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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    the bifurcation of the (rachea. Cases, however, iire coiitimially oeeiirring wliere no suoh disposition ol' nciglibouring parts is i'ounil to uxpliiin tliis peculiarity of the mvirnuir. It would seem that the most definite meaning which we can attach to tliis pecu- liarity of being audible nt a distance from the chest, relates more to I lie i-it nation tlian to the cause of the niurmm. In tins way, though it gives no fixed grounds for modi- fying the prognosis of the cases in whieli it occurs, yet, as regards diagnosis, its re- cognition might be useful. For, recol- lecting that a stomach distended with air may conduce, just as well as the trachea or bronclii, by its proximity, to the mani- festation of this peculiar sign, we may look here for an explanation of the cardiac symptoms which sometimes accompany an attack of dyspepsia. For, the same cause which, by distending the stomach, disturbs the heart's action and causes the murmur, may also make t ;e murmur audible at a distance fi-ora the patient. But in illus- tration of this I have not at command a case sutEciently in point to offer to your notice. The study of the exact mechanism of abnormal murmurs is one of exceeding beauty and interest, though it must bo confessed that it is wholly inapplicable to treatment. Why these mm-murs should come and go, what are the causes of their variety, why in this the stress should rest on the beginning, in that on the end, are all questions which arise so often, that, out of sheer curiosity, to rank the feeling no higher, one is very anxious to have a satis- factory solution of them. A means of imitating, after death, the exact mode of play of the mitral valve dm-mg life is here the great desideratum. For there is reason to think that many of the varieties of par- ticular cases may arise from peculiarities in the form of the lesion, rendering this valve (in relation to which the varieties most often occur) inefficient at particular stages of its action. Some of these differences, however, admit of explanation. The commonest, and probably the most im]3ortant defect in the mitral valve, is where the edges do not fit after the valve is shut to ; and where, consequently, regm-gi- tation takes place through the apertui'e during the contraction of the ventricle till the complete obliteration of its cavity. A murmiu' indicating this condition, however arismg, whetlier from thickening or per- foration of the valve itself or from shoi'tcn- ing of its chorda) tendmece, begins sud- denly with the first sound, and fades gra- dually un( il the oc(Jurreuce of the second sound, which coincides with the cessation of the contraction of the ventricle. But Honietinics the murmur at tlie apex, instead of suddenly rising to its iiiaxiinum of in- tensity and gradually declimiig, rises leas abru))tly, but suddenly falls with a smart click and jerk sensible to the hand all over the cardiac region. From careful ex- amination, it appears that this click and jerk are really tlie termination of the first sound, which the murmur accompanies, but does not follow. It may hence be hiferred that regurgitation takes place with a mur- mur thi'ough the jnitral aperture until the walls of the ventricle have approximated so that the edges of the valve can meet. The valve, being in itself sound and efficient, now precludes all regurgitation, and checks the stream suddenly, thus sending back an impidse nearly equal to that of the con- traction of the left ventricle, only more sudden; similar to what we may produce by suddenly checking the flow of a stream of water or air through a tube. It may here be objected, by those who only care to establish the fact that there is disease of the heart in a particular case, that tliis is a useless refinement. And the force of the objection could not be denied, w:ere this refinement the only object attam- able. But, with time to observe, and an unlimited field of observation, the interest of solving one of these problems is very great. And the ear, taught in this diflicult and complicated inquiry, finds itself more pei'fectly at ease among the ordinary inci- dents of daily practice, where more im- portant results than the solution of curi- ous problems hang on its accurate percep- tions : For it breeds great perfection if the practice be harder than the use. I cannot meet this objection in more forcible words than those of Dr. EUiotson on the same subject.* To condemn accurate diagnosis is to condemn accm-ate know- ledge,—to rest satisfied with imperfect in- formation, when industry would give us more, is to admire ignorance when know- ledge is withui our reach. By thus accurately determining when and where murmm's are loudest, and the chai-acter and history, so to say (though the liistory be that of less than half a second of time), of each murnim*, we learn to separate several somids from the category of indications of valvular disease. It ap- pears worth wliile to notice a few of those of most common occuiTcnce in practice. Such are the muscular murmiu', if it be correctly thus designated, the pericardial murmur, and metallic cliquctis. And to these have been subjoined a few remarks on purring tremor in its relation to organic * Lumleian Lectures, p. 5.
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