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Tricuspid valve disease. An historical and physiological perspective.

The distension and pulsations of the cervical veins afford signs of great importance in all affections involving the right side of the heart. A review of the extensive and colorful literature on the nature of venous pulsations will not be attempted.1 Our present objective is to trace the evolving phsyiological concepts of right ventricular function which centuries of observations of these external physical signs have evoked. An early account of venous pulsations is given by Homberg,2 a Parisian physician practicing during the years of the declining and final radiance of the Sun King, Louis XIV. Born in Batavia, in 1652, his father was a "Saxon gentleman" employed by the Dutch East India Company. Homberg's earlier education was grossly neglected in this tropical environment and only on his family's return to Holland did he study law at the University of Magdeburg. A passion for natural history evoked further studies in astronomy, anatomy, and botany at Padua. A peripatetic humanist, at times following the arts of war as a professional soldier in Rome, he settled finally in Paris, sponsored and sustained by the patronage of the Duc d'Orleans.3 In 1702, he married the daughter of Dodart, an eminent French physician under whose tutelage he devoted his remaining years to scientific observation in clinical medicine. In 1704, before the Academie Royale, the protocol of a 35 year old female asthmatic who died in right ventricular failure with venous engorgement was presented. On dissection, the cavities of the heart were greatly distended and the myocardium described as flabby, and soft as a bag of leather. Homberg attributed the cervical pulsations to reflux into the veins on each contraction of the heart, and like the tides of Brittany likened these unnatural recoils of blood to the turning back of cresting waters from the rising seas (Fig. 1). The association between abnormal right ventricular function with elevated right heart filling pressures was thus suggested.