i
I
Property of the
Lancaster City and County Medical Society
No
win
THE
AMEEICAN JOURNAL
OF THE
MEDICAL SCIENCES.
EDITED BY
ISAAC HAYS, M.D.,
FELLOW OF THE PHILADELPHIA COLLEGE OF PHYSICIANS ; MEMBER OF THE AMERICAN MEDICAL ASSOCIATION ; OF THE AMERICAN PHILOSOPHICAL SOCIETY ; OF THE ACADEMY OF NATURAL SCIENCES OF PHILADELPHIA; ASSOCIATE FELLOW OF THE AMERICAN ACADEMY OF ARTS AND SCIENCES,
&c. &c. &c.
NEW SERIES. YOL. XLIY.
PHILADELPHIA: B L A N C H A R D AND LEA. 1862.
69470
Entered according to tlie Act of Congress, in the year 1862, by BLANCHARD AND LEA,
in the Office of the Clerk of the District Court of the United States in and for the Eastern District of the State of Pennsylvania.
PHILADELPHIA : COLLINS, PRINTEE.
AblS Med.
TO READERS AND CORRESPONDENTS.
We have received a letter from Dr. W. F. Wade, of Birmingham, England, the author of "a very interesting case of Aortic Aneurism, in which a commu- nication with the pulmonary artery was recognized during life by means of Physical Diagnosis," published in the volume of Medico-Chirurgical Transac- tions for 1861, and reviewed in our No. for April last, p. 473, calling our atten- tion to a misprint of his name. We regret this mistake, and will ask our sub- scribers to correct it in their copies.
The following works have been received : —
Transactions of the Obstetrical Society of London. Yol. lY. For the year 1861. With a list of Officers, Fellows, &c. London : Longman & Co., 1862. (From the Society.)
Public Health in relation to Air and Water. By W. T. Gairdner, M. D., F. R. C. P. E., Lecturer on the Practice of Medicine, &c. Edinburgh : Edmon- ston & Douglass, 1862. (From the Author.)
On Intestinal Obstruction by the Solitary Band. Being a paper read at a meeting of the Medical Society of London, March 25, 1861, and reprinted from their Transactions. By John Gay, F. R. C. S., Surgeon to the Great -Northern Hospital, &c. &c. London, 1861. (From the Author.)
De r Application de la Suture Enchevillee a 1' Operation de I'Entropion Spas- modique au Moyen d'une Nouvelle Esp^ce de Cheville (cheville jumelle ou a double branche). Par F. Yauquelin, M6decin Oculists et Auriste a Paris, &c. Paris : Germer-Bailli^re, 1853. (From the Author.)
Rapport fait a la Society Universelle d' Ophthalmologic par le Secretaire Pro- visoire. F. Yauquelin, et Descours d'Ouverture par Francesco de Argelagos. Yersailles, 1861.
A Manual of Medical Diagnosis : being an Analysis of the Signs and Symptoms of Disease. By A. W. Barclay, M. D., F. R. C. P., Assistant Physician to St. George's Hospital, &c. &c. Second American from the second and revised London edition. Philadelphia : Blanchard & Lea, 1862. (From the Publishers.)
Handbook of Surgical Operations. By Stephen Smith, M. D., Surgeon to Bellevue Hospital, New York. Bailli^re Brothers, 1862. (From the Author.)
A Practical Guide to the Study of the Diseases of the Eye : their Medical and Surgical Treatment. By Henry W. Williams, M. D., Fellow Massachu- setts Medical Society, &c. &c. Boston : Ticknor & Fields, 1862.
Experiments and Observations upon the Circulation in the Snapping Turtle, Chelonura Serpentina, with especial reference to the Pressure of the Blood in the Arteries and Yeins. By S'. Wier Mitchell, M. D., Lecturer on Physiology. Philadelphia, 1862. (From the Author.)
A Description of the Newly Invented Elastic Tourniquet, for the Use of Armies and Employment in Civil Life : its Uses and Applications, with Remarks on the different Methods of arresting Hemorrhage from Gunshot and other Wounds. New York, 1862.
8
TO READERS AND CORRESPONDENTS.
Extension and Counter Extension in the Treatment of Fractures of the Long Bones, with a description of an Apparatus especially designed for Compound Fractures. By Joseph H. Vedder, M. D. Flushing, L. I. New York, 1862.
Advice to a Mother on the Management of her Offspring. By Pye Henry Chavasse, F, R. C. S., &c. &c. Reprinted from the sixth London edition. New York : Ballifere Brothers, 1862.
Quarterly Summary of the Transactions of the College of Physicians of Philadelphia.. From September 4, 1861, to February 5, 1862, inclusive. Phila- delphia, 1862.
Proceedings of the Academy of Natural Sciences of Philadelphia. January, February, March, April, 1862.
Mortuary Tables of San Francisco. Arranged by A. F. Sawyer, M. D., January, 1862. San Francisco, 1862. (From the Author.)
The Action of the Voluntary Muscles. By Louis Mackall, M. D. Alexan- dria, 1862. (From the Author.)
The Annual Address before the Medical Society of the State of New York, and the Members of the Legislature, delivered in the Capitol, February 6, 1862. By Edward H. Parker, M. D., President of Society. Poughkeepsie, 1862. (From the Author.)
Address before the Philadelphia County Medical Society. Delivered Jan- uary 30, 1862. By Joseph Carson, M. D., at the close of his official term as President. Printed by order of the Society. Philadelphia, 1862. (From the Author.)
An Address delivered before the BuflFalo Medical Association, April 1, 1862. By Dr. C. C. F. Gay, President of the Association, on retiring from the chair. Published by vote of the Association. Buffalo, 1862.
Valedictory Address to the Graduating Class of the Cincinnati College of Medicine and Surgery. Delivered February 12, 1862. By A. H. Baker, M. D., Professor of Surgery. Cincinnati, 1862.
Forty-fifth Annual Report on the State of the Asylum for the Relief of Per- sons deprived of their Reason. Published by direction of the Contributors. Philadelphia, 1862. (From Dr. J. H. Worthington, Physician and Superin- tendent.)
Second Annual Report of the Superintendent of Clifton Hall, a Private Hospital for Mental Diseases, to the Board of Supervision, for the year 1861. Philadelphia, 1862. (From R. A. Given, M. D.)
Fourth Annual Report of the Medical Board of the Charity Hospital of Philadelphia to the Board of Trustees, January 1, 1862. Philadelphia, 1862. (From Dr. A. M. Slocum.)
The following Journals have been received in exchange : — Gazette M6dicale de Paris. February, March, 1862.
Annales Medico-Psychologiques. Redege par MM. les Docteurs Baillarger, Cerise, et Moreau (de Tours). January, 1862.
TO READERS AND CORRESPONDENTS.
9
Gazette Hebdomadaire de Medecine et de Chirurgie. Redacteur en chef, A. " Dechambre. Tom. IX., Nos. 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 20, 21, 22. 1862.
Journal de Medecine de Bordeaux. Redacteur en chef, M. Costes. January, February, March, 1862.
Edinburgh Medical Journal. March, April, 1862.
British and Foreign Medico-Chirurgical Review. April, 1862.
The Glasgow Medical Journal. April, 1862.
The Dublin Quarterly Journal of Medical Science. May, 1862.
Medical Times and Gazette. April, May, June, 1862.
Dublin Medical Press. March, April, May, 1862.
The Medical Critic and Psychological Journal. Edited by Forbes Wjnslow, M. D., D. C, L. Oxon. April, 1862.
London Medical Review. March, April, 1862.
The Madras Quarterly Journal of Medical Science. January, 1862.
The Medical Record of Australia. Edited by Dr. Reeves, January, 1862.
The British American Journal. Edited by Archibald Hall, M. D. March, May, 1862.
Boston Medical and Surgical Journal. Edited by F. E. Oliver, M. D., and S. L. Abbot, M. D. April, May, June, 1862. American Medical Times. April, May, June, 1862.
The Cincinnati Lancet and Observer. Edited by Ed. B. Stevens, M. D., and J. A. Murphy, M. D. April, June, 1862.
Ohio Medical and Surgical Journal. Edited by the Professors of Starling Medical College. March, May, 1862.
The American Journal of Insanity. Edited by the Medical Officers of the New York State Lunatic Asylum. April, 1862.
The American Journal of Science and Arts. Edited by Professors B. Silli- MAN, B. SiLLiMAN, Jr., and Jas. D. Dana. May, 1862.
The Chicago Medical Journal. Edited by D. Brainard, M. D., and J. A. Allen, M. D. April, May, June, 1862.
The Chicago Medical Examiner. Edited by N. S. Davis, M. D., and F. W. Reilly, M. D. March, April, May, 1862.
Buffalo Medical and Surgical Journal and Reporter. Edited by Julius F. Miner, M. D. April, May, June, 1862.
American Medical Monthly. Edited by J. H. Douglas, M. D. April, May, June, 1862.
The Pacific Medical and Surgical Journal. Edited by James Blake, M. D. February, March, April, May, 1862.
The Cincinnati Medical and Surgical News. Edited by A. H. Baker, M. D., and J. A. Thacker, M. D. March, April, May, 1862.
San Francisco Medical Press. Edited by E. S. Cooper, A. M., M. D. April, 1862.
10
TO READERS AND CORRESPONDENTS.
The American Journal of Ophthalmology. Yol. I., No. 1. Julius Hom- BERGER, M.D., editor and proprietor. New York. July, 1862.
American J ournal of Pharmacy. Published by authority of the Philadelphia College of Pharmacy. Edited by Wm. Proctor, Jr., Professor of Pharmacy in Philadelphia College of Pharmacy. May, 1862.
The American Druggists' Circular and Chemical Gazette. April, May, June, 1862.
The Dental Cosmos. Edited by J. D. White, M.D., J. H. McQuillan, D. D. S., and Geo. J. Ziegler, M.D. April, May, 1862.
Communications intended for publication, and Books for Review, should be sent, free of expense, directed, to Isaac Hays, M. D., Editor of the American Journal of the Medical Sciences, care of Messrs. Blanchard & Lea, Philadelphia. Parcels directed as above, and (carriage paid) under cover, to Messrs. Triibner & Co., Booksellers, No. 60 Paternoster Row, London, E. C. ; or M. Hector Bossange, Lib. quai Voltaire, No. 11, Paris, will reach us safely and without delay. We particularly request the attention of our foreign correspondents to the above, as we are often subjected to unnecessary expense for postage and carriage.
Private communications to the Editor may be addressed to his residence, 1525 Locust Street.
All remittances of money, and letters on the business of the Journal, should be addressed exclusively to the publishers, Messrs. Blanchard & Lea.
The advertisement-sheet belongs to the business department of the Journal, and all communications for it should be made to the publishers.
To secure insertion, all advertisements should be received by the 20th of the previous month.
CONTENTS
OF THE
AMERICAN JOURNAL
OF THE
MEDICAL SCIENCES.
NO. LXXXYII. NEW SERIES. JULY, 1862.
ORIGINAL COMMUNICATIONS.
MEMOIRS AND CASES.
