HISTORY OF AORTIC REGURGITATION By SIR , 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 (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. It may be men- have offered inadequate payment to the physicians it appointed. In the summer described as “the first prominent phy- of 1859 he was granted the m.d . (Honoris sician of the race and religion (Roman causa), Dublin, and on April 9, 1855, he Catholic) of the majority in Ireland, was unanimously elected an Honorary Fel- and the populace were pleased with his low of the College of Physicians. On June success, and spread his fame through the 27 of that year he applied to be admitted country, so that no physician in Ireland to the examination for the license of the King and Queen’s College of Physicians of had before received so many fees as he Ireland and on the following July 27 he had.” was examined, approved, and admitted I he Water -Hamm er Pul se L.K.Q.C.P.I. On October 17, 1856, he was proposed as an ordinary fellow and was Corrigan insisted on the visibility elected unanimously 011 October 27, 1856. rather than on the collapsing character On St. Luke's day, 1859, he became presi- of the pulse and did not use the term dent of the College. “water-hammer pulse.” George and About 1830 he was appointed physi- William Dock undertook a long and cian to the Jervis Street Hospital where systematic search into the history of this he had five beds only which, however, comparison of the pulse of aortic reflux he utilized with much success. Unlike to the phenomena of the now obsolete his two great contemporaries R. J. “chemical” toy, the water-hammer. At Graves and William Stokes (1804-78) first and for some time the earliest ref- who both came of families with records erence obtained was in 1876 to A. L. of distinction at Trinity College, he was Galabin (1843-1913), a fellow of Trinity never a teacher in its school of physic, College, Cambridge, an active worker and was the son of a Dublin tradesman with the sphygmograph on cardiac dis- in poor conditions. Some evidence of ease, and later obstetric physician to early opposition was perhaps shown by Guy’s Hospital; then to Hilaro Barlow a clinical lecture published in February (1806-66), physician to Guy’s Hospital, 1833 by Graves, who stated that the who in 1852 spoke of the “splashing symptoms described as diagnostic of or water-hammer pulse”; and lastly, permanent patency of the mouth of the though with almost excessive caution, to aorta by Corrigan were uncertain, had (Sir) Thomas Watson (1792-1882) as been arrived at too hastily, especially writing in 1844: the “leaping’’ pulse, and instanced, in T he pulse of aortic regurgitation is, support of the last criticism, the case of sometimes at least, very striking and pecul- a woman with the characteristic pulse iar: sudden, like the blow of a hammer, in one only of her arms. Corrigan, how- without any prolonged swell of an artery. ever, had the advantage over his two It always reminds me of the well-known chief rivals of the stimulus due to per- chemical toy formed by including a small sonal poverty and absence of any family quantity of fluid in a glass tube, exhausted influence. He was physician in ordinary of air, and hermetically sealed. On revers- to Queen Victoria in Ireland, and was ing the tube the liquid falls from one end created a in 1866. Like fellows of it to the other with a hard, short knock, as if it were a mass of lead. of Trinity College, he was many-sided, with wide interests. In an otherwise Though the name of the “chemical” somewhat critical notice by his country- toy was not mentioned, this seems to be man Norman Moore (1847-1922) he was fairly convincing evidence that the par- entage of the expression water-hammer current passing between the curtains pulse may be brought home to Watson, throws them into vibration and gives whose “Lectures on the principles and rise to the characteristic blubbering practice of physic’’ were for thirty years murmur. The physical condition is in or more the favorite textbook of medi- effect analogous to contraction of the cine among English-speaking readers. mitral orifice from an adhesion of the It may be interesting in this connection curtains at their sides.” Flint’s explana- and from the aspect of prognosis to re- tion has usually been taken to ascribe call the case of a boy, aged thirteen the presystolic murmur to vibrations of years, for nine months an in-patient in the mitral valve segments; but the quo- the Middlesex Hospital, under Wat- tation given above, especially the “coap- son’s care, with severe carditis in 1834, tation” of the mitral valve segments, who on discharge from the hospital was might suggest that it also covered a later advised always to carry with him a card view, namely, that the impingement of giving his name and address