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February 26, 2017
19th Century Charles Hilton Fagge

Charles Hilton Fagge (1838-1883)

On the murmurs attendant upon mitral contraction. Guy's Hosp, Rep., 1871, 3 ser., 16, 247-342

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Fauvel's work on presystolic murmur of mitral stenosis was not noticed in England. In 1861, William Gairdner, of Edinburgh, described the "auricular-systolic" murmur of mitral stenosis. His observations were published in an article which appeared under the title, "Short account of cardiac murmurs." This article was responsible for introducing the concept of presystolic murmur of mitral stenosis in England. This subject, however, remained a topic of controversy among physicians.

In 1871, Charles Hilton Fagge published an exhaustive account of the knowledge of presystolic murmur of mitral stenosis. The history and position of different authors were explained. In his article, Fagge also gave full credit to Fauvel's work by reviewing his observations in detail and discussing the conclusions of his paper.

He then continued by indicating that this presystolic murmur was a direct diastolic murmur and described its characteristics:

"I.The first and most important, although not an essential quality of a direct mitral murmur is its place in the cardiac rhythm. It is "presystolic". The "first sound of the heart" is no longer the first audible sign of the heart's waking up from its quiescence during the pause; it is preceded by the morbid sound or bruit II. The direct mitral murmur has a special seat.  It is loudest over the apex of the heart, and is generally confined to the region of the apex III. The quality of a direct mitral murmur is, in most cases, peculiar.  Almost all those who have written on this subject have remarked that the "presystolic bruit" has a rough, churning (grinding) character, which of itself enables the auscultator to suspect its nature and origin."

Fagge then analyzed a series of 66 patients that came under his care at Guy's Hospital.

In his review, he divided these cases in three groups:

"1) Cases with direct mitral or presystolic murmur, in which the diagnosis of mitral stenosis was confirmed at 
     autopsy (7 patients).

2) Cases with the postmortem diagnosis of mitral stenosis, in which the presystloic murmur was not heard
     during life (40 patients).

3) Cases with direct mitral or presystolic murmur at auscultation, in which "no opportunity was afforded of
     verification by post-mortem examination" (19 patients)."

After this review, Fagge commented:

"The positive value of the direct mitral or presystolic (this word being used in its wider sense) is very great very little importance can be attached to the absence of a presystolic bruit, as disproving the existence of mitral contraction Among 47 cases in which this disease has been found in the post-mortem room there have been only seven in which a presystolic murmur had been heard during life.In the remaining 40 cases the presence of contraction of the mitral orifice was undiagnosed In a very large proportion of these cases the pulse was extremely rapid, and the action of the heart very irregular."

 In the same article, Fagge stressed the risk of embolization in patients with mitral stenosis which was often associated with a fatal outcome:

"In collecting the cases for this paper, I have been very much struck with the frequency of arterial embolism in contraction of the mitral valve.  In five out of seven fatal cases in which a presystolic murmur was heard, there had been embolism either of one of the cerebral arteries, or of some artery of the lower limb The embolon appears to have been a portion of ante-mortem clot from the auricular appendix, more often than a mass of vegetations detached from the valve; and this, perhaps, is the reason why it has more than once been large enough to obstruct the main artery of the thigh."

 An excerpt of Fagge's outstanding work is displayed here.

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Gairdner WL. Short account of cardiac murmurs. Edin Med J 1861;7:438-53


Austin Flint Paul Louis Duroziez