ART. PAGE
L Remarks on Fungi, with an account of Experiments showing the Influ- ence of the Fungi of Wheat Straw on the Human System ; and some Observations which point to them as the Probable Source of " Camp Measles," and perhaps of Measles generally. By J. H. Salisbury, M. D., of Newark, Ohio. (With a plate containing twenty figures.) . . 17
II. On Cardiac Murmurs. By Austin Flint, M. D., Professor of the Prin- ciples and Practice of Medicine iia the Belle vue Hospital Medical College, New York, and in the Long Island College Hospital 29
III. On Smallpox, and the Means of Protection against it. By S. Henry Dickson, M. D., Professor of the Practice of Medicine in Jefferson Medi- cal College, Philadelphia. 54
lY. Amaurosis and other Disorders of the Eye, resulting from Injury of the Terminal Branches of the Fifth Pair of Nerves. By Frederic D. Lente, M. D., of Cold Spring, New York. 70
Y. On Burns. By John Ashhurst, Jr., M.D., late Senior Resident Sur- geon to the Pennsylvania Hospital. 82
YI. On the Employment of India-rubber in obtaining Continuous Exten- sion in the Treatment of Fractures of the Femur. By John H. Packard, M. D., of Philadelphia. (With a wood-cut.) 88
YII. On the Epidemic Relationship of Zymotic Diseases. By E. P. Chris- tian, A. M., M. D., Wyandotte, Michigan 91
YIIL Description of a Pseudencephalic Monster. (Genus 11, Thlipsence- phalus, Isidore Geoff. St. Hilaire.) By Christopher Johnston, M. D., Baltimore. (With three wood-cuts.) 96
IX. Cases treated at the Medical Missionary Society's Hospital at Canton, China. By John G. Kerr, M. D. (Communicated by Professor S. D. Gross, M.D.) . . 99
X. Case of Puerperal Uraemia. By Y. J. Fourgeaud, M. D. of San Fran- cisco, California 103
TRANSACTIONS OF SOCIETIES.
XL Summary of the Proceedings of the Pathological Society of Phila- delphia 105
Singular Lesion of the Urinary Bladder. By Dr. Packard. . . 105 Compound Comminuted Fracture of the Skull, and Fracture of Ribs.
By Dr. Ashhurst 106
Gangrene of the Lung. By Dr. Leet 107
12
CONTENTS.
ART. PAGE
Mammary Carcinoma. By Dr. Ashhurst 107
Eupture of the Urethra. By Dr. Lee 108
Gunshot Wound of Femur and Pubis. By Dr. Packard. . . 109
Deformity of Legs. By Dr. Lee 110
Incarcerated Hernia. By Dr. Lee Ill
Compound Comminuted Fracture of Thigh; Fracture of Scapula
and of Ribs, with Scalp Wounds and Effusion on Brain. By Dr.
Ashhurst ' . 112
Compound Fracture of Sacrum. By Dr. Lee. .... 113 Compound Comminuted Fracture of Skull ; Fracture of Pelvis and
Rupture of Bladder. By Dr. Lee 114
Ruptured Peritoneum. By Dr. Ashhurst 114
Comminuted Fracture of Pelvis, Fracture of Thigh, &c. By Dr.
Lee 115
Tubercle of Kidney. By Dr. Ashhurst 116
Metastatic Abscesses. By Dr. Packard. 117
Deficiency in the number of Ribs. By Dr. Packard. . . . 118
REVIEWS.
XII. Theories of Life and Organization.
1. Recherches Physiologiques sur la Yie et la Mort. Par F. X. Bichat. Nouvelle Edition, precedee d'une Notice sur la vie et les Travaux de Bichat et suivie de Notes par le Docteur Cerise. Paris : Yictor Masson et Fils, 1862. 8vo. pp. 382.
2. De la Yie et de I'lntelligence. Par P. Flourens, Membre de I'Academie Francaise et Secretaire perpetual de I'Academie des Sciences (Institut de France), etc. Paris : Garnier Freres, 1858. 8vo. pp. 161.
3. La Medecine Nouvelle bas6e sur des Principes de Physique et de Chimie transcendantes et sur des Experiences capitales qui font voir mecanique- ment I'origine du Principe de la Yie. Par L. Lucas. Paris : F. Savy, 1861. Tome ler. 8vo. pp. 504.
4. La Yie dans I'Homme; Existence, Fonction, Nature, Condition pr6- sente, Forme, Origine et Destinee future du Principe de la Yie ; Esquisse Historique de TAnimisme. Par J. Tissot. Paris : Yictor Masson et Fils, 1861. 8vo.
5. La Yie dans I'Homme ; ses Manifestations diverses, leurs Rapports, leurs Conditions Organiques. Par J. Tissot. Paris : Y. Masson et Fils, 1861. 8vo. pp. 614.
6. Discours sur le Yitalisme et I'Organicisme et sur les Rapports des Sci- ences Physiques en General avec la Medecine : Discours prononce a I'Academie Imperiale de Medecine, 17 Juillet, 1860. Par M. le Profes- seur Bouillaud. Paris, 1860. 8vo. pp. 75 119
XIII. Epilepsy : its Symptoms, Treatment, and Relation to other Chronic Convulsive Diseases. By J. Russell Reynolds, M. D., Lond. London, 1861. 8vo. pp. 360.
Epileptic and other Convulsive Affections of the Nervous System, their Pathology and Treatment. By Charles Bland Radcliffe, M. D. Third edition. London, 1861. 12mo. pp. 312 134
XIY. Traite de Chirurgie Navale. Par Louis Saurel, Chirurgien de la Marine, Professor agreg6 a la Faculty de Medecine de Montpelier, Cor- respondant de la Societe de Chirurgie de Paris ; Suivi d'un resume de lecons sur la service chirurgical de la flotte. Par le Docteur J. Rochard, Chirurgien en chef de la Marine, Professor k I'Ecole de Medecine Navale du port de Brest, Officier de la Legion d'honneur. Illustr6 de 186 planches intercalees dans le texte. 8vo. pp. 592 + 104. J. B. Ballifere et Fils. Paris, 1861.
Treatise on Naval Surgery. By Louis Saurel, Surgeon of the Navy, &c., followed by a summary of lectures on the surgical service of the fleet. By Doctor J. Rochard, Surgeon in Chief of the Navy, &c. Paris, 1861. 149
CONTENTS.
13
ART. PAGE
XV. Lectures on the Germs and Yestiges of Disease, and on the Preven- tion of the Invasion and Fatality of Disease by Periodical Examinations. Delivered at the Royal Infirmary for Diseases of the Chest. By Horace Dobell, M. D., &c. &c., Physician to the Infirmary. London, 1861. 8vo. pp. 198 157
BIBLIOGRAPHICAL NOTICES.
XYI. Reports of American Institutions for the Insane.
1. Of the Butler Hospital, for the year 1860.
2. Of the New Jersey State Hospital, for the year 1860.
3. Of the Western Asylum of Virginia, for the fiscal year 1859-60.
4. Of the State Asylum of South Carolina, for the year 1860.
5. Of the Northern Ohio Asylum, for the fiscal year 1859-60.
6. Of the Hamilton County (Ohio) Asylum, for the fiscal year 1858-59.
7. Of the Asylum of California, for the year 1858.
8. Of the Wisconsin State Hospital, for the year 1860 165
XVII. Lectures on the Diagnosis and Treatment of the Principal Forms of Paralysis of the Lower Extremities. By E. Brown-S6quard, M. D., F. R. S., Fellow of the Royal College of Physicians of London, Hon. Fellow of the Faculty of Physicians and Surgeons of Glasgow, Laureate of the Institute of France (Academy of Sciences), etc. etc. 8vo. pp. 118.
J. B. Lippincott & Co. : Philadelphia, 1861. . . . . . .175
XVIII. Surgical Tracts.
1. Amputation of the Cervix Uteri. By J. Marion Sims, M. D. Extracted from the Transactions of the State of New York, 1861. New York, 1861. 8vo. pp. 16.
2. Extension and Counter-extension in the Treatment of Fractures of the Long Bones; with a Description of an Apparatus especially designed for Compound Fractures. By Joseph H. Vedder, A. M., M. D. New York, 1862. 8vo. pp. 23.
3. A Description of the newly-invented Elastic Tourniquet, for the Use of Armies and Employment in Civil Life, its Uses and Applications, with Remarks on the Different Methods of Arresting Hemorrhage from Gun- shot and other Wounds. New York, 1862; 8vo. pp. 31.
4. On Intestinal Obstruction by the Solitary Band. Being a paper read at a meeting of the Medical Society of London, March 25th, 1861, and re- printed from their Transactions. By John Gay, F. R. C. S., &c. London, 1861. Printed for private circulation. 8vo. pp. 16 179
XIX. Handbook of S.urgical Operations. By Stephen Smith, M.D., Surgeon
to Bellevue Hospital. New York : Bailliere Brothers, 1862. 12mo.pp.279. 181 ■ XX. Transactions of the Obstetrical Society of London. Vol. III. 8vo. pp.480.. London, 1862 182
XXI. Public Health in Relation to Air and Water. By W. T. Gairdner, M. D., Fellow of the Royal College of Physicians, Edinburgh ; Physi-cian to the Royal Infirmary, and Lecturer on the Practice of Medicine. 12mo.
' pp. 369. Edinburgh, 1862 192
XXII. The Ambulance Surgeon, or Practical Observations on Gunshot Wounds. By P. L. Appia, M. D., Fellow of the Royal Society of Naples, &c. Edited by T. W. Nunn, Assistant Surgeon to the Middlesex Hos- pital, and A. M. Edwards, F. R. S. E., Lecturer on Surgery in the Edin- burgh Medical School. Edinburgh, 1862. 12mo. pp. 266. . . .200
XXIII. Experiments and Observations upon the Circulation in the Snap- ping Turtle, Chelonura Serpentina, with especial Reference to the Pressure of the Blood in the Arteries and Veins. By S. Wier Mitchell, M. D., Lecturer on Physiology. Philadelphia, 1862. 4to. pp. 14. . . . 201
XXIV. A Manual of Medical Diagnosis : being an Analysis of the Signs and Symptoms of Disease. By A. W. Barclay, M. D., F. R. C. P., As- sistant Physician to St. George's Hospital, &c. &c. Second American, from the second and revised London edition. Philadelphia : Blanchard
& Lea, 1862. 8vo. pp. 451 202
14
CONTENTS.
QUAKTERLY SUMMARY
OF THE
IMPROVEMENTS AND DISCOYERIES IN THE MEDICAL SCIENCES.
FOREIGN INTELLIOENCE.
Anatomy and Physiology.
PAGE
1. On the Tactile Sensibility of tlie Hand. By Dr. Ballard. . . 203
2. Yalves of tlie Yeins of tlie Ex- tremities. By M. Verneuil. . 204
PAGE
3. Marriages of Consanguinity and Deaf-Dumbness. By M. Boudin. 205
4. Marriages of Consanguinity and their Influence on Offspring. By Dr. Mitchell 205
Materia Medica and Pharmacy.
5. Action of Alcohol as an Ali- ment in Disease. By Dr. F. E. Anstie 208
6. Therapeutic Properties of the Peroxide of Hydrogen. By Dr. Eichardson 209
7. Podophylliu. By Dr. Gardner. 210
8. Therapeutical Properties of Malt. By M. Fremy. . .212
9. Substitution of Daturia for Atropia. By M. Jobert. . . 212
10. Antiseptic Properties of Am- monia. By Dr. Eichardson. . 212
11. Inhalation of Pulverized Fluids.
By M. Poggiale. . . .214
12. Administration of Cod-Liver and other Oils, By Dr. Alex- ander Wallace. . . . 214
13. New Preparation from Chloro- form. By Dr. Thomas Skinner. 215
14. Vesicating Collodion. By Mr.
C. E. C. Tichborne. . . .216
15. Solid Creasote. By M. Stanis- laus Martin 217
16. Inefficiency of Hyoscyamus as usually prescribed. By M. Do- novan. . . . . . 218
Medical Pathology and Therapeutics, and Practical Medicine.