for identi- the regurgitant blood from the aorta on fication in case of need, and that he sur- to the anterior cusp of the mitral valve vived until 1888 when aortic regurgi- bulged the segment into the mitral ori- tation, mitral stenosis, and adherent fice so as to produce an inorganic steno- pericardium were found at the necropsy sis during the auricular systole. Another (Fowler). explanation put forward subsequently Half a century ago Sir Dyce-Duck- was that of relative mitral stenosis, worth (1840-1928), when physician to namely a normal mitral valve and a di- St. Bartholomew’s Hospital, kept a lated left ventricle, thus setting up ed- water-hammer in his wards to show dies in the blood stream. Flint’s accu- every three months each new batch of racy in correctly timing the murmur he his clinical clerks what a water-hammer described was bluntly questioned by was. George Dock when he began to G. W. Balfour (1823-1903) of Edin- teach physical diagnosis did the same, burgh who warned his students against but in 1915 when in want of another making such a mistake. Not unnaturally water-hammer for this purpose, found Flint in 1886 protested. W. S. Thayer that they were no longer in stock. Few (1864-1932) in 1901 found that Flint’s now know exactly what a water-hammer murmur was present in 63 per cent of was. the cases of aortic incompetence proved by necropsy to be free from mitral The Pres yst oli c Murmu r in Unco m- stenosis. pl ica ted Aort ic Regurgit ation Other Phys ical Signs Austin Flint (1812-86) of the Belle- vue Hospital, New York, described in Duroziezs sign. In 1861 P. Duroziez 1862 a presystolic or direct mitral mur- (1826-97) of Paris described a double mur, which he explained as follows: the intermittent murmur in the femoral left ventricle is rapidly filled with blood artery, which could be increased or regurgitated from the aorta in addition brought out by the pressure of the steth- to that from the left auricle; as a result oscope, in aortic incompetence. It is not “the mitral curtains are brought into constant in or confined to that lesion. coaptation, and when the auricular con- De Musset’s sign. The jerking move- traction takes place this mitral direct ments of the head, due to the carotid pulsations, were observed in 1842 in the cated by mitral disease, a remarkable person of L. C. A. de Musset (1810-57), difference between the systolic blood the poet and novelist, who had aortic in- pressure in the arm and that in the leg competence, and later recorded by his in the recumbent position, the systolic brother Paul E. de Musset (1804-80) in blood pressure being higher in the leg. his life of the poet. This personal in- Leonard Hill and his co-workers ex- terest perhaps justifies the eponym, sug- plained this as “due to the better con- gested by Delpeuch in 1900; later in duction of the great systolic wave by the that year Frankel reported this sign in leg arteries, which were maintained in a large pleuritic effusion on the left a somewhat contracted state in order to side, and therefore concluded that it secure an adequate blood supply to the was not pathognomonic of aortic regur- brain.” gitation. The association of aortic incompe- Capillary pulsation, or the visible al- tence with tabes dorsalis was probably ternating blush and pallor seen in the first pointed out in 1879 by Berger and skin, especially after a scratch, in the Rosenbach. Sir W. R. Gowers (1845- lips when lightly compressed by a mi- 1915) in 1886 wrote: croscope slide, under the nails, and in the uvula (Fr. Muller), corresponds Of the complications of tabes outside the nervous system, valvular heart disease with the pulse in the larger arteries. It is the most important, and usually devel- may occur in other conditions in which ops without any of the usual antecedents the arterioles are dilated (T. Lewis), as of heart disease, and at an age at which in toxic goiter, anemia, and neurasthe- degeneration is unlikely. Aortic regurgi- nia. It was described in 1861 by Lebert tation is especially frequent. It is not im- (1813-78) in aortic aneurysm, but this probable that the cardiac and neural dis- may obviously be due to concomitant eases own a common cause—syphilis, and incompetence of the aortic valves. The that the valvular lesion is due to the syphi- capillary pulse was specially correlated litic process that is known sometimes to with aortic incompetence in 1868 by attack the cardiac and especially the aortic Quincke (1842-1922). The retinal arte- valves. rioles may pulsate, and so may the sub- Twenty-one years later the frequent cutaneous veins, as seen on the backs of association of aortic insufficiency with the hands. The facial pallor often pres- tabes dorsalis was emphasized by ent and described in aortic reflux is, Striimpell (1853-1925). according to Lewis, due to the