I enjoyed CMAJ's tribute to Sir William Osler in the Oct. 5, 1999 issue, especially Peter Warren's article.1 He put forth strong arguments that Osler's unusual case, presented on Oct. 15, 1900, was indeed the syndrome described 51 years later by Churg and Strauss.2
Another example of an unusual case reported by Osler is his astute description of mitral valve prolapse 83 years before Barlow's landmark paper on the midsystolic click and late systolic murmur,3 which was subsequently called the Barlow syndrome.4 I would like to quote parts of Osler's paper entitled, "On a remarkable heart-murmur, heard at a distance from chest-wall" published in the Medical Times and Gazette in October 1880.5
"Numerous cases of heart-disease are on record in which a murmur could be heard at some distance from the chest. The following instance is remarkable from the absence of any evidence of serious disease, and from the exceedingly variable nature of the murmur... As she sits upright in the chair the heart-sounds at apex and base loud and clear; no murmur. When she stands, a loud systolic murmur is heard at apex ... it varies a great deal, being loud for three or four beats, and then faint for one or two succeeding ones, due to influence of respiration ... It disappeared quite suddenly, and could not be detected on most careful examination ... on causing her to lean forward and relax the chest the murmur was at once heard, and with greatly increased intensity. It was distinctly audible at a distance of three feet two inches by measurement, and could be heard at any point on the chest and on the top of the head ... On July 13 I saw her again at her home, and failed, after prolonged examination, to hear the murmur ... July 21 ... - When she stood up, the murmur at once became evident, presenting the same character as before described ... August 31 - Saw her again, and failed to hear a murmur in any posture, after a prolonged examination ... The points of interest in this case are, as stated above, the absence of sign of grave heart-disease, and the extreme variability of the murmur ... It was worthy of note that in three of the five cases of this sort here mentioned the patients were women - two of them weak and anaemic; and the third (the girl under my care) delicately built and nervous, though not anaemic."
Osler, of course, was describing all the characteristic features of mitral valve prolapse - its preponderance in young women, the extreme variability of the murmur depending on the delicate balance between the end-diastolic volume of the left ventricle and the amount of the mitral valve apparatus, and the benign nature of the condition.6