17. On the Exhibition of Food in Typhoid Fever. By M. Herard. 218
18. Quinine as a Prophylactic of Fever. By Dr. Smart. . . 221
19. Clinical Inquiry into the Use of Iron in Pulmonary Consump- tion. By Dr. James Jones. . 221
20. Chlorate of Potassa in Phthi- sis. By Dr. E. P. Cotton. . 223
21. Delirium Tremens treated by Large Doses of Digitalis. By Mr. Hester 224
22. Treatment of Pleurisy. ByM. Trousseau. . . . - . 226
23. Pneumonia in Infants. By M. Barthez. . . . . . 226
24. Treatment of Cancrum Oris. By Dr. Alexander Keiller. . 227 !
25. Pathology and Treatment of Jaundice. By Dr. Geo. Harley. 230
26. Treatment of Dysentery. By Dr. Smart 231
27. Subnitrate of Bismuth in Di- arrhoea and Chronic Dysenterv. By Dr. Gaubert. . . 231
28. Saccharine Treatment of Dia- betes Mellitus. By John Hughes, M.D 232
29. Chorea treated by Sulphate of Aniline. By Dr. Morell Mack- enzie. 235
30. Individual Eemedies in Epi- lepsy. By Dr. Anstie. . .235
31. Statistical Inquiry into the Prevalence of Numerous Condi-
! tions affecting the Constitution
CONTENTS.
15
in one thousand Phthisical Pa- tients when in Health. Bv Dr. Edward Smith. . . . 236
32. Brass Founders' Ague; Dis- ease produced br Fumes of Zinc.
By Dr. Greenhow. . . .238
33. Sudden Death from Emboli.
By M. Briquet. . . .239
34. Case of Syphilitic Disease ap- pearing in two Healthy Children
PAGE
after Vaccination from a Syphi- litic Child. ByDr.N. J.Haydon. 239
35. Yalue of ^gophony as a Sign
of Pleurisy. By Prof. Landouzy. 240
36. Tsenia Solium. ByM.Mauche. 240
37. On the Probabilities of the Duration of Life in the Apo- plectic and the Phthisical. Dr. Bruckner 241
SuKGiCAL Pathology axd Theeapeutics, axd OPERATiyE Surgery.
38. Treatment of Burns. By Prof. Eoser. . . . \ .242
39. Traumatic Tetanus cured by Chloride of Barium. By Dr. Gnecchi 243
40. The Influence upon the Growth of the Bones of Paralysis, Dis- ease of the Joints, Disease of the Epiphysial Lines, Excision of the Knee, Pickets, and some other Morbid Conditions. By Dr. G. M. Humphry. . . 244
41. Ligature of the Common Ca- rotid. By Dr. Redfern Dayis. . 245
42. Operations for the Cure of Varicocele and Varicose Veins. . By Dr. M. H. Collis. . . 246
43. Stability of the Cure of Va- rices. By M. Blot. . . .247
44. True Anchylosis of the Left Hip -Joint, from Rheumatism; the limb at a right angle to the body, and abducted; excision of a wedge-shaped piece of the femur; cure. By Dr. H. V. Berend 247
45. Dislocation of the Ulna for- wards without Fracture of the Olecranon. By M. Caussin. . 248
46. Dislocation of the Foot For- wards. By Dr. Demarquay. . 248
47. Fracture of a Rib produced by a Sneeze. By Dr. D. F. Cas- tella 249
48. Transverse Fracture of the Patella. _ By Mr. Holthouse. . 249
49. Statistics of Amputations at the Hospitals of Paris. By Dr. Ulysses Trelat. . ." .250
50. Perforating Gunshot "Wound through the Thickness of the Lung; Recoyery. ByDr.Voods. 250
51. Difficulties in the Treatment of Umbilical Hernia. By M. Huguier " . 252
52. Ether and Belladonna in Stran- gulated Hernia. By Dr. Burk- hardt. . . ^ . .253
53. Camphorated Chloroform as a Local Anaesthetic in Extirpation of the Toe Nail. By M. Mar- tenot de Cordoux. . . . 253
54. Congenital Inyersion of the Bladder; Cure. By J. Lowe,
M. D 253
55. The Cochin China Ulcer. By
M. Pochard. . . . \ 254
Ophthalmology.
56. Frequent Eyacuation of the Aqueous Humour as a Means of Causing the Absorption of Cataract. By Prof. Sperino. .
57. Hereditary Amaurosis. By Mr. Sedgwick
58. Amaurosis cured by Eyacua- tion of the Aqueous Humour. .
59. Retinitis Leuksemica. By Dr. Liebreich. ....
60. Embolism of the Arteria Cen- tralis Retinte. By Dr. Liebreich.
61. Loss of an Eye from the Bite
of a Leech. By Professor Von
Graefe 259
62. Piece of Stone Imbedded for
255 Seyen Months in the Cornea.
By Dr. Wm. Hutchinson. . 259
256 63. Rectification of Diyergent
Strabismus by the Methodical
257 Use of Prismatic Glasses. By Dr. Giraud-Teulon. . . \ 259
258 64. Hemorrhage into the Anterior I Chamber of the Eye. supplemen-
258 i tary to the Menstrual Flux. By i M. Guepin. . . . 261
16
CONTENTS.
Midwifery.
. 261
263
PAGE
65. Meclianism of Labour. By Dr. Halahan. .
66. Induction of Premature La- bour in Cases of Constitutional Affections. By Dr. Keiller.
67. Internal Surface of the Uterus after Delivery. By Dr. J. Mat- thews Duncan
68. Unsuspected Pregnancy and Labour. By Dr. H. Tanner.
69. Twins; One Dead at Six Months ; Both Eetained until full Term. By Dr. Flecken. . 266
70. Diagnosis of the Sex of the Foetus. By Dr. Steinbach. . 266
71. Epidemic of Puerperal Phleg-
265
265
PAGE
monous Erysipelas at Stockholm. By Prof. Retzius. . . .269
72. Treatment of Peritonitis by the Continued Application of Cold
to the Abdomen. By M. B6hier. 270
73. Broncho-Pneumonia of Lying- in Women. By Dr. Barnes. . 271
74. Ovarian Tumour cured by Tap-
pmr
and followed by Two
Pregnancies. By M. L. R. Cooke
75. Intra-Uterine Convulsions. By Dr. James A. Sidey.
76. Pathogeny of Retro-Uterine Hsematocele. By Prof. Braun.
271
272
273
Medical Jurisprudence and Toxicology.
77. Additional Experiments on the Poisonous Effects of Coal Gas upon the Animal System. By
Dr. C. J. B. Aldis. . . .274
78. Connection between Poisoning by Phosphorus and Fatty De-
generation of the Liver. By Dr. Lewin. . . . .275
79. Poisoning by Aniline and by Nitro-Benzol 275
80. New Mode of Detecting Minute Traces of Morphia. By M. Le- fort 276
AMERICAN INTELLIGENCE.
Original Communications.
Case of Opium Poisoning in which Belladonna was successfully used as an Antidote. By W. S. Dun- can, M. D 277
Clover-Hay Tea in Hooping-Cough. By Dr. Condie 278
Prolonged Abstinence. By Geo. Ord, Esq 278
Case of Monstrosity. By L. W. Baker, M.D 278
Syrup of Triticum Repens in Irri- table Conditions of the Urinary Bladder. By the Editor. . 279
Domestic Summary.
Case of Poisoning by Laudanum — Belladonna used as an Antidote. By Dr. James Blake. . . 280
On the Non-Shortening of the Su- pra and Infra-Yaginal Portion of the Cervix Uteri. By Dr. Isaac E. Taylor. . . .281
Body Transfixed by a Bayonet ; Recovery. By Dr. B. J. D. Irwin. 283
Inversion of the Uterus of Thirteen Years' Standing reduced by a Novel Method. By Dr. E, Noeg- gerath. 283
Nitric Acid in Hooping Cough. By Dr. S. W. Noble. . . 284
Seeds of the Cucurbita Pepo, or Pumpkin, in Taenia. By Dr. G. R. Patton 284
Staphyloma of Cornea ; Iridecto- my ; Suppuration of Globe. By Dr. Henry D. Noyes. . . 284
Polypus of the Ear successfully destroyed by the Persulphate of Iron. By Dr. E. L. Holmes. . 285-
THE
AMERICAN JOURNAL OF THE MEDICAL SCIENCES
FOR JULY 186 2.
Art. I. — Remarks on Fungi, ivifJi an account of Experiments sJioicing the Influence of the Fungi of Wheat Straw on the Human System; and some Observations ichich point to them as the P7vbable Source of Camp Measles,''^ and perhaps of Measles generally. By J. H. Salisbury, M.D., of Newark, Ohio. (With a plate containing twenty figures.)
The fungi belong to the lowest types of vegetable existence. Unlike the higher orders of plants, they are developed almost entirely in darkness (not being able to decompose carbonic acid under the influence of light), and they depend upon decaying or decomposing organic matter for the materials of their growth. They differ from flowering plants in their chemical influence upon the air. Like animals, they absorb oxygen and give out carbonic acid. Decay is an essential condition to their development. Besides organic decomposition, a certain degree of heat and moisture must exist. These three conditions are requisite, to excite their vegetative activity — but in very different degrees in the different families. There is another peculiarity ; their cells contain a large percentage of nitrogenized matter, making their composition more analogous to animal matter, than to the higher orders of plants. Their growth and maturity are usually rapid — requiring often but a few hours — and with almost equal rapidity they decay. The odours they emit in decay are more like those of putrescent animal than of vegetable matter. There are exceptions to this, however, in those families where their textures are of an almost woody firmness and of a slow growth, as in many of the Polypori and Boliti.
The fungi are variously distributed among organized nature; each species growing only upon such bodies (even though the temperature and moisture be rightly adapted) as will furnish to it the materials from which it can make the proximate products that are peculiar to it. For instance, the No. LXXXYII.— July 1862. 2
18 Salisbury, Effects of Fungi on Human System. [July
gory dew and red snow (Protococcus nivalis) form invariably a peculiar red secretion, to which they owe their colour; and they will grow only where they can obtain the elements to form this red matter. The yeast plant {Peyiicillium) invariably forms an albuminous secretion, and it will vegetate only in bodies which can supply the materials for this substance. From this it would appear that peculiar states and combinations of organ- ized matter control mainly the developmental distribution of parasitic fungi. The spores planted in their proper soil, only demand in addition a certain amount of moisture and degree of temperature — these present, they rapidly develop.
Those Fungi known by the common name of mould, mildew, smut, &c., attach themselves to and are developed from living tissues as well as from dead organic matter ; yet in both cases they depend alike upon decay for their development.
In plants we have common examples of this in the Uredo, which attacks tlie-maire plant; the Secali, which attacks the rye plant ; the Fuccinea, which attacks the rose bush ; the Botrytis infestans, which causes the potatoe.rot; the Merulius lacrymans and Folyporus destructor, which cause dry rot in timber ; the Sphderia morhosa, which attacks plum trees ; the Oidium, which produces decay in fruit ; the Fenicillium and Asper- gillus, which attack bread and cheese ; and the yeast and vinegar plants, which are submerged stems or mycelia of the Fenicillium. The savin or juniper tree is attacked by a peculiar genus — Fodisoma — which bursts from the bark and swells under the influence of moisture to a gelatinous mass ; and the black irregular scars on apples are produced by the Spilocena fructigena.