anemia of concomitant subacute bacterial en- Etiology docarditis or of rheumatic infection and The cause of aortic incompetence was not merely to regurgitation through the ascribed by Corrigan to dilatation of aortic orifice into the left ventricle. the aorta, the semilunar valves being The arterial blood pressure usually structurally normal (relative incompe- shows a moderate increase in systole tence), as well as to lesions, such as thick- and a considerable fall in diastole: so ening, of the valve segments. Acute that the pulse pressure, or differential rheumatism as a cause of cardiac disease pressure, is much increased. There is generally, but not of aortic valvular dis- often, especially in free and compen- ease in particular, was taught from 1788 sated aortic regurgitation, uncompli- by David Pitcairn (1749-1809) at St. Bartholomew’s Hospital, but he never tally in the report of one case, a woman, published this observation, which was, aged forty-seven, with widespread syph- however, vouched for by Matthew Bail- ilitic lesions, that the aortic valves were lie in 1797 and by W. C. Wells (1757- “thickened and indurated,” but did not 1817) in 1812. Edward Jenner (1749- insist on syphilis as a cause of aortic in- 1823) in 1789 read before the small competence. That syphilis was largely Gloucestershire (“Fleece”) Medical So- responsible for at least 50 per cent of the ciety “remarks on a disease of the heart cases of aortic aneurysm and that endar- following acute rheumatism, illustrated teritis of the aorta was one of the earliest by dissections”; but this manuscript, for and most frequent lesions of syphilis the return of which Jenner wrote in was shown by F. H. Welch (1839-1910), 1805 to C. H. Parry (1755-1822) who assistant professor of pathology (1871- may have acted as secretary to the Fleece 1876) at the Army Medical School, Net- Society, was never published. David ley; these observations had a prepara- Dundas, sergeant-surgeon to the King, tory bearing on the later recognition of published a paper in 1809 on “a pe- syphilitic disease of the aortic valves. In culiar disease of the heart, caused by a 1884 Sir B. Bramwell (1847-1931) in a translation of rheumatism to the chest”; list of the causes of aortic regurgitation he presented to the museum of the placed syphilis after acute rheumatism. Royal College of Surgeons of England In 1896 P. H. Pye-Smith (1839-1914) a specimen (number 1512, in catalogue recorded a case with the title “syphilitic 1848) of a “heart enlarged after acute disease (?) of the ascending aorta and rheumatism,” showing pericarditis; at- sigmoid valves.” At late as 1901 C. W. tached to the description was a note, by Chapman in reporting “a case of aortic (Sir) James Paget who prepared the cat- regurgitation probably due to syphilis,” alogue, giving the references to Pitcairn thought it necessary to quote in favor and Jenner and also to L. Odier (1748- of this diagnosis scattered references in 1817) who in 1811 spoke of the “metas- the works of Sir William Broadbent, tasis of rheumatism to internal organs.” Sir , and Dieulafoy. In 1826 Francis Hawkins (1794-1877) The importance of syphilis in the causa- gave the Goulstonian lectures at the tion of aortic incompetence was not ac- Royal College of Physicians of London cepted widely until after the Wasser- on “Rheumatism and some diseases of mann complement-fixation test (1906) the Heart and other internal organs.” came into general use. These observations preceded “the law Over-exertion. Sir Clifford Allbutt of coincidence” between acute rheuma- (1836-1925), in a paper on “The effects tism and pericarditis and endocarditis of overwork and strain on the heart and laid down in 1836 by J. B. Bouillaud great blood-vessels” (1871), included (1793-1881) of Paris. aortic incompetence. The condition was The relation of syphilis to aortic in- then regarded as to some extent an oc- competence, now a commonplace, was cupational disease especially when the not recognized until long after myocar- arms are much used as in sawyers, dial changes, especially gummata, were lighter-men, and hammer-men. But this well known. Lancereaux (1829-1910), was before the causal importance of who described in 1868 myocardial syph- syphilitic metastasis was generally rec- ilis at some length, mentioned inciden- ognized. Refe rences Allbutt , T. C. St. George's Hosp. Rep., 5:23, Hale -White , W. Guy’s Hosp. Rep., 1871. 1924. Baill ie , M. Morbid Anatomy of Some of the Hill , L. (With the co-operation of Flack, M., Most Important Parts of the Human Body. and Holtzmann, W.) Heart, London, 1:73, London, 1793. P. 25 (Aortic Disease). lgog-to. Idem . Ibid. Edit. 2. 1797. (Cardiac Rheuma- Hodgkin , T. London Med. Gaz., 3:433, tism.) P. 46. 1828-9. Balfo ur , G. W. 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