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May 22, 2017
Rheumatic Heart Disease David Dundas

David Dundas (1749-1826)

An account of a peculiar disease of the heart. Med-chir. Trans., 1809, 1, 37-46



David Dundas, of England, reported nine cases of rheumatic carditis that he observed over a 36-year period. His findings were published in an article, "An account of a peculiar disease of the heart,"  in 1809.

Dundas reported the following observation in his article: "...In all the cases which I have seen, this disease has succeeded one or more attacks of rheumatic fever."  Most these patients were young, and only two were above 22 years of age. Six of them were male, and three females.  They typically presented with dyspnea, palpitation, anxiety and chest pain.  At physical examination, regarding the arterial pulse, Dundas wrote: "The pulse is always very quick, and is often irregular: in some cases it has been weak, but more commonly very hard."

Dundas described the evolution of the disease in one of his patients as follows:

"In one case the affection of the heart appeared at the commencement of the rheumatic fever, and its action was so rapid, that the pulse could not be counted for many days; much difficulty of breathing and oppression attended with a sense of great debility took place, and the inflammation, pain, and swelling of the extremities , after having shifted from one joint to another for many weeks, subsided; but the affection of the heart continued, generally attended with great pain, producing in the progress of the disease, and toward its close, a considerable disposition to dropsy [congeative heart failure], under which the the patient lingered for ten months."

Congestive heart failure with anasarca was the most common cause of death among these patients. In that regard, Dundas noted: "...Towards the conclusion of the disease symptoms of water in the chest take place, the legs become oedematous, and frequently considerable collection of water is accumulated in the abdomen."

In his report, he mentioned that "most patients struggled for many months, seven of the nine have died.., six have been opened, and all of them agree in the general appearance of the heart. In all the heart was uniformly found to be enlarged, in some, the enlargement was much more considerable than in others. In one case, water was found in the pericardium, in all the others the pericardium adhered to the heart. The left ventricle, in all the cases, was most enlarged in size, but not in thickness, and in most of them the heart was found of an unusually pale colour, and very soft and tender in its texture."

The postmortem examination in two cases revealed abnormalities of the mitral valve:

"...upon opening the left ventricle was found an irregular excrescence of the nature of polypus, attached to, and nearly occupying the whole of one of the valvulae mitrales."

Regarding the second case, Dundas remarked:
"It [heart] was chiefly enlarged on the left side, but its muscular structure was not increased in thickness. The valvulae mitrales were edged with a substance of a spongy appearance perhaps coagulable lymph."

Dundas explained the relationship between rheumatic arthritis and cardiac manifestations as follows:

"The knowledge that this disease is always the consequence of, or is connected with, rheumatic affection, points out the necessity of attending to the translation of rheumatism to the chest; and shows the importance of employing very vigorous measures to remove it as soon as possible, but whenever it has made any considerable progress, I fear it will battle every effort."

Although Dundas did not appreciate the significance and severity of valvular lesions in rheumatic heart disease and the description of his autopsy findings lacks some degrees of precision, he understood that cardiac lesions in his patients resulted from rheumatic arthritis. 

Dundas' observations received minimal attention and was not mentioned in subsequent works which were published in the 19th century. 

REFERENCES

Jarcho S. Rheumatic carditis in the reign of King George III (Dundas, 1809). Am J Card 1968;21:572-574

East CT. The story of heart disease. London, Wm. Dawson, 1957


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