Others attack the housekeepers' preserved fruits, paste, mustard, and even clothing. Others the farmers' grain and grass ; the vintigers' grapes ; and the gardeners' vines, vegetables, and flowers. Scarcely any vegetable pro- duction, either living or dead, escapes the ravages of these parasites.
Animals also have their parasitic fungi. The disease (in Italy and the South of France) termed Muscadine, which sometimes attacks the cater- pillars of the silkworm in large numbers, just when they are about to enter the chrysalis state, has been ascertained to be due to the growth — within their bodies — of a minute fungus {Botrytis hassiana) nearly resembling the common mould.
It is capable of being communicated from one individual to another. It spreads in the fatty tissue beneath the skin, occasioning its destruction. The fungus spreads by the extension of its own stems and branches, and by the production of numerous sporules, which in their turn vegetate, and finally produce the death of the worm.
The flies found adhering to our windows are destroyed by a mould (Sporendonema muscae) which produces the little white rings between the abdominal segments and discharges its spores upon the glass around like a
1862.] Salisbury, Effects of Fungi on Human System. 19
little cloud. In the West Indies, it is not at all uncommon to see indivi- duals of the species Polistes (a wasp-like insect) flying about with plants, their own length, projecting from some part of the body. In time this growth spreads through the whole body, causing death ; after which the plants grow with much more luxuriance from the dead body than they formerly had from the living.
A similar growth {Cordyceps Robertsii) takes place in the bodies of certain caterpillars in New Zealand, Australia, and China. Some of our American caterpillars are destroyed by the Cordyceps militaris. The Onygena exigua attacks the hoofs of the horse, and the hoofs and horns of cattle. (The Isariafelina is found in the feces of cats deposited in dark and obscure places.)
In certain diseased conditions of the cutaneous surface — in man — named Porrigo favosa and Sycosis menti, a considerable development of fungous vegetation takes place ; and the same has been discovered to be true of the white patches {Aplithse) on the lining membrane of the mouth in children, which are known as thrush. In all these cases, however, a certain morbid condition of the animal fluids must exist in order that the germs of the fungus may develop themselves ; so that the condition, rather than the presence of the fungus must be looked upon as the essence of the disease.^ The individual cells and spores of the Fungi are microscopic, and so light that they are suspended in and borne about by the air. They are so minute that they permeate alike the tissues of animals and plants. Whenever it happens that the spores enter matter that is suited to their sustenance, and the proper amount of heat and moisture are present, they rapidly develop. It would be very strange if very many abnormal conditions of living tissues were not produced by this insidious vegetation. The plants being mostly microscopic, and requiring often but a few hours for their development and decay, renders their discovery one fraught with far greater difficulty than would at first be supposed. When no development of the spores takes . place in the tissues, no doubt in many instances they exercise a deleterious influence by their presence alone, as many of the larger and better known fungi have been ascertained to possess peculiar poisonous properties, which, in their action on the human system, resemble much in their depressing effects the animal poisons.
With these preliminary remarks we enter upon — Some observations connected with measles and the fungi ofioheat straiu.
Hon. J. Dille, of Newark, Ohio, came to my office on the evening of the 9th of December last, and stated that he was just recovering from what he believed to be an attack of measles. It was his opinion he had caught them from pitching straw from an old stack. He stated that on December 4th he pitched from an old stack a load of straw, and unloaded it in his stable.
' Carpenter's General and Comparative Physiology.
20 Salisbury, Effects of Fungi on Human System. [July
Portions of the stack had become partially decayed, and was already steam- ing with the heat of incipient decomposition. In pitching over and picking out the best straw the air became filled with a fine dust, which he freely inhaled. The dust tasted and had the odour of old straw. This took place during the forenoon. His throat soon began to feel dry and irritated. When he returned to dinner, he could still taste and smell the old straw. This taste and smell he could not get rid of. During the following night he awoke with a very sore throat, which became much worse by morning. After getting up and dressing he was taken with a severe chill, with pains in the head and back, and felt so sick and prostrated that he was compelled to return to bed again, where he remained through the day. The chill was followed by a high fever and severe pains in the head, so much so that a portion of the time he was delirious. He felt a heavy congested feeJing about the chest, his throat and fauces were swollen and inflamed, with severe catarrhal symptoms. An eruption like that of measles appeared on his face and neck, and the old straiv taste still continued. His fever continued high through the following (Thursday) night, with severe pains in the head.
Friday, December 6th, he felt much better, and was able to be up around the house. The fever and catarrhal symptoms had partially subsided. His eyes were sensitive, watery, and inflamed.
Saturday, December tth, felt much better. The eruption had passed downward over the whole body, and had begun to disappear from the face. He rapidly recovered, so that on Monday, December 9th, he was moving about the streets. In the evening of the 9th he called at my office. His eyes were still reel, inflamed, and sensitive ; throat sore, dry, and voice hoarse, and had a heavy congested feeling still about the chest. The blotches on his face could be faintly distinguished. He stated that he could still taste the old straw in his throat.
Measles at Gamp Sherman. — At the military camp — Camp Sherman — Newark, Ohio, the measles first appeared on Dec. 4th, the same day that Mr. Dille exposed himself to the straw dust. From Nov. 23d to 30th, the weather was cool, damp, with considerable sleety rain and snow. During this time (there being between six and seven hundred men in camp), many of the tents were furnished with ticks, which were filled with straw for the men to sleep on. In the centre of each tent was a fire, built in a hole in the ground, from which the smoke was led off by an underground flue, extending to the outside of the tent. The straw ticks were arranged around the fire, several in a tent, and each tick accommodated two men. On Dec. 1st, the weather became colder and snow fell to the depth of about an inch. On the 2d — which was quite warm — this melted and wet the soil and dampened the straw ticks. Dec. 4th, the measles made their first appearance in Camp Sherman. The men came from different parts of the county, and no one knew that he had been exposed to the disease. Some had been in camp two weeks, and no one supposed to have that disease had visited the camp. Subsequent inquiries have failed to discover any one who brought them there, or to account for their appearance from the contagion of the disease. On the first day (Dec. 4th) there were eight cases, and within a week after there were forty. The disease then disap-
1862.] Salisbury, Effects of Fungi on Human System. 21
peared for 10 or 12 days from its first appearance. Between the 14tli and 16tli the disease again made its appearance, and within a few days there were between forty and fifty cases more, when the disease ceased altogether. These last cases, occurring so near the usual time at which the disease ordi- narily makes its appearance after exposure, renders it probable that they were communicated from the first cases.^
On the 3d of Dec. it became warm and pleasant as growing weather in spring — and continued warm and delightful till Dec. 10th. On the 11th and 12th it was cold and freezing. The 13th and 14th were cool. From the 15th to the 21st the weather was warm and pleasant.
The following is the statement of Mr. S. — "In JSTovember, 1842, I returned home from school on a Friday. My father had the threshers, with a machine, threshing wheat. The wheat had been stowed away in the mow and in a couple of stacks outside the barn. It had undergone a slight heating, and some of the straw was mouldy. In threshing, the barn was filled with a fine dust, which tasted and smelled of old straw. I was on the straw stack all Friday afternoon and the whole of Saturday. About 4 P.M., Saturday, I became very chilly; throat and fauces became sore and swollen ; a tightness and congested feeling about the chest ; eyes in- flamed and sensitive ; and severe pains through the head and shoulders with a feeling of weariness. Following the chill, came on a high fever with increased pains and throbbing in the head and severe catarrhal symp- toms. I do not remember of ever passing a more disagreeable night. The next day (Sunday) had a high fever, with severe pains in head, back and limbs ; eyes swollen and sensitive, and considerable thin mucous secretion from the nose and fauces. Towards evening a few blotches made their appearance on my face. The follov^ang day (Monday) I felt rather better ; the fever and catarrhal symptoms had partially subsided, and my face and neck were completely covered with blotches. My father immediately re- marked that I had measles. This surprised us all, as I had not been exposed to the disease, there being none in the town where I was attending school, or in the vicinity. In the coarse of a couple of days, my Avhole body and limbs were covered with the eruption. The disease passed off' like a case of ordinary measles, leaving no bad effects, save inflammation of the mucous membrane of the eyes. This I did not get rid of till the warm weather of the following spring. In from seven to fourteen days after the eruption commenced in my case, all my brothers and sisters (seven in number) were in bed with the genuine measles. My eldest brother attended school with me, and returned home when I did. These were the only cases of measles anywhere in the vicinity during that fall and winter. In my attack the disease commenced with much greater violence than in either of the others. The fever ran higher and there was greater disturbance about the head, chest, and throat."
Bearing upon this may be mentioned the circumstance that in almost every instance, where our soldiers have gone into camp; in a short time after — the disease — called camj) measles, has made its appearance, without
' For these facts I am indebted to Hon. J. Dille, and tlie Assistant Surgeon Dr. James Hood.
22
Salisbury, Effects of Fungi on Human System. [July
any previous exposure — so far as known — to the measles. It should also be stated that their beds have been usually straw.
At the monthly meeting of the " Farmer^s Club,^^ near Newark, Ohio, last month, several of the farmers stated to Mr. Dille, that it was quite common, after threshing wheat, for persons who had been exposed much to the dust, to be taken with severe chills; followed by a high fever, catar- rhal symptoms and an eruption on the face. None of them could state, that any one had ever had the attack twice ; nor whether they had known any cases to follow the threshing of any other kind of grain than wheat.
It is well known among swine growers, that when they bed their hogs in straw, they are affected with an eruption in the throat, fauces and roof of mouth, accompanied with coughing.
Microscopical Examination of the Fungi of Wheat and Rye Straw. — With these observations before us, we deemed the subject one worthy of a further and more careful examination ; an examination which would afford something more positive. With this view, the fungous growths of wheat straw, and the dust rising from it when disturbed, were carefully examined under the microscope. The straw used for this purpose was taken from the beds at Camp Sherman, from Mr. Dille's stable, and from stacks in the vicinity of Newark. The accompanying drawings (see Plate, Figs. 1 to 14) represent the plants found — a description of which is given further on.
We then took clean bright wheat straw — free from fungi — packed it firmly into a box about one foot square and high, wet it with about four ounces of cold well-water, pressed on and secured the lid, and set the box near the stove in the ofiBce, where the temperature ranged from 60° to Y5° Fahr. Twenty-four hours afterwards I opened the box, and found the straw in the centre of the box heated and covered with a short white mould. As the straw was stirred, a fine dust of spores and cells were disengaged, and rose in the air, which, when inhaled, had the odour and taste of old straw. Examined the fungi under the microscope. The plants were in all stages of development, from those just starting to those with matured sporangia.
Again the straw was moistened, the lid secured as before, and left for forty-eight hours. The box was then opened. Found the mould had ex- tended wider through the mass and more completely covered the straw. Submitted the plants to a further careful examination under the micro- scope. Figs. 15, 16, 17, 18, 19, and 20, are drawings made from fungi grown in the box.
