An Inquiry into Certain Points Connected with Albuminuria
Authors: R. Saundby
Journal: BMJ (1880)

JQflN4.~~~~~~~~~~~~~~~~~~~e.$4 given square areas of gudface above and below the -?seinilunar-valves i , equal, whether those valves be present and -efficient, or be absent Granting thisy hbw can Drs.'F&tex nd'Fothergill refine upon supposed sets given to the current this' Was', ahd that as they Would reasonl of water in a closed culvert or in a-raitx water pipe?-Nor again, can admit the right of the author to find tn diminished 'tensi&n any 'such,explana tion as he assume's.:' Tension does' not depend upo !the forie of the heart-beat, but upon those nervous adaptations to *ihkh Dr. 'Fotherg;ll so eloquently appeals.-MAoreover,were it not so, he-will scavoely-deriy that tension is equal at any and all points say of the inter gnrface of the ventricle and of the aorta.This being so, hlow'can the 'blocsd'thrust itielf or be thrust harder into one coronary-'axteryIthaninirto'-ncther?The most elementary knowledge of-hydrodynamics would guiard us-from, so crude a conception as this.I do not 'Iesitate to advance that all elaborate prognoses based upon this conception' are worse thah wasted.Once more, does Dr. Fothergill really-believe thtt hyperthophy of a part bears an exclusive relation to the{quarstity of blood sublmitted to it?If blood be denied to the part, nro doubt it must starvt, but it would be too hardy an assertion to say that -in aortic regurgitation the blood is shut off from access to.thA coronary arteries.'Surely they have still the same supply that is given to any other artery in the body, and the cardiac muscle-can grow still in obedience to the general laws which rgovern hypertrophy.We know that fatty degener- ation of the heart may be' detected -during life, and the heart muscle nevertheless recover perfectly, if the coro-ntay atteriessbe normal.Ex- cessive arterial supply, on the other hanf,' cannot alone give rise to hypertrophy; so far as we know it is' the-vis a fronfenot the vis a tego which is herein concerned..We rmust look,'therefore, to some causes of systolic failure in aortic regurgitation' other than differential pressures at the mouths of the coronary arteries.The question' is of such direct practical importance that for many -years I have souight to solve it.'Dr. Fothergill will, perhaps, remember that when -he' lived in'Leeds, I showed him notes, preparatibong,-aind peifrensillustrativeof my views on causation of aortic arteritisard' valvtllitis by bodily effort acting -either suddenly or very gradlally.In these I 'frequently found the mouths of the coronary arteries lessened, and sometimes found -them occluded by "atheroma".It was thus possiblc in many cases to trace fatty change.in the mus- cular tissue supplied by one coronary artery to atheromnat6is'bt'embolic blocking and so to arrest of blood-supply.To prove that this cause is the only cause' of 'asystcde in aortic regurgitatian would be difficult, and probably it is not the only cause: that it is a comiimon cause of it I feel pretty confident.The compensation itself is but imperfect at best, and carries in itself no assurance of permanency.However; the purpose of my present criticisms is rather destructive than constructive.After I had committed these criticisms to paper, I consulted Dr. Stone`in order to secure myself against error.Dr. Stone wrote to' me as fol- lows on October 2nd, 1879."Dear Dr. Allbutt,-My views'would be entirely in agreement with yours.Indeed, it is quite unmechanical to suppose that the coronary arteries are filled by a 'squirting' action.Neither do I 'believe that hypertiophy originates in arterial action, though fatty degeneration may -depend 'on coronary starvation.'The regulating power must originate in the beautiful balance of 'motor and inhibitory centres which the arteries obey.. Dr. Fothergill is really going back to the obsolete humorism.Dr. 'Ottomar 'Roseb'bach's experiments, moreover, show conclusively that tenrsion and propulsion; in the closed cell of the circulation, are perfectly separable factors, and that the pressure is maintained unaffected, even when the aortic or mitral valves are artificially broken down.Thts r-worked "out in-rny third Croonian lecture, which I am now preparing for publication.