. When Jirst examined, I fi)und well detined mitra]
stenosis with cardiac murmurs audible in almost any part of the
chest, hut most acutely in the pericardial region. To have lived such
a length of time, and performed his usual otHcial duties, as an archi-
tect, was to me a subject of nnich interest, and the conclusion arrived
at, is, that in cardiac disease caution should be exerci.sed in giving a
positive oj)inion, as tt) the inability of the individual under such cir-
cumstances. In the present ca.se, it is evident the abnormal changes,
giving rise to tiie murmurs v.'cre very slow and progressive in char-
acter, having taken fully liO years to conipromise seriously the integ-
rity or function of the mitral valves.

niBLIOGRAPHY.

General Medicine, Flint, Watson, Dennett, Reynolds, Osier, Roberts, Pepper,

Latham, Gee, Walsh.
Foster'b Physiology.

Report New York State Med. Ass. No. 9, 1892.
Heart Disease in Pregnancy, Maodonald, Ed., 1878.
British Med. Journal, 1897, Musser.
British Med. Journal, 1897, Sansoin.
Braithwaite's Retrospect, 1887, Allhutt,
Thomas, Diseases of Women, 1887.
Skene, Diseases of Women, 1887.