We further varied the experiments in a variety of ways, and found that whenever the straw was exposed to a certain temperature, under the influ- ence of darkness and moisture, fungi were rapidly developed. We also found that' wheat or rye straw when stacked out or housed, unless unusu- ally dry, undergoes a greater or less degree of heating, fermentation or
1862.] Salisbury, Effects of Fungi on Human System. 23
decay, during which process a variety of fungi are developed, having the appearance of mould or mildew on the straw. When this straw is dis- turbed or agitated in any way the surrounding air becomes filled with innu- merable spores and cells of the broken and comminuted fungi. The indi- vidual cells and spores are too minute to be distinguished by the naked eye. They can only be seen when many are together and the air filled with them ; then they appear like a thin smoke or fine dust. Suspended in the air they are freely inhaled, tasting and smelling of old straw. This taste and smell is often quite persistent, lasting for hours. The air may be filled with them though invisible to us ; but generally their presence can be dis- covered by the taste and smell. These cells and spores are shown in Plate, Figs. 1, 2,' 3, 4, 9, 18, and 19. Those represented at Figs. 1, 18, and 19, make up by far the larger proportion. They are oval, and often several are attached to each other in a line, in the direction of their longest dia- meter. Figs. 2 and 9 represent spherical spores, much larger than those of Fig. 1, and united generally in masses instead of lines. Figs. 8 and 4 represent large oval spores. Figs. 5 and 6 represent sporangia, which pro- duce the large oval spores 8 and 4. Fig. 6 appears to be a partially broken down sporangium. The plants are of a dull yellowish brown colour ; the sporangia of a light greenish yellow w^hite. Fig. a plant which pro- duces the spherical spores 2 and 9. It has four sporangia — two nearly mature and ready to shed their spores and two in process of development. The stems or mycelia of these plants are of a yellowish snuff colour; the sporangia are of a light greenish yellow white. Figs. 8 and 10 represent plants that produce spores like those of Fig. The colour of the mycelia and sporangia are also the same ; yet the arrangement of the sporangia on the mycelia seems to differ and may represent a different species. Figs. 11 and 12 are plants with oval or egg-shaped sporangia, wdiich do not exceed one-thirtieth the size of those of 8 and 10. Their colour is an orange brown ; the mycelia are lighter. In this species, there is one main stem or mycelium with numerous branches, each bearing one or more spore cases. The branches are mostly made up of a single row of oval cells, like Fig. 1, attached end to end. Fig. 14 represents a plant from the sprout of a wheat kernel. The sporangia are small and nearly spherical. In this species there is a main stem with numerous short branches of nearly equal length, each terminated with a single spore case. The plants are of a light yellowish white colour. This species, or one similar to it, wdth generally shorter branches, is very common on the straw. Fig. 13 represents plants from the sprout of a wheat kernel. The whole plant appears to be dicho- tomous; colour, light greenish white. The sporangia are peculiar, being shaped like a tassel, with radiating lines of cells, attached to each other in the direction of their longest diameter, standing upon oval basidia. Fig. IT, plants from a straw that "was cut before it had matured. The
24
Salisbury, Effects of Fangi on Human System. [July
plants are white with a yellowish tint. Each plant consists of a single branchless mycelium terminated by a small oval sporangium.
Figs. 14, 15, and 16, are the plants which are by far the most common on the mature straw. They are very prolific ; maturing in from twelve to twenty-four hours under favourable circumstances ; having the appearance, to the naked eye, of short white mould or mildew, completely coating the stems. When the straw is agitated, the air is filled with thin minute elongated cells and spores. Figs. 1, 18, 19. These plants consist of a main stem — made up of interlacing cells — from which proceed numerous short branches (made up generally of a single line of cells), each one of which is either terminated by a small spherical sporangium or an enlarged cell. The plants Figs. 14, 15, and 16, are mingled together and are probably the same species. The branches of 14 and 15 are terminated with sporangia, while those of 16 are terminated simply by slightly enlarged cells. The plant Fig. 12, in frequency, ranks next to 14, 15, and 16, and is interspersed with them on the straw. When straw that is covered with these plants is slightly or carefully agitated, the cells and spores which are set at liberty and float in the air, are but little aggregated, as seen in Fig. 18. If the straw is agitated violently as in pitching it, the cells and spores set at liberty are more or less aggregated in masses and lines and mingled with them are the sporangia of plants Fig. 12 ; see Fig. 19. Fig. 20 is a peculiar white fungus, with a light straw tint, which occasionally is met with on the straw. It is, however, not common. The fungi, Figs. 5, 1, 8, and 10, we found generally on straw that had undergone further decomposition than that on which the others were met with.
Inoculation of the Human System ivitJi the Spores and Cells of the Fungi of Wheat and Rye Straw. — Case I. At 10 o'clock P. M., Feb- ruary 11th, 1862, 1 inoculated my arm with the spores and cells of the fungi of wheat straw, which I obtained by placing a straw — covered with the plants — on a plate of glass, and hitting it with a few slight taps. On removing the straw, under and both sides of it was a white cloudy band, about ^ of an inch wide, running across the glass. These spores and cells lay so thick on the glass, that, to the naked eye, they seemed to touch each other. Their appearance under the microscope is represented in Fig. 1. The straw from which I obtained these cells came from a stack near this place, and was the same kind of straw as that used for beds at the camp. Under the microscope the fungi presented the same appearance, and the cells disengaged in agitating the straw were precisely similar.
Wednesday, Feb. 12th, perfectly well. No inflammation or itching around the point of inoculation.
13//?. Slight nausea. A very slight redness and itching at inoculating point.
14//?. Got up with a feeling of lassitude and nausea, which continued all day. The redness and itching of inoculating wound increasing ; had diffi- culty in keeping warm ; chilly all day ; occasional sneezing ; eyes sensitive;' liad a peculiar feeling about the scalp, as if red pepper or mustard had been rubbed into the pores.
1862.] Salisbury, Effects of Fungi on Human System. 25
Saturday, Feb. 15. Nausea and lassitude continue ; occasional sneezing ; flashes of heat over the whole body ; itching and inflammation of the wound on the arm increasing ; thoughtlessly rubbed ofl' the scab, which was about three lines in diameter. The peculiar smarting, burning, congested sensation over the whole scalp, has increased since yesterday. It extends into the bone, with pains through the forehead and temples. A few blotches have made their appearance on the face and neck. Eyes weak and inflamed, so much so that I could not use them to read over half an hour during the evening. A heavy oppressive feeling about the chest ; mucous membrane of fauces and throat dry and irritated ; feel as if I had a severe cold.
Sunday, Feb. 16. Had a sensation of weariness and drowsiness, with nausea, all day. Eyes red, inflamed, and sensitive ; smart, so that I can- not use them to read by gaslight. Whole scalp feels sore, with a constant, congested, burning sensation all through it to the bone. Arm itches ; red- ness as large as a dime. A heavy congested feeling about the chest ; have had more or less fever since Saturday morning. Throat and fauces dry and swollen, and voice hoarse. Pains in back and head have been almost con- stant since Friday last.
Monday, Feb. 17th. The burning sensation of the scalp still continues. Eyes weak and inflamed ; cannot use them long at a time, without pain. There is still slight fever and nausea.
Tuesday, Feb. 18th. Nausea ; face feels as if it had been exposed to the heat of an open fire till it had become inflamed. The peculiar burning soreness of the scalp is somewhat relieved. Eyes still sensitive ; catarrhal symptoms and fever less than yesterday.
Wednesday, Feb. 19th. Yery much better; the soreness of scalp almost entirely relieved ; blotches and redness of face disappeared ; catarrhal symp- toms and fever gone ; eyes quite well.
Case II. Wednesday Evening, Feb. 19th. Inoculated myself again in the same place, with the spores and cells of fungi as before.
Thursday, Feb. 20th. Feel perfectly well, except a slight sensitiveness of the eyes.
Friday, Feb. 2 1st. Same as yesterday.
Sunday, March 2d. Have felt perfectly well since Feb. 21st. Eyes com- pletely recovered.
Monday, March 3d. The last inoculation has produced no effect upon the system, that I can discover.
Case III. Wednesday Evening, Feb. 19, 1862, inoculated my wife on her arm, with the spores and cells of the straw fungi. The cells were taken from the same group as those used in the second inoculation of my own arm, on the same evening.
Thursday, Feb. 20th. Perfectly well all day.
Friday, Feb. 21st. During the day, a dry constricting feeling of the throat made its appearance, and grew much worse during the following night. Voice hoarse ; has felt chilly through the day, with a feeling of lassitude and drowsiness. Nausea; ate no dinner. Throat and fauces in- flamed.
Saturday, Feb. 22d. Nausea ; but little appetite ; severe pains through the forehead and temples ; tongue considerably furred ; throat feels dry and inflamed, with a very disagreeable constricting feeling, as if it would close up. A tumid appearance of fauces ; voice hoarse ; slight fever.
26
Salisbury, Effects of Fungi on Human System.
[July
Sunday, Feb. 23d. All through last night her throat felt as if it would close up. Rest very much disturbed. In the morning, throat felt better. Occasional sneezing ; voice hoarse ; some pain in swallowing. Stupid, weary, and inclined to sleep.
Monday, Feb, 24th. Throat did not trouble her much last night; still hoarse ; head stopped up, as if with a cold ; towards evening a fulness and throbbing about the head, which felt sore.
Tuesday, Feb. 25th. Had rather a restless night; head feels sore, swol- len, and heavy, as with a severe cold; eyes sensitive; catarrhal symptoms severe ; heaviness about the chest ; slight cough ; considerable lassitude and drowsiness; slept from 10 A.M. till 3 P. M. ; but little appetite. Had through the day occasional sensations of deafness ; slight redness in spots under the skin on the face. During the evening the pains in the head were relieved, and bowels became tender and sore.
Wednesday, Feb. 26th. Had a good night's rest ; head relieved ; eyes still sensitive ; catarrhal symptoms subsiding ; chest feels easier ; bowels very sore and tender to the touch. Appetite returning ; redness on arm nearly gone ; slight itching yet.
Thursday, Feb. 2Hh. Rapidly recovering ; head and eyes feel quite well ; bowels still slightly tender.
Friday, July 28th, quite well.
It will be seen from this case, that although there was scarcely any per- ceptible blotches, yet the other symptoms, such as chills, followed by fever, pains in the head, catarrhal symptoms, nausea, lassitude, &c., were all present. The disease commenced in the head, throat, and fauces, and passed downward, the bowels being very sore after the head, throat, and chest were relieved.
Case IY. On Sunday, March 23d, 1862, Chas. B. Pierce, a fine healthy boy, six years of age, was exposed to measles, by contact with the disease.
March 26th, seventy-two hours after the exposure, inoculated him with the fungi of wheat straw. The fungi were grown in my office, and shaken off from the straw on plates of glass, between which the spores and cells were preserved for use. On the second day after the inoculation (March 28th), a redness appeared around the inoculating point, about the size of a dime. This was preceded and accompanied by catarrhal symptoms resembling a slight cold. Did not complain. Played out of doors every day. This redness at the point of inoculation soon disappeared ; the catarrhal symp- toms subsided, leaving no bad effects ; and on April 2d, he was perfectly well. Forty -two days have passed since this boy was exposed to the dis- ease, and there are no signs of measles yet.
Cases Y. to IX. Mr. Bartholomew, of Newark, Ohio, has a family of seven children, ranging from three to seventeen years of age. On Wednes- day morning, April 2d, Franklin Bartholomew, the next to the oldest son, broke out with measles. On Saturday evening, April 5th, three days after Franklin came down with the disease, and three days after the exposure of the entire family, I was called upon by Dr. Teller, their family physician, to go with him and inoculate the other six children and the mother, none of whom had ever had the disease. We inoculated the mother, and four of the children, leaving two boys — one thirteen and the other seventeen
1862.]
