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
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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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    is nothing more in our confessed inability to ilraw sueli pnieticiil inl'eronees from tliese grountls, thun what an abstract considera- tion of the premises would have led us to anticipate. JJoubtless tliere is a cause for each modification of each sound ; but anidogy would lead us to look for this cause anywhere rather than in the nature of the walls of the aperture of sound. At least within certain limits. For by vai-yiug the form of the aperture, or altering tlie mode of propulsion of the current of an*, we can elicit a wide range of soiuids from an instrument composed of almost anything capable of being thrown into sonorous vibrations at all. Or con- versely, an equal variety may bo elicited by varying the mode of propulsion of the current, or the length of tlie tube leading to or from the aperture, while the apertiu'e itself remains unaltered. And the range we can obtain by either of these methods, on any instrument, as far as I know, exceeds, both in tone and pitch, the limits within which the variation of endocardial murmm-s is found to occur. The ease, then, stands thus. Briefly, m Dr. Latham's* woi-ds, Experience does not countenance the belief that the kind of endocardial murmur follows the kind of endocardial disease. Nor, abstractedly considered, and by analogy, have we any reason to think that it should. But, apart from all such general considerations, the daily, nay the hourly variations of the character of endocardial mm-mui-s, in some cases, show that these differences of tone or pitch depend on some cause capable of rapid change, rather than on fixed organic disease. Probably, differences in the mode of the heart's contraction, or in that of the coaptation of the valves, are sufficient to explaiii all these varieties. Probably, from the fact that these temporary variations occiu- during the systole, and at the auriculo- ventricular valves. For where the form and mode of action of the parts is not so susceptible of physical modifications, as, for histauce, dm-ing the diastole, and at tlie sigmoid valves, though we have the same range and variety of sounds, takuig one case with another, yet these variations do not all occur in the same person. Under the circumstances supposed, the Umits of the scale are much narrower. The truth is so very obvious here, on a httle reflection,t that it may seem almost trifling to have dwelt so long on exposing this soiu-ce of fallacy. And it may seem t o * Op. cit. p. 51. t Bouillaud has most happily expressed, in words which lose their force in n translation, the diflTfience between the musical and the ordinary blowini? murmurs. II y a la mOnic diftdrence qu'cntre I'action de soufffer ct celle de siffler.— Mai. du CiKur, torn. i. p. lUO, 2d. edit. be tlirowing needless difficulties in the way, by thus parading all our weaknciscs and shortcomings in the foreground. But we are still inclined to interpret before we understand, to take up with a plausible error nither than to rest in doubt, and so far in truth. As Thucydides* told us long ago, Ovrm araKalwupos rots troWots fi ^^rna-is Tvjy aKrideias, Kcti M to. iroiixa fiuKKov rpeirovTai. And our minds need, no less tlian our eyes, to be warned at each moment not to trust to what is intrinsi- cally unsound, however specious. The determination of the exact position of the heart in the thorax has latelj' oc- cupied a good deal of attention; more, apparently, than the intrinsic importance of the subject could command. For the position of the heart is not so uniform in all cases, as that we need to inquire into the cause of each lesser deviation. The hand and the ear are the best guides to the relative or actual position of the heart, in the individual case; for they tell us not only the present situation of the heart, but the uatm'e of the cause, if so it be, of its displacement. If we can neither feel the apex of the heart, nor ascertain the point of greatest mtensity of the first or second sound, ah accm-acy of diagnosis is at an end. But if these can be made out, we want no further information, than what an ordinary knowledge of anatomy suppUes, for our educated senses to explain the conchtion of the parts in their nattiral or altered relations. But let me not be misunderstood as seem- ing to underrate the valueof theseresearches, in confessing my own mabihty to apply their results to cardiac pathology ; or, as judging of theu' applicabihty in other hands, and to other diseases, from what they have appeared to me in diseases of tlie heart. Whatever value may be assigned them, as contributions to practical medicine, it is impossible not to apjjreciate most highly the talent and uidustry with which the investigation has been conducted bv Dr. Sibson,t who has placed om- knowledge in these ])articulars on so much more sin-e a foundation. Such is, I believe, a just estimate of the comparative value of the indicat ionsattbrded by the time, situation, tone, and intensity, of mm-miu's presmned to be endocardial. Having thus generally glanced at these prehminaries, it remains to apply them to the more particular examination of some of the physical signs of valvidar disease. * De Bello Pelop. A. 20. t MuDicAL Gazettk, 1848; Prov. Med. and Surj?. Trans, vol. xii.; Med. Cliir. Trans, vol. xxxi.