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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    inallbrmnl ion, on llu; contrary, induces sif:;inoi(l riillicr lliaii iiiiriciiio-vcnt.ricuinr clist^iiso; olworving tliis )iri;f'(!r(;nco on l)otli sides oi' till) heart, though still (illecting the left rather than the right side. The various causes which are included under the name of want and intemperance appear to act almost exclusively on the left side of tlie heart, and, by a slight preference, on the sigmoid valves. Ontheeil'ects of three of these causes, namelj', rheumatism, con- genital malformation, and renal disease, there ai-e a few remarks to be made which will find their most appropriate place here. Rheumatism.—It is often asked, what becomes of the patients who are dismissed from om* large hospitals after an attack of acute rheumatism with an endocardial murmur ? In other words, what is the pathological value of an endocardial mm-mur under such circumstances ? Tiie question is very natural and simple, and part of the answer is certain and satisfactory. Some of these patients have no valvidar disease at all, the murmui' is ansemie or functional, and as they get strong the murmur ceases. Some of them, agam, die, at a more or less distant period, of valvular disease of the heart. But the answer, as it relates to tlie re- mainder, is, with all its importance, so very obscure, that it will not be superfluous to point to a few of the causes which have continued to keep it in obscurity, in spite of the industry and intelligence which have been for some years bestowed upon the solution of the question. And the same facts may seiwe to show the gromids on wliich we form our prognosis under these circumstances. Practically, the question is little more than one of morbid anatomy. All other sources from which information might be expected are almost entu-ely closed against inquiry. For comparatively few of the pa- tients who have been the subjects of obser- vation at the beginning of the disease fall again under notice, and stiU more rarely has the same observer the opportunity of watching the disease thi-ough, in one indi- vidual. The same remark, of course, ap- plies more or less to all chronic diseases; but it applies pre-eminently to the results of acute rheimiatism, as pre-eminently the disease of the poor patients of our hospitals. And difBeult as it is to follow up the cases of aU. hospital patients, yet here another difReidty is added, from the fact that a large proportion of rheumatic patients are young persons of no settled habitations, many of them servant-girls, so that they can very rarely indeed be observed, for any length of time, after tliey have left the hos- pital. We may conveniently divide the history of rheumntic valvular disease into three l)eriods. Our knowledge of the first \ie- riod,namely, tliat when tiie valvular i(;sioii ik inflicted, is ])retty complete in all its details, for the application of the cause is readily appreciable; and the effects are easily re- cognized, very c]iara<;teristic, and of not uncommon occurrence. Again, another tolerably well-defined period, is that when life fails under tlie effect, direct or secondary, of obstruction to the circulation by valvular disease; and here, again, our knowledge ig pretty com- plete, for the various lesions may be recog- nized and interpreted with gi-eater faciUty ' f han in most other organs ; and the symp- toms and physical signs are well under- stood. But between these two periodK there is much of the utmost interest and importance almost entirely unknown, and this is the void to be filled up. As far as my knowledge of what has been I' expressed on this subject goes, I think that physicians in general have filled up this- ' void in rather gloomy colom's ; and natu- rally enough, we come to take an unfavour- able view of the question. For we can; * speak only of what we see and know, and: ^ of nearly all tlie cases of which we know anytliing, we know that the disease has gone on from bad to worse, till it has de- stroyed life. And tliis, too, happens natu- ■ ' rtilly enough, because, so long as the pa- ■ tients are weU, they do not ofier themselves • to observation, and we see nothing, except: by the merest chance, of those who have completely recovered. It is only those who have not recovered who fall under notice. So we come insensibly to look upon an . endocordial murmur arising in the com'se.' of acute rheumatism as indicative of the existence of fibrinous growths on the edges of the valves, and upon these fibrinous growths as the fia-st stage of the most serious valvular lesions : for several reasons. First: because patients with an endocardial murmur dying during, or shortly after, an attack of acute rheumatism, mostly present such fibrinous gi'owths ; then, because many patients coming under observation with • confirmed valvular disease of the heart date theu' symptoms from an attack of I acute rheumatism :* and lastly, because <he facts to justify a contrary opinion are so few and so liable to error. All that pathology has to tell us, then, ' serves but to illustrate the unfavourable ' half of the answer; it tells us only what is too obvious to remain long concealed. Wliere there is any thing that can attract a * Boiiillaud (Khumatisme Articulaire, p. xiij. Paris, 1840,) says that of 300 patients with dis- ease of the heart, more than half dated tlieir !• symptoms from an attack of acute artirrJnr . rheumatism.