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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    right side of tho heart is more rapidly fatal tlittu disease of tho left -valves, 1 am not able to dcteniiiiu!; for theordinapy results of praetiee give no means for sottiijig tliis iliiestion, whieh it must be allowed that the more limited observation of less equi- vocal cases leaves doubtful. We cannot, in the majority of cases, judge of the abso- lute pathological value of disease of the right side of the hetu-t from its ap]iarent ell'eets ; for these are usually mixed with, and, indeed, based on, the ell'eets of disease of the left valves—namely, on a condition of tho ]iulmonary similar to that of the systemic capUlarios. And by the time that the efleots of the obstruction have readied the systemic capillaries, they have made themselves felt jiretty well all tlirougli the circulation. For by this time the dis- ease has probably assumed a very serious aspect, from the secondary affections of tho left side, independent of this new soxiree of danger and distress from those of the right. Whatever be tlie importance of func- tional imperfections of the right side of the heart,—and great, confessedly, it is,— yet they should hold a lower place, patho- logically, than diseases of the left—the effect, to wit, being lower than the cause. For dilatation and hypertrophy—the indices of the virtual amount of imperfection—are, with two exceptions,* rarely met with independent of organic valvular disease, that attribute of the left side. All expe- rience agrees in placing, on such grounds, disorganization of the left side of the heart first in the series of changes, and assigning to it the highest importance. Functional imperfection of the tricuspid valve, and consequent disorganization of the right side of the heart, however fre- quent and serious its occurrence may be (and I may, with many others, have often erred in overlooking its existence), is com- monly but a secondary effect of disorgani- zation of the left side.f * Viz. dilatation of the right side of the heart, consequent on pulmonary, and hypertrophy of the left, on renal obstruction. t The subject of functional imperfection of the right side of the heart engaged the attention of the late Mr. Wilkinson Kiii^''(Guy's Hospital Reports, vol. ii. p. 104) and others. More re- cently, l)r. Blakiston (l)iseasesof the Chest) has pursued the subject in its patliological bearings. Of the fact that th.; tric\ispid doi's not act as perfectly as the mitral Valve at all time;-, ther^ is scarcely room to doubt. Of the caus-- of this imperfection there is some dillerence ofO|iinion. Physically, indeed, I think we must admit that the tricuspid valve is less ellicient than the mi- tral,—as tar, at least, as the very simple, but very equivocal, experiment of injecting water backwarc's against the valves of tlie dead heart goes; but that rcsrurgitation always takes place at each contraction of the right ventricle is scarcely admissible. The hypothesis that tri- IV. In the nature of the secondai \ affections theinsi^lvos, abstractly considen-d, there is little iM'culiiir; but in the mode (jf their treatment and tlie choice of remedi(.-s there is mueli to be remarked. The broii- chitis, for instance, which ensues upon disease of the heart, does not diff'er in such a way from tliat whicli arises in con- nection witli disease of the kidneys or ein- physema that it could be certainly recog- nised as such at first sight; hat the difference may bo well made to appear in the treatment. From this pohit of view the secondary affections have been cliirfly regarded in the following remarks. 'Ilic cure, indeed, of the original disease is n matter to be left out of consiileration ; but its existence and continual agency nin-l never be lost sight of. Our treatmcjit must relate entirely to the secondary symp- toms ; but it must be modified by llic knowledge that, as the cause of the di- ease will still remain behind, the same thing may still have to be do:ie over and over again, and each time under less fa- vourable circumstances than before. Yet, indeed, these are not cases to leave alone, nor routine cases, to all of wliich one uniform plan of treatment is applica- ble. Each case is a study of itself; and, provided only that the nimin medici dtligenlia do not place the patient in a worse condition to resist any futm'e at- tacks, there is no cause to fear doing too much to relieve these patients. And the close attention to their symptoms wliich such a plan of treatment would involve, is now and then rewarde:l by the discovery of some ha]5py idiosyncrasy with regard to the effects of particular remedies, or of the action of particular organs on the system at large. Our knowledge of diseases of the heart has advanced much since the time of Senae ; but could the most accomplished physi- cuspid regurgitation takes place on occasion, when required, by dilatation of the right ven- tricle, tlie segments of the valves being by this means drawn asunder, in consequence of the di- vergence of their bases, is more satisfactory ; and Dr. Blakistoa's patholofi-ical obsenations of cases where dilatation has become the abiding condition srreatly favour this view. But I tliink that all puiely physical explana- tions full far sliort of the truth. The more com- plex structure of the right ventricle, and its comparative immunity from disease, sciin to show that its functions are of a less >:ureiy me- clianical nature than arc those of the left. Apart from these very important considerations, to which Dr. Williams (Diseases ot ihe Clie.st, ji. 266) has called attention, it would be difficult to believe that so impoi taut a function as the regu- lation of tlie pulmonary circulation had been left to any mere mechanical conrrivtmce. how- ever beautiful, and that no remedy had been provided, midcr such circumstances, against comrestion of the lungs, short of that degree which should thus relieve itself by forcible dis- tension of the right ventricle.