Commentaries on the Surgery of the War in Portugal, Spain, France, and the Netherlands / from the battle of Roliça, in 1808, to that of Waterloo, in 1815; with additions relating to those in the Crimea in 1854-55, showing the improvements made during and since that period in the great art and science of surgery on all the subjects to which they relate.

by G. J. Guthrie

If the chest of the dead subject be transfixed with long needles, it will be found that the center of the first bone of the sternum corresponds with the lower edge of the left subclavian vein and to the arch of the aorta crossing the trachea, the center of the second bone to the upper edge of the appendix of the right ventricle, and the center of the third bone to the right side of the right auricle, the right ventricle being lower down. A needle penetrating the chest at the costal extremity of the fifth rib, close to the upper edge of its cartilage, will touch the septum of the ventricle. The apex of the heart is an inch and a half below this, and inclined to the left side.

The semilunar valves of the pulmonary artery correspond to a spot a little below the center of the third bone of the sternum. The aortic valves are a few lines below and behind the pulmonary. The mitral valves are a little lower, and still more deeply seated. The pulmonary artery, after touching the sternum, inclines to the left, and is found close to the sternum between the second and third ribs. The aorta ascends to the first bone, and crosses it to form the arch.

One-third of the heart, consisting of the upper part of the right ventricle and of the whole of the right auricle, is beneath the sternum; the remainder of the right, with the left ventricle and auricle, are to the left side of that bone.

356. On applying the ear to the precordial region, the patient being in the erect position, two sounds are distinguishable in a healthy heart—one duller and more prolonged, the other clearer and shorter; between these there is scarcely an appreciable interval. The period of repose is sufficiently marked before the first or duller sound returns. Of the time thus occupied, one-half is filled up by the first or dull sound, one-quarter by the second or sharp sound, one-quarter by the pause or period of repose.

Twenty-nine theories have been proposed, each accounting for the sounds of the heart. The theory of Dr. Billing appears to prevail at present, which supposes that the sounds thus heard “are caused by the valves, which, being membranous, each time they resist the reflux of the blood are thrown into a state of sudden tension, which produces sound.”

The impulse of the heart, as far as it can be felt by the touch, depends much on the position in which the body is placed. In the erect position, it is heard between the fifth and sixth ribs. In the recumbent posture, the impulse is almost imperceptible. It is perhaps more observable when the body is turned on the right side, but decidedly more so when it is turned on the left. A clearer sound proceeds from a thin, and a duller sound from a thick heart; a sound of greater extent from a large heart, and a sound of less extent from a small one. A more forcible impulse is given by a thick heart, and one more feeble by a thin one; the impulse is conveyed to a longer distance from a small heart.

From a clearer sound we believe in the probability of an attenuated heart, but we argue its certainty from a clearer sound joined with a weaker impulse. A stronger impulse denotes the probability of a hypertrophied heart, but we argue its certainty from a stronger impulse with a diminished sound.

The terms endocardial and exocardial are used to designate the alterations which take place in the sounds of the heart under disease—endocardial when they occur within the heart, and exocardial when they take place upon its surface. The endocardial murmur of disease, or bellows-sound, takes the place of and is substituted in certain cases for the first or second, or even for both the healthy or normal sounds. The exocardial murmur of disease is heard with the normal sounds, but confusing and overpowering, sometimes overwhelming, them by its rubbing or crumpling noise. The natural sounds exist, although rendered imperceptible by the greater distinctness and nearer approach of the unnatural or unhealthy ones.

The heart apart from the pericardium never moves without a sound; the pericardium apart from the heart never gives out one. Under disease the heart gives out the natural sound, diminished, exaggerated, or modified, or it may be totally altered. The sounds given out by a diseased pericardium must always be new, (there being no old ones,) and are described as rubbing, or to-and-fro sounds. The pleura, when diseased, being a serous structure, like the inner membrane of the pericardium, gives out less marked but somewhat similar sounds (the “frottement” of the French) in particular stages of disease.

The alterations in the ordinary sounds constituting the endocardial murmurs of the heart under disease depend principally on the altered state of the endocardium, or membrane lining its cavities; the sounds given off, and called exocardial, on an altered state of the serous membrane of the pericardium, reflected over the outer surface of the heart. The endocardial or bellows-sound, when it accompanies the normal sounds of the heart, may result from any kind of derangement affecting the internal membrane of that organ, particularly rheumatic inflammation, or from any force which may compress its cavities; or it may depend on the altered quality of the blood, from anemia. It should be present after excessive hemorrhages have greatly reduced the powers of the sufferer. When this murmur or sound occurs after injury in the vicinity of the heart, and is accompanied by fever, it indicates inflammation of the lining membrane, although no local pain, no palpitations, no irregular movements of the heart be present.