GAILLARD'S MEDICAL JOURNAL. VOL. LXVII. NEW YORK, SEPTEMBER, 1897. ORIGINAL ARTICLES. No. 3. THE KNOWLEDGE OF HEART DISEASES IN THE XVIII CENTURY.* Assistant Visiting Physician to Mount Sinai Hospital, New York City. In choosing this subject for my paper I was actuated by two motives: (1) To give a general, although brief, sketch of what was known of diseases of the heart in "pre-stethoscope" times, and especially in the early part of the XVIII century; (2) as a corollary to this, to recall how much may be accomplished by means of well-directed observation and a correct appreciation of manifest and simple signs. In our time, when instruments of precision are so extensively employed; when percussion, the various stethoscopes, sgphymographs, cardiographs, etc., are at our disposal; when general laws of hydrostatics and dynamics have been called upon to explain the various phenomena of the circulation, we naturally lay much less stress upon the many minor features which alone afforded diagnostic indications to the physicians to whom these indispensable aids were unknown. Far be it from my purpose to underrate in any way the valuable results which have thus been obtained; yet it cannot be gainsaid that in the general diagnosis and treatment of cardiac diseases we rely entirely too much upon our modern instruments of precision, and are thus led to treat not patients, but circulatory conditions. It is erroneous to suppose that but little was known of cardiac disorders before the discovery of percussion and mediate auscultation. The anatomy of the heart was well known to the ancients, but organic diseases were not recognized till the XVI century, and then only at autopsies. This ignorance was due to the Hippocratic doctrine that the heart could not become diseased, inasmuch as it was the source of animal heat and the seat of the soul. In 1628 Harvey announced his views on the circulation; Auerbrugger discovered percussion in 1761; * Read before Metropolitan Medical Society of New York City. Y 8'08 while Laennec's treatise on auscultation did not appear till 1821. Nevertheless a wonderful amount of good work was accomplished in the pathology, diagnosis and treatment of cardiac diseases by such men as Vieussens, Lancisi, Morgagni, Albertini, Senac and others who lived in the earlier part of the XVIII century. Their work it was which laid the foundation of all our knowledge of these lesions. Even Laennec admits the great importance of their investigations. That so much should have been accomplished is all the more remarkable when we consider the state of medical science of this period. Thus Vieussens believed that the circulation of the blood was maintained by the continuous explosions in the heart and blood vessels which resulted from the combustion of the saline and sulphurous particles in the blood with the nitrates of the air and the vital spirits. Dyspnoea was believed to be always due to hydrothorax; asthma was only a nervous disturbance. Polypi in the heart (ante- and post-mortem clots) were for a very long time considered the cause of many protracted diseases. In passing, it may be of some interest to take a hasty glance at the condition of the medical profession in the early part of the last century. It was an age of transition in which observation and speculation each played a great part. How far reaching were some of the theories promulgated during this period may readily be appreciated by reading Virchow's Croonian lecture.* No less than eighteen great systems of medicine were formulated, ranging from the eclecticism of Boerhaave down to the realism of Bichat, each in turn usurping a temporary supremacy in the medical thought of the age. The rage for theory was a sign of the times, an endeavor to assimilate the many facts which careful observation revealed and which the existing state of knowledge. could not explain. And yet it was a curious age of contradiction, where superstition prevailed to no small degree. Witches were burned as late as 1782. Baas states that an ordinance of the Berlin authorities in 1704 required that those who died, even of the plague, without having taken. any medicine, should be hanged after death in their coffins. In 1714 the days and hours on which the King of England would cure the King's evii (scrofula) were announced on posters. How terrible was the condition of the insane asylums we all know; but some of the great hospitals were even in a worse state. Single halls in the Hotel Dieu at Paris contained enormous numbers of patients; large beds (5 feet wide) held four to six patients, the feet of one to the head of another. Men, women and children were indiscriminately mingled together; patients with the plague were alongside of a woman in labor. The bodies of the dead usually lay twenty-four hours before they were removed from these large * British Medical Journal, March 18, 1893. 1 beds! In Spain, the physicians solemnly recommended that the streets ought not to be cleansed, since it would be injurious to disregard the prevailing customs, and furthermore the offensive air was especially good for destroying the materials of infection. The materia medica of this century is scarcely credible, including, as it did, precious stones, dung of various animals, various kinds of lice and vermin, etc. In 1798, Marcus, in treating fevers on the Brunonian principle, used on an average for each patient one drachm of opium, 200 grains of camphor, one ounce of Hoffmann's anodyne, over one ounce of cinchona bark, one pound of rectified spirits; musk, sulphuric ether, etc., being used as well. He, too, fed the fevers! The Prussian medical edict of 1725 was to be applied to physicians, surgeons, apothecaries, grocers, bath keepers, midwives, mountebanks, dentists, students of medicine, old women, shepherds, executioners and water sellers. The exact details may be read in Baas's excellent treatise on the History of Medicine to which and a monograph by Phillipp* I am indebted for many data. Passing then to the special knowledge of the diseases of the heart, I shall refer to a few cases of hydropericardium, in which Vieussens was able to make a correct diagnosis during life, as was proved by the autopsy. He first learned to recognize the condition in a boy six years. of age. After frankly admitting his inability to make the diagnosis in this case, he speaks of the following patient, with whom he was more successful. His description reads as follows: "The patient was a boy six years old, of a pituous-melancholic temperament, with a pale complexion