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February 25, 2017
19th Century James Hope

James Hope (1801-1841)

A treatise on the diseases of the heart and great vessels. London, W. Kidd, 1832

James Hope
Portrait of James Hope
Portrait of James Hope

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James Hope was a British physician who had a great interest in cardiovascular diseases and made many important contributions to our knowledge of heart diseases. Following the invention of the stethoscope by Laennec, there was a great interest in the "art" of auscultation and many British medical graduates studied in Paris which was the center of  medical education in Europe. Hope also studied in several major Paris hospitals and worked under the mentorship of several Laennec's disciples such as Gabriel Andral, Pierre Louis, and August-Francois Chomel.

At his return to England, Hope became one of the early advocates of cardiac auscultation and made important researches on the mechanism of production of the heart sounds and cardiac murmurs.These investigations were done in collaboration with Charles Williams between 1830 and 1832. In their research, they used stunned donkeys that were kept alive with the use of artificial ventilation. The chest and pericardium of these animals were opened and the heart was examined directly with the stethoscope. They were able to demonstrate that the second heart sound was due to the closure of the aortic and pulmonic valves. In their experiment, they introduced hooks through the great vessels and prevented the closure of the semilunar valves, which was associated with the abolition of the second heart sounds. They were, however, unable to describe correctly the origin of the first cardiac sound and thought that it was due to the ventricular contraction.

In 1832, James Hope published his monograph, "A treatise on the diseases of the heart and great vessels." This textbook became a classic and was edited several times.

In his monograph, he described murmurs associated with valvular heart diseases. He referred to the systolic murmur of aortic and pulmonary stenosis. He explained that the contraction of the mitral or tricuspid orifice was associated with an alteration of the second heart sound and a below murmur which "was difficult to hear." Hope, however, did not appreciate the timing of diastolic murmur of mitral stenosis.

James Hope reported for the first time the systolic murmur of mitral regurgitation. In the corresponding  text, he mentioned for the first time chordae shortening as a lesion responsible of mitral regurgitation:

" A slight patescence of the valve [mitral] admitting of regurgitation, may result from a structural lesion not sufficient to present an obstacle to the blood flowing in its natural direction from the auricle into the ventricle, -as that, for instance, from a contraction of the chordae tendineae, preventing the margin of the valve from coming in perfect apposition: and in this way is to be explained a phenomenon which I have frequently noticed; namely, that a murmur from regurgitation sometimes accompanies the first sound, when none attends the second."

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In his monograph, Hope discussed valvular heart diseases in a chapter entitled, "Diseases of the valves and orifices of the heart."

He described the fibro-cartilaginous indurations and ossifications of the mitral and aortic valves. In the mitral position, he distinguished several anatomic topographies "according as the disease occupies the base, the margin, or the whole of the valve." He explained that more severe mitral stenosis was encountered if the disease process affected the margin of the valve:

"Sometimes the membranous portion and free margin of the valve are healthy, while the fibrous zone at the base is cartilaginous, or beset with small calcareous incrustations, or, as sometimes happens, its whole substance is converted into a thick ring of bone. By these depositions at the base of the valve, the orifice is more or less contracted, while the valve itself may remain capable of closing. In many cases, again, the base and middle are sound, and the free margin alone is diseased, its conical processes forming adhesions with each other and contracting the circumference of the valve to such an extent as almost completely to close the orifice."

 He also commented on the effect of the age on valvular ossification (calcification) noting that the prevalence of the disease was greater in patients above the age of 60 years old.

Hope also discussed the etiology of valvular diseases and noted their rheumatic origin:

"Exciting causes of valvular induration.- These are, first, such as overstrain the valves by increasing the force of the circulation; namely, violent efforts, hypertrophy, increased action of the heart from nervous , febrile, or inflammatory excitement: secondly, inflammation of the internal membrane of the heart, resulting from carditis, pericarditis-especially rheumatic, from fever or from any other cause."

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James Hope also discussed the clinical manifestations of valvular heart disease. He noted that obstruction to the blood circulation was at the origin of most symptoms. He also had a great understanding of the effect of valvular heart disease on the myocardium and the effect of ventricular dilatation on the worsening of clinical symptoms:

"The general symptoms, however, when of an aggravated nature are seldom dependent on the valvular obstruction exclusively; they are partly attributable to a co-existent disease of the muscular apparatus of the heart. For, so long as the organ remains free from dilatation, hypertrophy, or softening, the valvular disease, according to my observation, is not in general productive of great inconvenience."

He correctly described pulmonary symptoms of valvular disease: dyspnea, orthopnoea, cardiac asthma, pulmonary oedema, and haemoptysis. He also mentioned rhythm disturbances such as palpitation and irregular pulse, and manifestations of right-sided heart failure including turgescence of the jugular veins, hepatomegaly, splenomegaly and anasarca.

In this section, he again emphasized on physical diagnosis and the stethoscopic signs of mitral valve disease:

"Signs of disease of the mitral valve.- When this valve is contracted, the second sound loses, on the left side, its short, flat, and clear character, and becomes a more or less prolonged bellows-murmur. When the valve is permanently patescent, admitting of regurgitation, the first sound likewise is attended with a murmur. These murmurs are louder opposite to the mitral valve (viz. at the left margin of the sternum, between the third and fourth ribs, i.e. about three or four inches above the point where the apex of the heart beats,) than elsewhere. With respect to the mitral valve, the murmur is diminished when the contraction of the orifice is extreme: when, for instance, the aperture does not exceed two or three lines in diameter; for then, the quantity of blood transmitted is not sufficient to create a loud murmur."

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He finally described in great detail with elegance and modernity the pathophysiology of mitral stenosis and regurgitation. This text is displayed here and deserves to be read entirely.

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James hopes' contributions were of major significance and following his important observations, the auscultatory features of valvular lesions became more precise. His influential monograph was edited by himself for the third time in 1839 and two years later, he died at the age of 40 from tuberculosis.


Pierre-Adolphe Piorry Jean Baptiste Bouillaud