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[ 
 
ORGANIC HEART DISEASE. 
 
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 BY 
 
 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. 
 
 BY 
 
 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. ' ■■ ■. 
 
2 
 
 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 
 
3 
 
 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. 
 
5 
 
 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. 
 
6 
 
 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.