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February 19, 2017
19th Century Robert Adams

Robert Adams (1791-1875)

Cases of diseases of the heart, accompanied with pathological observations. Dublin Hosp. Rep., 1827, 4, 353-453

Robert Adams
Portrait of Robert Adams
Portrait of Robert Adams

Robert Adams was one of the most outstanding physicians of Ireland who contributed extensively to the knowledge of the heart disease.

He gave one of the first accounts of heart block with convulsive syncope which was published in an article under the title, "Cases of diseases of the heart, accompanied with pathological observation," in 1827. This entity now carries the eponym Adams-Stokes syndrome.

In this work, Adams also described diseases affecting the pericardium and he discussed the natural history and potential etiology of patients suffering from heart failure associated with changes affecting the muscular structure of the heart, "active enlargement of the heart without any valvular disease."

He also reported his observations in valvular heart disease. Adams described a case in which mitral valve lesions were consistent with infective endocarditis. The case was entitled:

"Active enlargement of the heart with rupture of the cordae tendineae of the mitral valve (communicated by Dr. Cheyne)":

"...a musician, 34 years of age, of a very robust frame,... was seized with a most acute pain in the left side of the thorax, precisely in the region of the heart,... he had a very dry cough, his breathing was oppressed, from which oppression he had most relief when leaning forward inclined to the left side, in which position he usually sat... His pulse was 148, unequal, irregular and indistinct... unable to lie down... A walk of not more than a few hundred yards wonderfully added to the disturbance of the vital functions. While such an exertion increased the dyspnea, it gave strength and distinctness to the stroke of the artery. His abdomen was swelled... and he died..."

At autopsy examination, he noted:

"...the pericardium contained a considerable quantity of fluid. The heart was so large that it resembled the heart of a bullock, the parietes of the left ventricle were thickened, its internal surface much inflamed, various irregular excrescences grew from the mitral valves and semilunar valves of the aorta, and the cordae tendineae, which connect the larger portion of the mitral valve to the walls of the left ventricle, were torn off just at the point of their insertion into the edge of the valve; at this point there were also some of the above mentioned excrescences ; four of the broken cordae tendineae hung loose into the ventricle."

He also described several cases of mitral stenosis. For each case he gave a detailed account of clinical presentation and autopsy findings.

In the postmortem examination of the case one, Adams described very carefully mitral valve lesions including leaflets thickening and retraction.He also explained the existence of concomitant mitral regurgitation in the setting of mitral stenosis:

"...in the interior of the organ [heart] everything was natural except the mitral valve, which as yet, was not beset with earthy concretions, but was shortened to more than half its natural depth. It was yellow, opaque, and at the same time thickened as if a cartilaginous substance had been deposited between its laminae; the aperture which the edges of this valve circumscribed was sufficiently open to allow the blood a free passage from the auricle into the ventricle; but it was manifestly incompetent to perform the full office of a valve, or prevent a regurgitation of blood into the auricle during the contractions of the ventricle."

Adams also provided an excellent summary of clinical symptoms and features of physical diagnosis in patients with mitral stenosis:

"The person affected with it [mitral stenosis] has the general symptoms of diseased heart; there are paroxysms of dyspnoea haemoptysis; much uneasiness also is experienced in lying in any but one position... The palpitations of the heart are irregular, widely extended; they are seen underneath the lower extremity of the sternum, and the heart beats with considerable force against the side of the chest... Strong pulsations are seen in the jugular veins, and there appears a general thrill through the branches of the arterial system... When the ear is attentively applied to the side of the thorax, a very complex kind of movement, hard to describe, is heard, a hissing purring noise as it has been denominated, caused by the transmission of blood through a narrow orifice, is in most cases very evident."

Although Adams described here the findings of immediate auscultation, he did not refer to mediate auscultation with the use of stethoscope which was discovered by Laennec a decade earlier.

In the case 3, Adams reported the case of a 15 year-old patient with mitral valve obstruction and pulsatile jugular veins. In the autopsy examination, he noted:

"...The left auricle was largely dilated, while the corresponding ventricle was diminished; the right side of the heart was actively enlarged, or in a state of hypertrophy, and the pulmonary artery and aorta were in size proportioned to the ventricles from which they respectively arose."

He then discussed the significance and the pathophysiology of the jugular vein pulsation:

"The pulsation seen in the jugular veins demand our consideration: the cause of this symptom has been so much disputed; to me it appears most probable that it results from the regurgitation of blood from the right ventricle into the auricle, by which the current descending from the jugular veins is repelled back into these vessels during the systole of the ventricle.  The pulsations in the jugular veins I have always observed to be synchronous with the action of the heart, even with the pulsations which were not perceptible in the arteries."

In his closing comments, similar to Hunter's view, Adams expressed the opinion that the closure of the mitral valve was more perfect than that of the tricuspid valve. He also explained that for the same very reason, the left-sided valves were more affected by the disease process than the right-sided valves:

"...from the unyielding nature of the mitral valve, all reflux into the auricle is prevented, from this very cause, which renders it effective in the circulation, is it exposed to more frequent injury from which organic disease may arise."

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Rene-Joseph Hyacinthe Bertin Pierre-Adolphe Piorry