Salisbury, Effects of Fungi on Human System.
21
years of age — without being inoculated. On April 14th, the boy seventeen years of age, and on April 16th, the one thirteen years of age broke out with the disease. It has now been five weeks since the exposure of the mother and the four children inoculated. Although there has been three successive cases of measles in the house, none of those inoculated have had any symptoms of the disease. From twenty-four to thirty-six hours after the inobulation, !hey all had symptoms, resembling a slight cold, with a little chilliness, catarrhal symptoms and sneezing. Beyond this they have been perfectly well from the date of the inoculation to the time of this writing. May 5th.
The inoculation does not produce a pustule and scab, like the vaccine virus, but simply a redness, around the wound, like a measle blotch. There is seldom any soreness, but usually a simple itching sensation for two or three days, extending generally from the second or third to the fifth or sixth day after the inoculation.
Cases X. to XIII. April 12th, inoculated with rye straw fungus
Mrs. , and two of her children, none of whom had ever had measles,
and who had been exposed to the contagion of the disease from a case of genuine measles in the family, which broke out April 6th. On the evening of the 13th and morning of the 14th, they all had symptoms of chilliness followed by fever, catarrhal symptoms, slight cough and sneezing. The inoculating wound became red over a surface about the size of a dime, pre- senting the appearance of a measle blotch.
Their symptoms were so slight that the children were not kept in doors, and the mother was not prevented from attending to her ordinary duties.
On the 18th they had all quite recovered. It is now four weeks since the exposure, and no signs of measles in any of the cases inoculated.
From the inoculations as far as they have gone, in from twenty -four to seventy-two hours, the effects begin to show themselves in lassitude, chilli- ness, catarrhal symptoms and pains through the forehead and temples. It is highly desirable that these experiments should be extended further. For this reason we publish thus early our observations and experiments (much more limited than we could have desired, on account of the difficulty in this place of obtaining subjects who are willing to sacrifice a few hours' health to such purposes) that others in larger places, who have greater facilities in the way of hospitals, &c., for carrying out more extended series of experiments under the eye of the attending physicians, may take up the matter and aid in its further investigation.
I have not been able to distinguish thus far any difference between the eruption and attendant symptoms of genuine measles and "camp measles," or straw measles. When the disease is communicated to the human sub- ject, however, by inhaling the spores and cells of straw fungi, the eruption appears to follow the exposure or inhalation in from twenty-four to ninety- six hours. While in exposures to the contagion of the disease, the erup- tion does not usually make its appearance until from eleven to fourteen days thereafter. It is stated that in inoculations made by using matter obtained
28
Salisbury, Effects of Fungi on Human System.
[July
from the measle blotch, or by using the tears, blood, or salivary secretions of subjects broken out with the disease, the modified type of measles which results makes its appearance generally on the sixth or seventh day after the inoculation. In inoculating, however, with the spores and cells of straw fungi, the symptoms commence usually in about twenty-four hours; though sometimes they do not make their appearance till as late as seventy- two hours thereafter.
This matter, however, requires further investigation before fully reliable statements can be made.
To what extent inoculation with straw fungi may prove effectual in pro- tecting the human system against the contagion of measles can only be settled by careful and extended experiments.
In Wood's Practice, under the head of Causes of Measles, we find the following statements, which we here quote, as they point indirectly to a possible origin of the disease somewhere in the direction of the results of these examinations.
''Though capable of being propagated by contagion, measles prevail much more at some periods than at others ; probably under a peculiar epidemic influ- ence. Whether this influence is sufficient of itself to produce the disease ; or whether it merely acts by increasing the susceptibility to the contagious princi- ple, may perhaps be considered uncertain. If the fact quoted by Eayer from an old author, that the disease was not known in the new world until the year 1518/ when it was imported from Europe, could be relied on, it would go far to prove that epidemic influence is alone insufiicient ; but the testimony can hardly be admitted to have much weight; and the very frequent occurrence of the dis- ease without any possibility of tracing the cause to personal communiccdion, ivould lead to the opposite conclusion} Still there is no impossibility in the production at once by the human body and by other unknown agencies in na- ture, of the same identical poison, whatever that may be. . The difficulty would be removed one step by admitting the vital organic character of contagions. Cold iveather^ appears favourable to the production of the disease, as epidemics of it are most frequent in winter. They occur, however, at all seasons. No age is exempt from the disease. It attacks the foetus in the womb and old per- sons in their second childhood. Yet it is much more freciuent in children than in adults. One reason of this may be a diminished susceptibility ; yet a much stronger one is the fact, that most persons have the disease in early life, and can have it but once. There is a general susceptibility to measles ; and there are very few who are not attacked at one or another period of their lives.
" Though, as a general rule, measles are capable of being taken but once, in- stances have undoubtedly occurred, as in all other contagious diseases, in which the same individual has been affected a second- time."
* Wheat and the other small grains were introduced into the new world about this time. Having no straw to generate the fungoid cause, they probably did not have the disease.
2 It would, if there existed in the new world the proper material from which the cause or contagion emanates. If this be confined to the straw of our cereal grains and these were not known here previous to 1518, then there is a probability that the author, whom Rayer quotes from, may be correct.
Wheat and the other small grains are generally threshed during the fall and . winter, and these are the seasons when the straw is the most used, and the periods when the disease usually occurs. When it occurs at other seasons, it is highly probable it may originate from straw beds.
1862.]
Flint, Cardiac Murmurs.
29
Art. II. — On Cardiac 3Turmiirs. By Austin Flint, M.D., Prof, of the Principles and Practice of Medicine in the Bellevue Hospital Medical College, N. Y., and in the Long Island College Hospital.
The clinical study of cardiac murmurs, within the last few years, has led to our present knowledge of the diagnosis of valvular lesions of the heart. By means of the organic murmurs it is positively ascertained that lesions exist in cases in which, without taking cognizance of the murmurs, the existence of lesions could only be guessed at. The absence of the organic murmurs, on the other hand, enables us generally to conclude with positive- ness that valvular lesions do not exist. As a rule, to which there are but few exceptions, these lesions may be excluded, if there be no murmur. These are great results ; but the practical auscultator of the present day need not be told that the clinical study of cardiac murmurs has led still further into the mysteries of diagnosis. Having ascertained the different murmurs which occur in connection with valvular lesions ; having traced their connection, respectively, with different lesions ; having shown their relations to the movements of the several portions of the heart, and to the cardiac sounds-/ and, having explained satisfactorily the mechanism of their production, we are able to determine not only the existence or non- existence of valvular lesions, but their particular situation when they are present, and, to a certain extent, their character and consequences. The practiced auscultator, by listening to the murmurs alone, is able to tell whether lesions are situated at the mitral, or the aortic, or the pulmonic orifice, and he is able to say, in certain cases, that the valves which are to protect these orifices against a regurgitant current of blood, have been rendered by disease inadequate to their office. It is unnecessary to adduce proof of these statements ; their correctness is sufficiently known to those who are conversant with physical exploration as applied to the diagnosis of afi'ections of the heart. How strikingly do these facts exemplify the progress of practical medicine to those who, although still among the junior members of the jDrofession, have practised before and since the recent -developments in this department of our knowledge !
These remarks are introductory to the consideration of various practical points pertaining to the cardiac murmurs. And the first subject will relate to these murmurs in general — viz., the limitations of their significance. After having considered certain points embraced in this subject, I propose to take up various points relating to the different murmurs separately.
' The conventional distinction between the cardiac sounds and murmurs is to be borne in mind ; t}ie former term being limited to the normal heart-sounds with their abnormal modifications, and the latter to newlj-developed or adventitious sounds, which are altogether the products of disease.
30
Flint, Cardiac Murmurs.
By the limitations of the significance of the murmurs, I mean the actual amount of knowledge respecting valvular lesions to be derived from this source. It is evident, from what has been stated already, that the know- ledge which they convey is of very great importance, but, important as this knowledge is, it has certain limits which are not always sufficiently under- stood ; and, as a consequence, the practitioner is liable to fall into unfor- tunate errors of opinion as regards the gravity of the lesions which the murmurs represent.
Prior to the clinical study of the cardiac murmurs, the existence of or- ganic affections of the heart was recognized when, in conjunction with disturbed action of the organ, symptomatic events had taken place which belong to an advanced stage of only a certain proportion of cases. Dys- pnoea, palpitation, and dropsy, were the symptoms mainly relied upon for the diagnosis. The recognized cases were then comparatively rare, and, when recognized, a speedily fatal issue was expected. This fact, together with the frequency with which cardiac lesions were revealed by post-mortem examinations in cases of sudden death, rendered the diagnosis of organic disease of the heart equivalent to a summons from the grave. The prog- nosis, as a matter of course, was as unfavourable as possible ; the doom of the patient was either to die unexpectedly at any moment, or to endure protracted sufferings until released by death. The study of the murmurs, together with the application of other signs, enabled the practitioner to recognize organic affections at a period in the disease when otherwise they would not have been discovered. The recognized cases became more fre- quent. Persons were found to have cardiac lesions who presented few or no symptoms pointing obviously to disease of the heart. The ideas which had prevailed relative to the gravity of organic affections, however, natu- rally enough, continued to prevail. An organic murmur, consequently, had a fearful significance. It was considered as proof of disease which was not less surely destructive because earlier ascertained. Let it be said of a patient that he had a cardiac murmur denoting a valvular lesion, and his doom was pronounced; sudden death, which might occur at any time, or an early development of the distressing symptoms characteristic of cardiac disease, were to be expected, whatever might be his present condition.
So far from concealing from patients the fearful significance of cardiac murmurs, it was considered important for them to understand fully their precarious condition, in order to receive their co-operation in the measures of management which were deemed essential. These measures embraced general and local bloodletting, depletion by cathartics, sedative remedies addressed to the circulation, mercurialization, low diet, together with as much inaction of mind and body as possible. The consequences of this management were calamitous in the extreme. In fact, these measures' contributed, in no small degree, to the fulfilment of the gloomy predictions impressed upon the minds of the unfortunate patients who were found to
1862.]
Flint, Cardiac Murmurs.
31
present the auscultatory sign of valvular lesions. So long as these notions with regard to the treatment of cardiac affections prevailed, an early diag- nosis, instead of being desirable, was a serious disadvantage, and truly fortunate were they who kept aloof from the stethoscope of the auscultator !
Erroneous views respecting the significance of cardiac murmurs, and also respecting the indications for treatment in cases of organic disease of the heart, are still, to a greater or less extent, prevalent. I propose now to confine myself to the former, i. e., the significance of the murmurs. It is obvious that with the acquirement of means of ascertaining the existence of lesions at an early period, when, without these means, the lesions could not have been discovered, clinical experience had to take a new point of departure as regards prognosis. And experience has shown that lesions giving rise to cardiac murmurs by no means invariably denote impending danger or serious evils, and that they are not unfrequently innocuous. Several clinical observers, within the last few years, have contributed facts going to show the correctness of this statement. Of these. Dr. Stokes' is especially prominent. Dr. Gairdner, of Edinburgh, has lately communicated a valuable paper on this subject.^ I have been able to gather some facts having an important bearing on the subject under consideration. Of the cases which have come under my observation, exemplifying the ''limitations of the significance of cardiac murmurs," I shall select a few of the most striking.
