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May 5, 2021
19th Century Walter Hayle Walshe

Walter Hayle Walshe (1812-1892)

A practical treatise on the diseases of the lungs and heart, including the principles of physical diagnosis. London, Taylor, Walton & Maberly, 1851.

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Walter Hayle Walshe, of Dublin, was professor of medicine and physician at University College Hospital in London. He studied medicine in Paris.

Walsh published his textbook entitled, "A practical treatise on the diseases of the lungs and heart," in 1851. Following the tradition of the French school of medicine, he stressed the importance of newer techniques of physical diagnosis throughout his book as indicated in the title. Walshe's monograph was the most popular textbook in cardiology and was studied by the English physicians who were candidates for the membership of the Royal College of Physician. This textbook remained a reference for a quarter of century and its fourth edition appeared in 1873. This treatise of 542 pages covers all aspects of cardiothoracic disorders. There is a detailed section on cardiac auscultation and several chapters on the diseases of the heart.

Walsh was one of the first British physicians to recognize the presystolic character of the direct mitral murmur in mitral stenosis in 1851.

In the chapter on cardiac auscultation, regarding the murmur of mitral stenosis, Walshe wrote:

"A diastolic murmur, of maximum force, immediately above and about the left apex, and conducted on the same principle (though less extensively) as the systolic murmur of the same seat, indicates obstructive narrowing of the mitral orifice, or simple roughness of the auricular surface of the mitral valve, or both...I have spoken of this murmur as diastolic in rhythm; but in point of fact it is rather post-diastolic or pre-systolic, than precisely coincident with the diastole. This murmur is not very unfrequenlty wanting, where constriction is found after death. Sometimes this may be fairly referred to the weakness of the auricular systole and smoothness of the constricted orifice; where the constriction is slight, there will be but slight friction too. When deficient, as it has been, in cases of extensive contraction, Hope thought the deficiency depended on the very fact of the extreme smallness, - an explanation not over plausible. I have known this murmur come and go from day to day in a case where the mitral orifice was very greatly contracted and rigid."

Walshe was among the first British physicians to use the term "endocarditis" which was introduced by Bouillaud in 1835. This term was used to describe valvular lesions secondary to both rheumatic fever and infective endocarditis. The latter was not identified yet as a separate clinical entity as the field of microbiology did not exist. Walsh's textbook contained an interesting chapter on acute and chronic rheumatic endocarditis. In the acute phase of "inflammatory endocarditis", he classified valvular lesions in order of frequency as follows: "aortic obstructive; mitral regurgitant; aortic regurgitant; aortic obstructive and mitral regurgitant together."

He then formulated several hypotheses regarding the mechanism of production of murmurs in the acute phase of the rheumatic fever: "the murmurs of acute endocarditis are produced by roughness on the surfaces, by interwined lymph (or mere fibrin) interfering with the play of chordae tendineae, or, probably by non-closure of orifices through irregular action of the papillary muscles."

In this chapter he also discussed the clinical signs, evolution, prognosis and treatment of this condition. He recommended blood-letting and mercury for the treatment of rheumatic endocarditis.

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The section on the valvular heart disease entitled, "Diseases of the orifices", is also of great interest.

Walshe described in great detail and clarity mitral valve lesions resulting in stenosis or regurgitation. He was among the first authors to use the term "calcification" rather than "ossification" to describe advanced rheumatic mitral valve lesions. In his monograph, He distinguished lesions affecting the leaflets, the annulus and the subvalvular apparatus. Commenting on mitral annular lesions, he described isolated annular dilatation which would lead to mitral regurgitation and annular calcification which would result in mitral stenosis.

He then continued with the description of clinical signs and diagnosis of valvular heart diseases including mitral stenosis and regurgitation. He emphasized the importance of auscultatory features of these diseases in the physical diagnosis. He also discussed the impact of ventricular hypertrophy or dilatation on the intensity of a cardiac murmur.

Regarding the treatment of the valvular heart disease, Walshe recognized the limited options available at his time and suggested early treatment of rheumatic arthritis:

"...Valvular disease once chronically established cannot be cured: we can neither remove deep seated induration-matter, atheroma, nor calcareous substance, nor lengthen tendinous cords that have been shortened by morbid processes. Hence the importance of at once guarding as much as possible against one of its frequent causes, acute articular rheumatism, and of preparing for the active treatment of acute endocarditis the moment there is reason to suspect its immediate advent. But though these diseases be anatomically incurable, their worst functional effects may be long,...,Whatever be the valve implicated, the treatment is directed not towards its own disease, but towards the moderation or prevention of hypertrophy of the muscular substance of the heart or dilatation of the cavities, and the removal or relief of any symptoms that may rise."

Walshe's chapter on "Diseases of the orifices" is displayed here.

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Jean Cruveilhier William Stokes