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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$•10 mnnifestation. Notloing moving in onu tliroctiuii only can bo, in bo far, in a state ol' vibration; and the foroo boing, in'tho caso sui)i)osed, exerted in one direction only, a eertain degree of tension or elasti- city of the parts is required to ensure alter- nate motion and vibration. This condition is wanting in the cases under examination ; for such regiu'gitant or direct stream, as the case may be, flows not into a cavity whose walls are at this degree of tension, but into a loose yielding bag, as it were; and, under ordinary circmnstances, as soon as tlie walls of this cavity have acquired that degree of tension, the currents are in- terrupted or reversed by the regular move- ments of the heart. An instance occurs now and then clearly showing that the rule which has been proved for simple tubes does apply to the comjilex arrangements and action of the heart; and enough is generally found on dissection to explain why the purring tremor should have been perceptible at some one given point in jjarticular cases : but it is commonly very diiBcult to ascer- tain why it should have been perceptible only at one, and why particularly at that one point. Perhaps the above considera- tions may tend in some measm'e to remove that dilRculty. Probably, too, the direc- tion m which sounds connected wdth lesion of particular parts have a tendency to be propagated, is an important element i]i the explanation of each individual case; for there is no reason to doubt that purring tremor, in this respect, obeys the same laws as valvular murmiu*s. There is one case seemingly so very ap- posite, that it may at first sight appear strange that the whole of this question has not been discussed on that ground— namely, the case of anem-isms. The evi- dence, hovtever, from tliis source is almost entirely negative; for a piu-ring tremor is far from being a constant, or, indeed, a common, sign of the existence of an aneu- rism : and the so-called aneurismal thrill, said to be perceptible in the pulse, has its origin, to my experience, where not in the state of the heart of the patient, in the imagination of the observer. The structural conditions requisite for the manifestation of purring tremor are, indeed, seldom present in anem-isms. For the common form of aneurism—the false one, nosologically speaking—is not an elastic bag, to be emptied by pressm-e, but a hard mass, with thick unyielding walls. Nothing could be better calculated to stop the transmission of any vibration tlian these walls, with their iri'egularly laminated structure and unequal consistency. And their linn unyielding nature would render tlie blood in their cavity very unHkely to originate any vibrations. For, havuig no power of eiii])tying itself, the cavity must always be nearly fuU : so the amount of blood injected at each contraction of the lioart would be very small, and commonly inider scarcely any greater degree of pres- sure than the blood already in the aneu- rism. So tliat aneurisms have, on both these accounts, as originating or transmit- ting vibrations, but httle to do with the matter under discussion, generally speak- ing. Generally speaking : but when there is a cavity with thin elastic walls, traversed by a stream of blood, and capable of considerable changes of dimension, possessing, in fact, those properties which a common aneurism has not, then this tremor is manifested in the greatest perfection. Thus we &i\d it in aneurismal vai-ices,—thus in the true noso- logical aneiu-isms ; and thus it may be pro- duced in the large superficial vessels of almost any person, but especially of the anaemic, by artificially applied pressure. II, FUNCTIONAI, MtJEMITES. In what has been said above of the phy- sical diagnosis of valvidar disease, each mm-mur has been referred, as far as might be, to its specific local organic cause. But there has been fi'cquent occasion to remark on the necessity of distinguishing each organic from its corresponding functional murmm-. Much,indeed, of what might have properly found its place here, has already so been anticipated; and, but that the im- portance of the subject of functional mur- ■ mm's claims a separate consideration, nearly all that remains to be said here might have • been with equal propriety inserted in the • preceding remarks on organic mm-murs, so • closely are the two subjects interwoven in i practice. To the practical rules by wliich the dis- • tinction between functional and organic • murmurs is to be made, there is nothing ; here to add to what has been already said; for, lay down what rules we may,, the diagnosis is at times very dilBcult, whe- ther the physical or the constitutional I signs, or both, be consulted. It cannot be • facihtated by multiplying rules of uncertain . appUcation, but rather by making these • rules more practically intelligible. No very long experience is wanted to > show that there is scarcely any one of the • ordinary endocardial murmurs fro)n which we are in the habit of mferring the existence of valvular disease, which may not co-exist with a healthy condition of the valves. Even the diastohc murmiu* at the base is • not free from tliis fallacy in connection with the neighboui'ing veins. Were our knowledge of heart diseases during life.$