and a somewhat dull eye; the extremities were cool, the breathing labored, especially after climbing stairs; the pulse soft and rapid. After considering these symptoms I told the boy's father that his son would undoubtedly suffer from an incurable thoracic disorder unless frequent mild diuretic laxatives and gentle resolvents were soon employed. Soon after I was called away to Paris, where I remained a year. On my return I ascertained that the boy had only received occasional doses of wormseed and manna, because the physician in charge had diagnosticated worms. Being called there a second time I visited the boy for three days, morning and evening. The dull pain on the right side, which increased on lying over on the left side; the low fever, the increased flow of saliva, the occasional chills, the superficial respiration, which was very rapid even while sitting up, the obstinate and very annoying cough --all these signs led me to believe that the lobes of the right lung were adherent to the pleura and were indurated; and inasmuch as the child's legs were swollen, as he could not lie with his head low, and as the dyspnoea was increased when he lay on the right side, I concluded that Berlin, 1856. there was fluid in the left pleural cavity. Finally I also diagnosticated the presence of fluid in the pericardial sac, because the disease, both at its beginning and end was accompanied by palpitation of the heart, leaden color of both eyelids and great depression; and because there were several attacks resembling those in the boy with hydropericardium. "Two other eminent physicians who saw the case pronounced it disease of the liver and chest; however, another whom I called in, corroborated my views. "At the autopsy the liver and other abdominal organs were found normal. But the left pleural sac was distended with yellow serum; likewise there was an excess of lymphatic fluid in the pericardial sac. The heart was soft and contained no polypi. The left lung was flaccid, but the right was as hard as Roquefort cheese and was so adherent to the pleura that the greatest force was necessary to separate them." Surely, to-day, we could make no better diagnosis of a case which began as a right pleuro-pneumonia with consecutive induration and pleuritic adhesions. The pleural and pericardial effusions were due to the subsequent cachexia. To any one who may object that this was simply a lucky guess, I would reply that these observers, unlike many of ourselves, always faithfully reported their failures as well as successes. Lack of time forbids my giving additional cases. In all of them there is the same attention to details, especial stress being laid upon the color of the cheeks, lips and eyelids; the turgescence of the lips, the changes in locomotion, the temperature of the various parts of the body, the posture of the patient and the effects of changes of it on the pulse, respiration and color of the face. Even the mental condition is always noted. It is also very interesting to read how correctly this same observer not alone described a case of mitral stenosis, but even correctly explained the effects of the lesion upon the heart and the circulation. His statements are true even to-day. Where so much attention was bestowed upon the pulse it is by no means surprising that the pulse of aortic insufficiency was observed by him; nor did its significance and the manner of its production escape Vieussens. It was quaintly described as follows: "The pulse on both sides was very full, very hard, slightly irregular and very rapid; the artery struck the finger-tip like a tense string which was vibrating with great force. Such a pulse I had never before encountered, and I pray to God that I may never again feel one like it!" And now to briefly recapitulate what was known on the subject of heart lesions at this period. Of course, the majority of these facts was obtained from post-mortem examination and not from diagnoses during life. But this in no way lessens their importance. Pathology. Three classes of lesions were recognized: the structural, mechanical or valvular, and nervous. The relations of the two sides of the heart were clearly understood; it was known that the left side was more frequently hypertrophied, while dilatation was more common on the right. Senac showed that valvular stenosis was found more frequently on the left side. Morgagni explained how lesions on the right side caused pulmonary stasis and hæmorrhage. Hypertrophy and dilatation were both included under the term aneurism of heart, the former being called aneurismal enlargement, the latter varicose, a classification which is obviously based upon the differences in the dilatation of arteries and veins. Eccentric hypertrophy was clearly explained by Albertini. The various mechanical effects of valvular lesions were well known; it was recognized that insufficiency as well as stenosis would interfere with the circulation. The frequency of pericardial changes in organic diseases was noted, while even inflammatory lesions were recognized by Senac. He asserted that the inner surface of heart was more frequently covered with lymph than the outer, and that this condition was most often found in "epidemic stitches-in-the-side" (a quaint name for pneumonia) and pulmonary and mediastinal diseases. The relations of endocarditis to rheumatism are undoubtedly alluded to in Senac's assertion that the heart itself may be the cause of the fever. The real nature of heart-clots (so-called polypi of heart) was also, for the first time, made manifest. Morgagni called attention to the rarity of primary hydropericardium; he also proved that when it was secondary it was always associated with general anasarca. Senac even showed that the forcible action of the heart in fevers was not due, as was popularly supposed, to a thickening of the bodily juices, but to disturbances in the innervation of the heart. Etiology. In discussing the etiology of aneurism of the heart Lancisi includes: (1) Heredity; (2) mechanical causes; (3) chronic catarrhs (i. e. emphysema); (4) nervous excitement; (5) overexertion, as in orators, players on wind instruments; (6) excesses in venery and eating (syphilis and gout). If to this list were added congenital defects and the inflammatory lesions, it would almost fulfil our modern requirements. The importance of atheroma was recognized by Senac, to whom also belongs the credit of having first described inflammatory conditions of the heart. The relations of pericarditis to organic disease were also understood. |