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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    tako plonsuvo in being nuscviltod niid vimde objects of iittoiition. Jiut us soon us (hey are loft to tiicmsolves, their eyes Ox again upon some object, andtliey lie looking at it without apparently nolioing it, like liguren in wax. Tho expression w quite different in per- son.s of more adv need ago ; it is no longer one of placid quiet, but of anxiety untl pain. There are still tho same constrained unnatural postures, and tlio same fixed yet vacant gaze, but the face is drawn and livid, the lij)s are bhie and pinciied, tlio C loeks are of a dusky purple, and wiierever the skin is put upon the stretch by subjacent parts, vessels may bo seen rami- fying just beneath tlio siu-face. Conunonly the skin liangs in a fold from the lower eyehd, so as to expose the dull dingy con- junctiva covering the sciorotic ; bloodless, indeed, but wanting that pearly white which we see in anaemia. Much as bron- chitis has to do with the siili'erings of these patients, and with tliese particular appear- ances, yet attentive observation will recog- nise here qmte a dillerent expi-ession to what we see in connection with that dis- ease. Tliere is neither the intense restless agony of the present attack, nor the pas- sive endiu'ance when the acute stage of bronchitis is past. But to an expression which might suit with the most urgent distress and despau', there is joined a quie- tude of demeanour which might betoken perfect resig-nation. In all the ]3atient's distress and uneasy movements, tne gi-eat object of Ids eflPorts is to maintain the most complete rest. As if it were a question whether to bear the present posture, or the wearying search after one more tolerable to his feehngs, were the greater misery. He cannot bear to be at rest, for rest biings lum no relief; he seeks but in one to be freed from the feeling of another pain.* II. The effect of valvular disease on the heart itself in producing hypertrophy or dilatation of its walls or cavities respectively, enters into the pathology of the secondary complications of valvular disease to such an extent as to require preliminary con- sideration. Hypertrophy and dilatation, like most scientific words in very common use, are not always apphed with strict precision to the things intended to be so designated. In then' ordinaiy acceptation, however, these terms are quite sufficient for most, as for the present purposes; the one or the other, or both, being employed as the condition thereby expressed predominates. Hyper- trophy, indeed, almost always imphes tlie CO-existence of some degi'ee of dilatation, and the converse. Dilatation would soem to be most com- monly ])redominant on tlie riglit side of the heart and in the auricles, cssentiiiily the feeblest parts of tlie organ. Ilvpcr- tropliy is found most often, and man*ife»ts itself most strikingly, in the left ventricle, essentially tiie strongest ciian;ber of the lieart. ihit as disease of tlie puhnonar> valves is as surely followed by hypertro|jhy of the right, as is disease of the aoi'tic valves by that of tlie left ventricle, tlie ex- planation why somt'tunes dilatation ensues, and sometimes hypertrophy, must be sought rather in the difference of their causes tlian in that of the oonstitution of the two sides of the heart respectively. Dr. Hope says :*— The exciting causes of hypertrophy are equally those of dilatation ; and suppo'-iug no unknown agencies to interfere, it de- pends on the proportion whicli tlio cause bears to the reacting energy of the cavity exposed to its influence, wlietlier that cavity become affected with hypertrophy, with dilatation, or with a combination of: the two. It may be said generally, tiiat when congestion is constant in a cavity, dilatation is more commonly the result; and that when there is only resistance to the expidsi'~>u of the blood, vrithout; constant ei j:)rgeraent of the cavity, it is- more common for hypertrophy to be pro- - duced. Contraction, for instance, of the aortic orifice, causes hypertrophy of the left ventricle in a greater degree than dila- tation ; whereas, patescence of that orifice, attended with regui'gitation, and constant engorgement of the cavity, causes dilata- tion in a greater degi-ee than hypertrophy. Perhaps this is as near the truth as we are likely to attain, for the principle is not of very generally precise application, the causes being commonly mixed : but when an opportunity does occm' of watching the efiects of these causes separately, the residt: is agi-eeable to Dr. Hope's observation. Thus, emphysema and chronic bronchitis, which always cause more or less obstruc- - tion to the circulation, but on occasion for a while completely inteiTupt it, and cause the blood to accumulate on the right side of the heart, induce dilatation of these cavities. Grranidar disease of the kidney, on the contrary, where the obstruction to the cumulation is tolerably unifoi-m, and habitually sm-mounted, induces hyper- trophy of the corresponding ventricle. It would seem, too, that hypertrophy ensues rather in the robust, dilatation in the cacliectic and weakly. And, as a corollary to this, dilatation more commonly affects both sides of the heart than hypertrophy is found to do. * Arctseus de TonsiHanu« iilccribus. * Diseases of tlic Heart, 3d ed. p. 250.
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