Thirteen years ago, I attended a child, aged 11 years, with a slight rheumatic attack. Directing attention to the heart, I found a very loud mitral, regurgitant murmur, heard over the left lateral surface of the chest and on the back. The heart was enlarged, the extent and degree of dulness in the pr^cordia being increased, and the apex beat without the nipple. The murmur was evidently not due to an endocarditis developed during the present attack of rheumatism ; the lesion giving rise to it probably origi- nated in an obscure thoracic affection which had occurred seven years before. I was at that time less acquainted with the significance of cardiac murmurs than now, and I deemed it my duty to inform the mother of the patient of the existence of an organic affection of the heart, which would be likely to destroy life within a period not very remote. The patient is still living. She is now 24 years of age, and, although presenting a delicate appearance, a casual observer would not suspect the existence of any disease. She is suliject to palpitation, to coldness of the extremities, and experiences want of breath on active exercise, but she does not consider herself an invalid, and the apprehensions caused by my communication . to the mother have long since disappeared.
It is fair to presume that my opinion in this case was considered as a mistake. It was, indeed, an error of judgment as regards the prognosis, but the diagnosis was correct ; the loud bellows murmur is still there, and
' Diseases of tlie Heart and Aorta.
2 Edinburgh Monthly Journal of Med. Science.
32
Flint, Cardiac Murmurs.
[Jnly
heard over the whole chest, even through the dress, and the heart is con- siderably enlarged. The patient, if not destroyed by some intercurrent affection, will ultimately die of cardiac disease, yet it is now twenty years since the probable commencement of the lesions giving rise to the cardiac murmur.
Nearly twenty years ago a person was examined by a medical friend with reference to an assurance on his life. My friend, finding a loud murmur, and an abnormally strong action of the heart, brought the person to me as an interesting case for examination. I failed to record the case, and am not therefore positive as regards the particular murmur present, but I think it was the mitral regurgitant. Since that examination, until recently, I have been in the habit of meeting this person often, although he has never been my patient. He has been, and still is engaged in active business. He is now about fifty years of age. He has survived his wife, and been again married within a few years.
I have selected these two cases as illustrating the duration of' life and comfortable health for thirteen and twenty years after a loud organic mur- mur, together with enlargement of the heart, had been ascertained ; in both cases life and comfortable health continuing at the present moment, I could cite, in addition, numerous cases of persons now living, and appa- rently well, who have had organic murmurs for several years. In making examinations of chests, supposed to be healthy, for purposes of study, I have repeatedly found a murmur, evidently organic, when no disease of the heart was suspected either before or after my examination. The following case is instructive, as showing the Importance of taking into account the coexistence of functional disorder of the heart, dependent on anemia, with organic disease.
In November, 1852, I visited, in consultation with Professor Kogers, of Louisville, a lady aged about 25. She had had repeated attacks of acute rheumatism. She had an infant several months old, which she was nursing, and she had become quite ansemic. She had begun to suffer from palpitation during the preceding summer, and her attention was attracted to a sound in the chest which she heard in the night-time. This sound was also heard by a sister with whom she slept. She described, of her own accord, the sound to be like that produced by a pair of bellows. She had never heard of cardiac bellows-murmurs, and at this time there had been no examination of the chest. Prof. Rogers had been called to the patient a short time before my visit, and detected at once the existence of organic disease.
She presented an aortic direct and a mitral regurgitant murmur, both loud ; the heart was moderately enlarged, and its action violent. She was conscious of this violent action, and slight exercise or mental excitement occasioned much distress from palpitation. The urgent symptoms in the case were attributed to anaemia ; weaning was at once enjoined, and chaly- beate remedies, etc., advised. I met the patient a year afterwards without recognizing her. She was apparently in perfect health, and presented a blooming appearance. Her friends thought we must have been mistaken in our opinion as to the existence of organic disease of the heart. The murmurs and the signs of enlargement, however, were still there. She
1862.] Flint, Cardiac Murmurs. 33
continued to enjoy good health until the summer of 1856, when she suffered from uterine hemorrhage, and again became ansemic. The action of the heart became irregular, and she complained much of vertigo. Tonics, stimulants, nutritious diet and fresh air failed to remove the anaemic state, and at length she was seized with apoplexy and hemiplegia. She recovered from the apoplexy, but the hemiplegia continued, and death took place between two and three weeks after the apoplectic seizure.
The significance of organic murmurs is limited to the points of informa- tion already stated in the introductory remarks, viz., the existence of lesions, their localization, and the fact of valvular insufficiency or regurgitation. Whether the lesions involve immediate danger to life, or, on the contrary, are compatible with many years of comfortable health, the murmurs do not inform us, nor do they teach us how far existing symptoms are referable to the lesions, and how far to functional disorder induced by other morbid conditions. Neither the intensity nor the quality of sound in the murmurs furnish any criteria by which the gravity of the lesions or their innocuous- ness can be determined. A loud murmur is even more likely to be pro- duced in connection with comparatively unimportant lesions than with those of a grave character, because in the former, rather than in the latter case, is the action of the heart likely to be strong, and the intensity of the murmur, other things being equal, will depend on the force with which the currents of blood are moved. Whether the murmur be soft, or rough, or musical, depends not on the amount of damage which the lesions have occasioned, but on physical circumstances alike consistent with trivial and grave affections.
It may be imagined that these assertions, although true as regards murmurs produced by the direct currents of blood, do not hold good with respect to the regurgitant murmurs. The latter, it may be said, involving as they do insufficiency of the valves, will be loud in proportion to the amount of blood which regurgitates, and, therefore, the intensity of the murmur should be a criterion of the amount of valvular insufficiency. But clinical observation disproves this surmise. A minute regurgitant stream is as likely to be intensely murmuring as a large current, perhaps even more so. Here, too,, the loudness of the sound will depend, in a great m.easure, on the power of the heart's action. To this point I shall recur when I come to consider the different murmurs separately.
The practical injunction to be enforced in connection with the limitatioas of the significance of the cardiac murmurs is^ that we are not to j;Udge of the magnitude of valvular lesions, of the amount of danger on the one hand, or of the absence of danger on the other liand, by the characters Monging to the murmurs. The physician who undertakes to interrogate the heart by auscultation is not to decide that the condition of his patient is alarming, simply because he finds a murmur which he satisfies himself is dependent on an organic lesion of some kind. The lesion may be at that Ko. LXXXYII.— July 1862, S
34 Flint, Cardiac Murmurs. [July
time, and perhaps ever afterwards, innocuous ; the evils arising from cardiac affections maybe remote, and so far from plunging the patient into despair by the announcement of the fact that he has an incurable disease of heart, there may be just grounds for holding out expectations of life and com- fortable-health for an indefinite period. Neither does it necessarily alter the case when more than one murmur is discovered ; the existence of several murmurs by no means excludes the possibility of similar encouragement. We are to look to other sources of information than the murmurs in forming an opinion respecting the gravity of the affection. What are the sources of information on which our opinion is to be based ? It does not fall within the scope of this essay to consider at length the points involved in the answer to this inquiry. I shall answer it in a few words.
The heart-sounds furnish means of determining whether the lesions are of a nature to affect materially the function of the valves. I must here pass by this useful and beautiful application of auscultation with a simple allusion to it, referring the reader • elsewhere for a full exposition of the subject.* I shall, however, return to the subject presently in considering the murmurs individually. Means requiring less proficiency in physical exploration relate to enlargement of the heart. It is not a difficult problem to determine whether the heart be or be not enlarged, and it is easy to determine the degree of enlargement. Now, in general, if valvular lesions have not led to enlargement of the heart, they are not immediately dangerous, and the danger is more or less remote. Here is a criterion of great importance in estimating the gravity, on the one hand, or the present innocuousness on the other hand, of lesions giving rise to murmurs. So long as the heart be not enlarged, the lesions cannot have occasioned to much extent those disturbances which arise from contraction or patency of the orifices. The murmurs, in themselves, give no information respect- ing the amount of obstruction from contracted orifices, or of regurgitation from valvular insufficiency. Let this fact be constantly borne in mind. But obstruction and regurgitation singly or combined, inevitably lead to enlargement of the heart ; hence the latter becomes evidence of the former. The degree of enlargement is, in general, a guide to the extent and duration of the disturbances occasioned by contracted and patescent orifices. As a rule, if the heart be slightly or moderately enlarged, the immediate danger from the lesions which may give rise to one or more loud murmurs is not great.
The truth is, the evils and danger arising from valvular lesions, for the most part, are not dependent directly on these lesions, but on the enlarge- ment of the heart resulting from the lesions. We may go a step further than this and say that, ordinarily, serious consequences of valvular lesions
' Clinical Study of the Heart-sounds in Health and Disease, Prize Essay, Trans. .Amer. Med. Association, 185y.
1862.] Flint, Cardiac Murmurs. 35
do not follow until the heart becomes weakened either by dilatation or by degenerative changes of tissue. So long as the enlargement be due mainly to hypertrophy of the muscular walls, the patient is comparatively safe. Hypertrophy is a compensatory provision, the augmented power of the heart's action enabling the organ to carry on the circulation in spite of the disturbance due to obstruction and regurgitation. Happily, in most cases, hypertrophy is the first effect of valvular lesions, and, for a time, it keeps pace with the progress of the latter. Dilatation, which weakens the heart's action, is an effect consecutive to hypertrophy, and, as a rule, it is not until the dilatation predominates that distressing and dangerous evils are manifested..
The practical bearing of these views respecting hypertrophy and dilata- tion, on the management of organic affections of the heart, is obvious. They are inconsistent with the employment of measures to prevent or diminish hypertrophy ; on the contrary, they point to the importance of an opposite end of management, viz., to encourage hypertrophy in prefer- ence to dilatation, and to maintain the vigour of the heart's action. It does not fall within the scope of this essay to consider therapeutical appli- cations, and I must content myself with this passing notice of an immensely important reform in the management of organic affections of the heart.
Returning to the means of determining the gravity of valvular lesions, I repeat, they become serious, in other words, the distressing and dangerous symptomatic events are to be expected, in proportion as hypertrophy merges into dilatation, or as weakness of the organ may be induced by structural degeneration or other causes. In connection, then, with murmurs, we are to determine the condition of the heart as respects the points just mentioned, in order to estimate properly the gravity of the lesions which the murmurs represent. In leaving this subject, viz., the limited signifi- cance of the cardiac murmurs, I will give a case which is a type of a class of cases not unfrequently coming under observation.
In the spring of 1860, I was consulted by a medical gentleman from a distant State, who furnished me with the following written statement of his case : —
" About a year ago I went to the city of to place myself under the care
of Dr. , for a trifling surgical difficulty with which I had been annoyed for
a long time. At long intervals previous to that time I had had severe pains in the left breast about the cardiac region, but at no time from any coustant pain.
I thought the pain was of a neuralgic character. While at • I thought I
would have my lungs examined, as some members of my family had been con- sumptive. I went to Dr. and to Dr. , both of whom pronounced my
lungs sound, but said that my heart was affected. I came home much depressed by their opinion, and suffered so much from mental anxiety that in the course of a month or two I determined to go back and consult another medical gentleman.
Dr. . He told me there was some roughness about the sounds of the heart
but no serious organic disease. I was much relieved by this opinion, and clung to the belief that the pains were of a neuralgic character.' Previous to my
' Doubtless thej were so.
36
Flint, Cardiac Murmurs.
