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

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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$question is one, if not of importance, at lonst, of frt'ciuont occurronco; and it is of especial interest with regard to a subject previously under discussion—namely, the diagnosis of ]3ulmonary mumiurs. The real dilUeidty lies rather in their discrimi- nation from such cu-cumscribed pericardial than from aortio murmurs. 3. Melallic cliqnetin.—Occasionally there may be heard over the region of the heart a very jieculinr soimd, to which the name of metallic cliquetis, or tinnitus, or costal percussion, lias been appUcd. In tlie in- terpretation expressed by the use of the last api^ellation both Hope* and Bouillaudf agree, and Hope gives some details expla- natory of the mode in which the sound appears to him to be produced. LaennecJ explains the occurrence of this sound in the same way by costal percussion— Wlien the heart, beating in a sharp and rapid manner, though without any really forcible impulse, the apex oidy comes to strike the walls of the chest. Now, ob- viously, this explanation is somewhat shaken by the fact that this peculiar sound —which there can be no question about, for any one may produce it quite pure for himself in the way specified by each of these observers §—is not always audible at the apex in cases where it may be heard at the base of the heart. Dr. Hope correctly remarks that thin nervous persons are the most common subjects of it, but they are not exclusively so ; and this fact again impairs the general appHcability of the details of his explanation. The sound may be, and I beUeve is, trivial, and almost whoUy unimportant; but, for all that, we need not accept a wrong or an unduly limited explanation. I have met with it under four different conditions :—First, in nervous ansBmic sub- jects, when the action of the heart was sharp ; secondly, with more violent action of the heart, imder circumstances which have led me erroneously to conclude, from the thu'd condition with which I have less frequently found it connected, that it was indicative of the commencement of periear- ditis. The fourth condition with which it has been found connected is a rough, almost scaly, state of the pericardium about the base of the heart; and perhaps a fifth might be subjoined, but for the fact that it s not always constant under these circum- stances—namely, adhesion of the pericar- diu.m, with which we may class the occur- 1 enoe of this sound over an aneurism. Dr. * Op. cit. pp. 41, 602. t a5uv. cit. tome i. p. 218. ± Tome iii. p. 105. § By layinff the palm of the liand over the ear, and lightly tapping the back of the hand with a finger. Latham tells me that he frequently meets with it in children, in wlioni he has noticed that it may be entirely susjjended by a litf le pressui-e on the walls of the chest. What should be the conclusion from these facts ? The explanation by cohtal pere\i88ion is insufficient: it does not take in all the cases. The explanation by aifec- tion ofthepericai'dium again is insufficient; certain as far as it goes :* yet tliere is positive proof, in the continuance of tlie sound after the two surfaces of the pericar- dium have become adherent, that the ex- planation does not go all the way. Tliei-e are, then, three explanations of the mode of production of this sound—namely, costal percussion, friction of free surfaces, and movement of connecting areolar tissue. Each probably apjilies to a limited number of cases. There does not appear to be any one general explanation ; nor, considering the nature of the sound, ought we perhaps to look for one. 4. Purring tremor is a sign which natu- rally attracts much attention. Really, it means little more than any valvular mur- mur heard under simdar circumstances.f It is important, therefore, to dwell on aU the facts wliich detract from its value as a certain evidence of irreparable organic dis- ease. Purring tremor may be produced either by the action of causes wholly external to the blood-vessels, or by abnormal condi- tions, organic or frmctional, of the blood- vessels themselves ; or, lastly, by changes in the composition of the blood. Pericar- ditis occasionally furnishes an instance of * This interpretation is favoured by three of Bnuillaud's cases (28, 30, 73), where metallic cliquetis was noticed in connection with traces of inflammation of the pericardium discovered after death. t Opinions are at variance on this matter. Dr. Hope (Diseases of the Heart, p. 123} says that he had never known tremor to exist in the heart independent of organic causes. Bouillaud (Mai. du Coeur, tome i. p. 182) takes the opposite view. Laennec (Aus. Med. tome iii. pp. 123, 130) says that he has frequently no- ticed its occurrence without there being any organic affection of the heart, and quotes a case where the tremor was produced by a simple change of position. And Andral (CEuv. cit. note, pp. 123-5), while he cautions us about ac- cepting Laennec's statement, and maintains an opposite opinion, quotes a case where this sign depended on at least a removable cause. l>r. Graves (Clin. Med. p. 926, 1st edit.) gives the particulars of a veiy striking case, where the tremor apeared to be independent of organic change. My own experience is to the effect that this sign is usually manifested in the most severe case? of cardiac disease, but that it does not infallibly indicate the existence of such dis- ease. The three most striking cases of tliis kind that I can recollect presented in two cases dilatation of the right auricle, while m the third the auscultatory signs of cardiac lesion were removed, and I believe that no organic disease ot the heart or vessels ever existed in this patient.$