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.

Ormerod, Edward Latham, 1819-1873.

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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$lar disease through this point of view, than to recapitulate what I will not merely say > oil ah-eady know, but what you have had a large share in originally discovering or estabhshing. One of the rarest of all morbid cardiac sounds is the chrect mitral murmur ; and its origm is attributed, as its name implies, to obstruction to the onward passage of tlie blood tlu'ough the mi'ral orifice. Here is a case in point, showing the correctness of the general opinion :— A woman, past middle age, was admitted with anasarca, and albuminixria, and bron- chitis. Her heart for some time presented no abnormal sound, but about three or four days before her death a murmiu- was audible with the second sound at the apex. On cxamhiation of the body after death, the left ventricle was found dilated; and at a short distance beneath the ring of the mitral valve, with its edge projecting into the onward stream of blood,^thcre was a large coagiilum adiierent. It was evidently some days old ; it had the form of an obliquely- truncated cone, and the upper edge pre- sented to the stream of blood an angle of about forty degrees. In connection with a severe attack of neuralgia which she had suffered from three years before in the right leg, it is of interest to notice, in passing, the existence of a few cartilaginous flakes on the posterior roots of the nerves on the same side of the lower end of the spinal cord. This single diastohc murmm- at the apex is exceedingly rare. I never met with more than one other instance of it. But a double murmur has been recognised at the apex m eighteen cases. Out of these eighteen cases only four are knoAvn to have died,—one during the period of observation, and three at subsequent periods. Eleven of them left the hospital mucli relieved. If, in the absence of more certain data, and of the obsei-vation of single cases watched through the whole course of their disease, it be allowable to infer fi-om the greater fre- quency of muraiurs at one period of a dis- ease than at another, a very em'ious conclu- sion follows with regard to the miu-miu- under consideration. For, on these gi-ounds, it appears to be a moi-e common sign at some distance from the fatal period than durhig the chstiirbance of the heai-t's action which more mimediately precedes death: since, out of many scores of obsei-vations, in only tins one has the double murmur been heard about the period of dissolution. Iho lesion on which this combination depends would seem, however, to be very serious, judging from the symptoms. And m the only dissection which has been ob- tained, two years subsequent to the last auscultation, the amount of the changes was certainly very striking. This patient had annxilar contraction and thickening of the mitral and tricuspid valves m the most extreme degree. The singularity of any sign is scarcely a sufBcient cause for detaining us on the pre- sent occasion. So the reduplication of the first sound at the apex,* which Bouillaud has denominated the druit de rappe/, claims here only a passing mention, and this only lest it should be confounded with the double mmmur at the apex, just noticed, to which it bears so close a resemblance. The distinction, however, is important rather m theory tlian in practice; for my own more hniited experience agrees with that of BouU- laud in connectmg it, like the munnur last noticed, with extensive disorganization of the heart. Still, as depending rather on the hypertrophy which that disorganization has induced, than on the cause of the hypertrophy, it is in so far a sign of less importance than is the double valvular murmiu' at the apex above deseribed.f We need some better term for it than that in common use, namely, the redupli- cated fii'st sound.J The French name is much more expressive. Semetimes an endocardial murmur may be heard by the j^atient himself or by other persons at a considerable distance from liis body. The most probable explanation is that suggested by Laennec,§ who connects this phenomenon with the accidental cu*- cumstance of the vessel where the murmur originates lying in the neighbourhood of a cavity full of au\ This is the generally received opinion; and it was well borne out by the most striking case of this kind which has come under my own observation. In connection with a mm-mur audible at a considerable distance from the patient, a large aneurism was found immediately over * Bouillaud, Des Maladies du Coeur, torn. i. p. 213. t Dr. Williams has heard it sometimes where there was no reason to suspect permanent lesion, but where the action of the heart was languid. —Diseases of the Chest, p. 211, 4th ed. t Sometmies the second sound is redupficated over the sigmoid valve : apparenth from the time of closure of the aortic and pulmonary valves not exactly coincidingp. § Aus. Med. tome lii. p. 133. Dr. Abercrom- bie, Ed. Med. Chir. Trims, vol. i. p. 48, men- tions a curious circumstance, which was noticed 111 one of his patients, of interest in relation to this subject. He attempts to relieve his uneasi- ness by frequent and verv deep inspirations vMiile the lungs are inflated in the state of full inspiration, a sound is heard by himself, aud by a person sitting near him, exactly resembling the loud tick of a watch : it corresponds in frequency with the fre(|URncy of the pulse, and IS only heard while the lungs are fullv inflated ; but It continues to be heard as long as he keeps them inflated, by resting upon the deep inspU ration. ^ D$