On the pathology and treatment of valvular disease of the heart and its secondary affections : being the Gulstonian lectures, delivered at the Royal College of Physicians in February 1851 / by Edward Latham Ormerod.

  • Edward Ormerod
Date:
1851
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Licence: Public Domain Mark

Credit: On the pathology and treatment of valvular disease of the heart and its secondary affections : being the Gulstonian lectures, delivered at the Royal College of Physicians in February 1851 / by Edward Latham Ormerod. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    Tliis, liowcvcr, is quite sufficient for (lie iliiignoflis ill those enscs wlievo tlie entire iibseiice ol llio niurniiir irom the oonrse of the asc'ciuUiig iiorln, or from a corrcsponcl- iiig sitiiiition on tJie right side of the chest, clearly shows it not to have its existence in that vessel.* The determination of the existence of a inurinur in the pulinonurv artery is, in fact, easy enough. The distinction, however, is not urgetl here merely as a refinement in the ))artieular diagnosis of valvular lesions, but rather in relation to the most interest- ing, yet most obscure jiart of cardiac patho- logy—the distinction between functional and organic rnurmui's of the heart, to much of vvhicli I believe that this is the key. For, under these circumstances, a comparison of diderent observations —that is, of ausculta- tion—tells us sometliing more than that the murmur is here or there; practising the oar like intricate scales in music, but leading to nothing beyond. It tells us something of the cause of the murmur : for disease of the j^uhnonary valves is so ex- ceedingly rare, that m an enormous majority of cases we may certainly infer that pul- monarj' murmurs are independent of organic changes. The recognition of a mm-mur in this situation inclines to a favourable mter- pretation of all other murmurs in the par- ticular case; for it renders probable the present active existence of a cause, other than organic disease, adequate to their ex- planation. At the same time, it supplies additional means for ascertaining the cor- rectness of such an interpretation: for it uici'eases the field of observation of the variation of murmurs. For instance: if a murmur be heard always at the base of the heart, the presumption is, that it depends on an abiding—to wit, an organic cause. But if, though always audible at the base, thus generally expressed, it be sometimes audible in the aorta only, and sometimes only in the puhno..ary artery, the case is quite altered. All tlie doubt and anxiety which hang over the long continuance of an endocardial inurniur are cUspcUed, when that murmur, as under such circumstances, is clearly shown to be independent of or- ganic changes of the valves. Without exploring the subject of proba- bilities to determine what is the exact diagnostic value of the fact of the recogni- tion of a murmur in the pulmonary artery in relation to other co-existmg nuirmurs in jiarticidar cases, it may be said, for all ])ur- jioses of practice, to be very considerable. But it would be better for each one for * Dr. Latlmm notices tlie frequent occurrence of a iniirinur witli such nrpative evidence of its lieiug in the pulmonary artery in cases ot plithisis. Op. cil. vol. i. p. Of). 'See, n'lso, Med. G.^z. vol. X.X. p. U. Ur. Officr Ward. himself to determine its just value, than to rely on any general uilerences, where the coiiBoquences of an error may be so serious. It may aiijiear very irrational to tiiiiik one way and to act another; but however justly we may he assured that the frequency of alfectioii oi' thelieart in rlieuiimt ii^in is much oveiTated, still we are not justilied m with- holding the apiirojiriate treatment from particular cases on the strength of such a belief. And this, too, though we may seem to hold the right clue in our hands: for the same process — namely, tlie rigorou< investigation of the subject with the ste- thoscope and the scalpel, which assures us that the right valves are generally healt hy— proves how very often the left are diseased. The safe rule for practice, as applying to acute cases where the lesion appears to be progressive, is this:—A puhnonary mur- mur, if it be the only sign of endocardial lesion, may, under almost all circumstances, be disregarded: but when co-existing witli an aortic or mitral murmur, its co-existence shoidd not bhud us to the possible impor- tance of those other mm-murs. It is true that the signs from the left valves mat/ mean as Uttle as those from the right, but they mai/ mean much more ; and in neglect- ing them we mai/ be losing the favom'able moment for treatmg organic disease. Sinking, however, the use of tlie recog- nition of a pulmonaiy miu'Uiur to its lowest degree—that, namely, of giving us a hint often, and an assui'ance now and then, still, recollecting how obscure these cases oi'ten are, we may often turn it to the best ac- count. Keeping witliin every limit of even the most superlative caution, still I believe the value of the recognition of murmurs in the puhnonary artery to be very gi-eat; and havhig for some years paid much attention to the subject, have found no reason to deviate from this opinion lormerly ex- pressed.* It is scarcely possible to cultivate any part of a subject hkc practical medicine for any length of time witliout obtaining infor- mation, either in itself new, or as a new form of expression or confirmation of a recognized truth; and the practice of St. Bartholomew's Hospital seems to have sup- pUed two or tln-ee instances of the latter in connection with the present inquiry. It appears better, on the present occasion, to regard om- knowledge of the signs of valvu- * K(l. Med. and Sure- .Tournal, vol. Ixv. Two ilieuniatic cuves tlicrc montiuned in tlic second talile liiive since eonie under notice. In one the murmurs liad all disappeared; in the i tlicr the apex nnirnivir and the inuriiiur in the luiisrs hnd disappeared, and the existence of a inurnnir at the base was very iiuestionahle. She was then, however, sull'erinf? from another attack of rheu- matic f< ver.
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