Multiple congenital cardiac lesion : a clinical lecture delivered at the university hospital / by Wm. Pepper.

Date:
1889
Catalogue details

Licence: Public Domain Mark

Credit: Multiple congenital cardiac lesion : a clinical lecture delivered at the university hospital / by Wm. Pepper. Source: Wellcome Collection.

Provider: This material has been provided by the Royal College of Physicians of Edinburgh. The original may be consulted at the Royal College of Physicians of Edinburgh.

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    all improbable that the systolic murmur heard over the body of the heart is largely the transmitted pulmonary murmur. Therefore, in view of the fact that this child is apparently so well, and has been free from colds, coughs, con- gestions, oedemas, and the like, I hesitate to say that there is a mitral regurgita- tion in addition to aortic insufficiency and pulmonary stenosis. My impression is that we must regard the pulmonary stenosis as the chief lesion, that we must regard the left cavities of the heart as fairly sound, that we must explain the aortic murmur, as far as possible, by the condition of the ductus arteriosus, and that we must be forced to admit some aortic implication, but that we must fight against the admission of mitral disease. Why has not this child cyanosis ? Why is there not blue discoloration and clammy fingers ? Is it the case that, in spite of this tremendous murmur, the roughness of the pulmonary orifice, is, after all, not so very great? You know you cannot possibly tell by the intensity of the murmur how great a valvular lesion is. Some of the loudest murmurs that you hear are murmurs that are caused by small patches of roughness with very strong heart muscle driving the blood rapidly and powerfully over them. Some of the most serious lesions, where it seems that life can scarcely be prolonged, are not attended by marked murmurs, because the heart is not able to drive the blood forcibly enough through the opening to produce such a murmur. Now, it may be that, while the pulmo- nary orifice is diseased, and while there is a calcareous rough ring or hard fibrous ring with little vegetations, and while the enlarged right ventricle, driving the blood through this, causes this transmitted murmur, the amount of actual obstruction is not so extreme, and this would explain why the admission of a certain amount of blood through the ductus arteriosus to the pulmonary artery, would keep up the equilibrium of circulation, and preserve the child from c} anosis or serious congestions. Lastly, the auricles of this heart are enlarged, and there is a mechanism in the auricles, as you very well know, the foramen of Botal, with its valve, which is in foetal life open, and which is an expedient to permit the excessive pressure of the right side of the heart to relieve itself by the passage of the blood into the left auricle. Now, if this be a congenital lesion, would not the excessive tension of the right auricle have prevented the closure of this fora- men ? You know that the foramen ovale closes a few days or weeks after birth because the balance of pressure becomes equal, the valve is held vertically between the auricles, it secures an attachment, and closes the foramen. But, in a case like this where there must be an excessive tension of the right cavities of the heart due to obstruction at the pulmonary orifice, this occurring in foetal life must have kept that foramen from closing, must have prevented the valve from becoming adherent. Hence, I would add unhesitatingly here, that we have a patulous foramen ovale, and I think very likely, some of this diffuse humming murmur heard here over the upper segment of dulness, is due to a current passing from the right auricle into the left auricle. So that the total diagnosis of this case is—congenital cardiac lesion ; the initial lesion, endocarditis of the pulmonary orifice with stenosis and roughen- ing ; consecutive changes, the inability of the ductus arteriosus or foramen ovale