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HISTORY of AORTIC REGURGITATION by SIR HUMPHRY ROLLESTON, BT., G.C.V.O., K.C.B

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HISTORY of AORTIC REGURGITATION by SIR HUMPHRY ROLLESTON, BT., G.C.V.O., K.C.B HISTORY OF AORTIC REGURGITATION By SIR HUMPHRY ROLLESTON, BT., G.C.V.O., K.C.B. HASLEMERE, ENGLAND The Histo ry of Aort ic Inco mp et enc e HE history of the recognition pital with palpitation and a loud noise of incompetence of the aortic in his breast synchronous with the beat valves is of interest not only of the heart and audible at some dis- from the rather barren aspect tance from the bedside. At the necropsy of priority, whether an eponym, suchDouglas as found that the heart was enor- Tmaladie de Corrigan or Corrigan's mously enlarged and that the aortic pulse, should be conferred on the first valves were so hard and contracted that person to record a symptom-complex or they allowed the blood to flow back into sign, or on the first to give a full account the ventricle. He had thus heard an of the condition. There is also the par- aortic murmur more than a hundred ticular point that aortic regurgitation, years before the appearance of Laen- which might be regarded as safely en- nec’s “Traite de l’auscultation mediate” trenched in the physician’s province, (1819). owed its discovery in no small degree to I he museum of the Royal College of the activities of surgeons in anatomy Surgeons of England contains a number normal and morbid. of Hunterian specimens showing the William Cowper (1666-1709), a Lon- changes which cause incompetence of don surgeon and anatomist, was in 1705 the semilunar aortic valves. One of these the first to report a morbid change in (number 1554 in the catalogue) was de- the aortic valves; the pulse in his cases scribed in full detail and was also men- was described as “intermittent,” but no tioned by John Hunter in his “Treatise mention was made of a collapsing char- on the Blood” (1794). This, “Mr. Bul- acter. In 1715 an independent account strode’s case,” was in a man about thirty of the valvular lesion and the collapsing years of age with, as the necropsy pulse was published by Raymond de showed, lesions causing aortic and mi- Vieussens (1641-1715), born in a small tral regurgitation; it was stated that “the village with his surname in Rouergue, blood must have flowed back into the who was a physician at Montpellier and cavity of the ventricle again at each was elected a fellow of the Royal So- systole of the artery.” In two other ciety of London in 1688 after the publi- Hunterian specimens the aortic valves, cation of his great “Nevrologia Uni- which were thickened and opaque, were versalis” (1685) based on 560 necropsies. described in the catalogue (1848) as In the same year (1715) James Doug- probably the site of congenital malfor- las (1676-1742), anatomist and the lead- mation. With the help of Mr. W. E. ing obstetrician of his day in London, Thompson of the Hunterian Museum reported the case of a young man whom one of these specimens has been traced he had seen in St. Bartholomew’s Hos- further back in order to determine if the congenital nature of the bicuspid and regarded this case as unique. In aortic valves was recognized before 1844 James Paget recorded acute endo- 1848. In the Hunterian MS., “Dissec- carditis of a bicuspid pulmonary valve in a girl, aged twenty years, with gonor- rhea, and emphasized the liability of congenital bicuspid semilunar valves, aortic or pulmonary, to disease in a very severe form, and thus supported the generalization that malformed parts are specially prone to other morbid change. Osler in 1880 and 1886 emphasized with statistics the danger of such bicuspid valves to superimposed infection. Matthew Baillie (1716-1823) in 1793 referred to the frequency of disease of the aortic valves, which necessarily in- volved a loss of their function, and briefly mentioned a case of John Hunt- er’s in which an aortic segment was much thickened, and had undergone rupture. His “Series of Engravings which are intended to illustrate the morbid anatomy of some of the most important parts of the human body’’ contained one of thickened bicuspid aortic valves (Fasc. I, plate 2, Fig. 5. tions of Morbid Bodies,’’ specimen 85, London, 1803). page 126, it was merely stated that there In 1829 Thomas Hodgkin (1798- were two instead of three aortic semi- 1866), curator of the museum and lec- lunar segments. In the catalogue of turer on morbid anatomy from 1825 to 1830, written by W. Clift (1775-1849). 1837 at Guy’s Hospital, published a val- it was left in doubt whether the bicus- uable account of “retroversion of the pid condition was a congenital confor- valves of the aorta.’’ The paper was in mation or due to inflammation. It there- the form of two letters in 1827 and fore appears that (Sir) James Paget 1829, to * my dear Friend’’ Charles (1814-99), who wrote the accounts of Aston Key (1795-1849), surgeon to the specimens in the 1846-48 catalogue, Guy’s Hospital, who had drawn Hodg- was responsible for the addition about kin’s attention to the condition, as congenital bicuspid valves. The liabil- shown by a specimen he had placed in ity of congenital bicuspid valves, aortic the Guy’s Hospital museum (number or pulmonary, to be attacked by acute 2451, catalogue, 1910). In his catalogue bacterial endocarditis was not fully rec- of the Guy’s Hospital museum in 1829 ognized until the middle of the last Hodgkin listed four specimens of re- century. troversion of the aortic valves (numbers Graves (1796-1853) in 1843 recorded 1422-1425) and to the description of the acute endocarditis on a bicuspid pul- first added the note that C. A. Key was monary valve in a man, aged sixty-six, the first to observe retroversion of the aortic valves, a statement repeated in his Hodgkin gave a good pathological and published paper in the same year, clinical description of the disease. The though he later agreed that Bertin in Guy’s Hospital (Gordon) museum con- 1824 had recorded this lesion (see p. tains a specimen (number 2470 in the 274). Key had in 1814 been appointed catalogue of 1910) stated to have been to perform necropsies at Guy’s Hospi- presented by Hodgkin in 1827, °f the tal, and in 1848, the year before his lesion in a woman aged twenty-eight sudden death from cholera, was elected years. In 1871 Hodgkin’s account of the second president of the Pathological aortic regurgitation was said to be more Society of London, but he does not ap- complete than that of Corrigan: this was pear to have ever recorded his observa- the estimate of Sir Samuel Wilks (1824- tion of retroversion of the aortic valves. 1910), who had in 1856 rescued from Thus, disclaiming any originality, absolute oblivion Hodgkin’s account of lymphadenoma (Hodgkin’s disease). Sir tioned that he and Corrigan had crossed William Hale-White, another loyal cardiological swords in 1830. Guy’s physician, in his article on Hodg- The well-known article widely re- garded as the first description of “per- manent potency of the mouth of the aorta or inadequacy of the aortic valves” by Sir Dominic John Corrigan (1802- 1880), was published in April 1832. It drew an independent and systematic picture, based on eleven cases (two in women). He had been accustomed, he stated, to speak of the condition as “in- adequacy of the aortic valves,” but had adopted “permanent patency” in defer- ence to Elliotson (1830). In one case the disease followed acute rheumatism, oth- erwise the cause was uncertain. The most important divergence of his clin- ical account from subsequent opinion was the statement that the patients were not prone to sudden death. He depre- cated, for aortic reflux, the then ortho- dox treatment of cardiac disease in general, namely antiphlogistic and de- pletory measures, as indeed Hodgkin had done, and also the use of digitalis. kin’s life and work (1924) analyzed the The trying period of early competition paper on retroversion of the valves of and waiting for practice and success was the heart. In 1830 John Elliotson (1791- not without trials for Corrigan. Though 1868) referred to Hodgkin’s paper, but for five successive years (1859-64) presi- was more interested in stenosis than in dent of the King and Queen's College incompetence of the aortic orifice in the of Physicians of Ireland, he was not production of murmurs. He quoted elected when he first came up for admis- Bertin’s earlier observation in 1824 and sion there. Professor T. Percy C. Kirk- said that he had pointed it out to Hodg- patrick, registrar of the College, has kin who readily accepted this matter of most kindly given me the following in- priority about aortic reflux. James formation about this incident: Hope (1801-41) whose “Treatise on the Diseases of the Heart and Great Ves- [Corrigan] was proposed for the honor- ary fellowship of the College on St. Luke’s sels” was published at the end of 1831 day, 1847, and came up for ballot on the (1832), and so before Corrigan’s paper following November 1, when 12 white in April 1832, wrote a short section, ex- beans were cast for him against 15 black, panded with a claim for priority in and he was rejected. It is said that his re- subsequent editions, on disease of the jection was due to a feeling against him aortic valves, in which stress was laid on on account of his connexion with the the jerking character of the pulse in Board of Health which was considered to aortic incompetence.
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