[July
going to I had all my life taken a good deal of out-door exercise, such as
riding, hunting, fishing, etc., for the purpose of warding off any tendency to consumption. I have always had a frail figure and been inclined to despondency. I have suffered a great deal of anxiety, owing to family afiairs and business
matters. After my return from consulting Dr. I thought it best to give up
active exercise for fear of increasing any cardiac affection that might exist. I do not think that I have had any severe pain in my chest frequently, at any time, but only at intervals and apparently occasioned by anxiety about patients, etc.
"In December last I went into the country, 13 miles, to see a patient. The weather was very cold, rainy, and windy ; I returned in the night. I was suffer- ing from toothache and smoked a cigar in order to relieve the pain. I went over to my office to write a prescription for a sick child, and on my way back I was attacked with palpitation of the heart for the first time in my life. I came into the house and lay down, when I was seized with severe rigors without chills. I had also pain in the back and afterwards fever. Since then I have been subject, at intervals, to a jarring or knocking sensation about the heart, but no palpitation of long continuance. I cannot sleep as well on my left side as formerly, as it causes an uneasy sensation with something like palpitation and some pain. I do not take much exercise, and find that I get out of breath easily. I am very sensitive to cold. The attacks of increased action of the heart are always accompanied by rigors and irritability of the bladder. On the 19th of March, I was taken with a feeling of fatigue and indigestion, followed by severe rigors together with great heat of the head and body. The circula-' tion was rapid and accompanied by palpitation. The attack lasted nearly an hour, and I feel the effect of it to-day, March 22d. I notice, when reading a newspaper or small book, that the action of the heart causes it to vibrate. During my first attack in Dec, I had an intermittent pulse. I did not recover from that attack so as to go out for a week, and have not since been as well as before.
"Fearing that my situation was critical I have been careful of myself. I have feared to increase the affection and that I might die suddenly. But I have had fear that in taking care of the cardiac affection I shall increase a tendency to consumption. Any mental anxiety increases the action of the heart. I do not smoke nor chew tobacco, nor drink any alcoholic liquors. I have suffered much from toothache ; in other respects have had generally very good health. I have never had rheumatism. I am a married man with five children. I think my cardiac affection has been getting worse since December last, and I suffer in mind dreadfully on that account, as I have a great deal to live for."
On examination of the chest, in this case, I found the apex-beat in the 5th intercostal space half an inch within a vertical line passing through the nipple. The area of superficial cardiac dulness carefully delineated on the chest, was found to be of normal extent. The left border of the heart fell within the nipple. The respiratory murmur, on a deep inspiration, was heard over the whole pr^ecordia. The apex-beat was not abnormally strong ; no other impulse was discovered, and no heaving of the prtecordia.
At the first examination, the heart being but little excited, I discovered a slight murmur just to the left of the apex, heard only during the latter part of each inspiratory act. T could discover no murmur at the base. At a subsequent examination on the same day, made after dinner, the patient having drank a little wine with his dinner, the action of the heart was much greater than at the previous examination. I then discovered a well- marked systolic murmur at the apex, to the left of the apex and at the lower angle of the scapula ; I also ascertained the existence of a soft sys- tolic murmur at the base on the left side of the sternum and not on the right side. This murmur extended over the whole summit of the chest on the left side. At the summit it came evidently from the subclavian, as the
1862.-]
Flint, Cardiac Murmurs.
87
pitch differed from that of the murmur over the pulmonary artery, i. e., in the 2d intercostal space on the left side.
On the next morning I made an examination while the patient was still in bed. The heart was then acting tranquilly. I discovered a feeble murmur at the apex only ; this murmur was not perceived behind, and no murmur was heard at the base.
The aortic and pulmonic second sounds were normal, and so also were the mitral and tricuspid valvular elements of the first sound.
I shall quote from my record book the remarks which were appended to this case when the record was made : —
"The heart is but little if at all enlarged, and the heart sounds are normal. There exist, therefore, no lesions which at present are of serious import. Tlie cardiac trouble which has occasioned the patient so much unhappiness and anxiety, is purely functional.
"Dr. (who first examined this patient) evidently discovered a
murmur. His examination was not very critical, and was made after the patient had just mounted stairs at his hotel. The opinion that there was organic disease without any qualifying explanations produced a profound
moral impression on the patient. The opinion of Dr. ■ subsequently
did something toward relieving the apprehensions of the patient ; but his coming such a long distance to consult me is evidence how much his mind was ill at ease on the subject."
" The heart is not entirely free from lesions ; there is slight mitral regur- gitation. The murmur at the base is perhaps inorganic, or at all events it does not denote important valvular lesions, since a comparison of the aortic and pulmonic sounds shows the two to be in a normal relation to each other. The lesions in fact which exist in the case are of no immediate seriousness, and of this I assured the patient in the most positive manner."
"This case affords an illustration of the importance of discriminating between functional disorder and the effects of organic disease when there is evidence of the latter. It illustrates, also, the importance of the heart sounds and of the size of the heart in determining the gravity of lesions. The evils which may arise from the lesions (if they ever occur) are remote, and I felt warranted in assuring the patient that his condition involved no present danger, and that he might dismiss all thoughts of disease of the heart. I ordered him to live well and to resume his out-door sports. His apprehensions were entirely relieved by my assurances, and his expressions of gratification afforded evidence of what he had suffered mentally from the idea of an organic disease incapacitating him for the duties of life and randering him liable to sudden death."
As I have said, this case is a type of a class of cases of not unfrequent occurrence. The existence of a cardiac murmur was discovered in conse- quence of an examination with reference to the lungs. Prior to this time no symptoms of disorder of the heart existed ; the discovery of the murmur was an unfortunate circumstance for the patient ; the belief that he had serious disease of heart became fixed in his mind, and doubtless contributed to the disorder which subsequently occurred. The functional disorder was slight in comparison with cases which are of daily occurrence ; but the patient naturally attributed it to organic disease. The affection was in
38
Flint, Cardiac Murmurs.
fact altogether functional, albeit the existence of an organic murmur ; this is the practical point which the case is intended to illustrate.
I propose now to consider certain practical points pertaining to the cardiac murmur separately ; I shall limit my remarks mainly to the mur- murs produced by the blood-currents, in the left side of the heart, viz., the aortic direct, the aortic regurgitant, the mitral systolic and the mitral direct. Exclusive of the pulmonic direct murmur I have but little prac- tical acquaintance with murmurs emanating from the right side of the heart.
Aortic direct murmur. — The question whether a murmur be organic or inorganic has reference generally to a murmur produced by the current of blood from the left ventricle into the aorta. The aortic regurgitant mur- mur and a mitral murmur which is truly regurgitant are of necessity organic; they require lesions involving more or less insufficiency of the valves. The mitral direct murmur, as will be seen presently, is inorganic only as a rare exception to the rule. A practical point, then, in certain cases, is to determine whether an existing aortic direct murmur be organic, i. e., dependent on lesions, or whether it be inorganic, i. e., dependent on a blood-change. This point cannot always be positively settled, but when such is the case it is practically not very important that it should be settled ; in other words, when a murmur exists concerning which we are at a loss to decide whether it be organic or inorganic, if it be the former, the lesion giving rise to it must be trivial, since under these circumstances the heart sounds will be found to be normal and the heart not enlarged. If in con- nection with an aortic direct murmur we find the aortic second sound impaired and the heart enlarged, we are warranted in considering the murmur organic. But a slight rippling of the current by roughening from an atheromatous or calcareous deposit which occasions no obstruction, and no valvular insufficiency, may yield a murmur. How are we to dis- tinguish this from an inorganic murmur ? The absence of the anaemic state, of other cardiac murmurs, of arterial murmurs, of the venous hum, and the persistency and uniformity of the murmur are the circumstances which render it probable that it is organic ; while the existence of anaemia, of other cardiac murmurs, of arterial murmurs and the venous hum, together with intermittency and variableness of the murmur, render it probable that it is inorganic.
In my work on diseases of the heart, 1859, I have stated roughness of the murmur to be one of the circumstances showing it to be organic. I then believed that an inorganic murmur was never rough. The able reviewer of my work in the Dublin Quarterly says, with regard to this point, "We are unable to give unqualified assent to the statement that an inorganic murmur is uniformly soft." The criticism of the reviewer is just; I was mistaken in the statement as the following case will show: —
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I visited in May, 1860, a female patient who presented a loud rasping murmur which had led to the suspicion of aneurism. The patient was exceedingly anaemic ; there was total loss of appetite with vomiting and diarrhoea. The anemia could not be accounted for; it belonged in the category of cases described by Addison as cases of idiopathic ansemia. I found a rough rasping murmur at the base of the heart on the right of the sternum, and a similar murmur was heard over the subclavian and carotid. On examination after death, in this case, the heart was perfectly normal, the aortic orifice, the aorta, subclavians, and carotids were free from any morbid change, and the lungs were healthy. The murmur was evidently due to a blood change.
The discrimination of an aortic direct from a pulmonic direct murmur is a point of interest. If the normal situation of the aortic and pulmonic artery in relation to the walls of the chest be preserved, an aortic direct murmur has its maximum of intensity and may be limited to the point where the aorta is nearest the surface, viz., the second intercostal space on the right side close to the sternum. But the normal relation of the vessels to the thoracic walls is not infrequently changed when the heart becomes enlarged, or as a consequence of past or present pulmonary disease, and hence this murmur may be loudest or limited to the base on the left side of the sternum. The situation of the murmur or of its maximum, there- fore, is not always reliable in the discrimination. A pulmonic direct murmur has its maximum or is limited to the second or third intercostal spaces on the left side close to the sternum, the artery being at these points nearest the surface, but, as just stated, an aortic direct murmur may be found to be loudest in this situation. If the heart be not enlarged or displaced by pressure from below the diaphragm, the chest not depressed, and the lungs are free from disease, the fact that a murmur has its maxi- mum at or is limited to the right side of the sternum, is evidence of its being aortic rather than pulmonic, and per contra, the fact of a murmur having its maximum at or being limited to the left side of the sternum, is evidence of its being pulmonic rather than aortic. But the propagation of the murmur into the carotid is the most important circumstance in this discrimination. An aortic direct murmur, unless it be quite weak, is generally propagated into the carotid. A pulmonic direct murmur of course cannot be. Here attention to the pitch and quality of sound is called into requisition. It is to be determined that a murmur heard over the carotid is propagated from the aorta not produced within the carotid. How is this to be determined ? Yery easily in most cases, by a simple comparison of the murmur as heard over the carotid and at the aortic orifice. If the murmur in the neck be a propagated murmur it will differ from that at the base of the heart chiefly as regards intensity ; the pitch and quality will not be materially changed. If it be rough or soft at the base of the heart, it will be the same in the neck ; if the pitch be high or low at the base of the heart, it will be the same in the neck. On the
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other hand, a murmur produced within the carotid, will be likely, in the great majority of cases to differ in quality and pitch from a coexisting murmur at the aortic orifice.
In accordance with what has been stated with reference to the limitations of the significance of organic murmurs in general, an aortic direct murmur, when undoubtedly organic, alone affords little or no information respecting the nature and extent of the lesions which give rise to it. A comparison of the aortic with the pulmonic second sound of the heart enables us fre- quently to form an opinion as regards the amount of damage which the aortic valve may have sustained. The aortic second sound, in health, as heard in the right second intercostal space near the sternum, is more intense, and has a more marked valvular quality, than the pulmonic second sound as heard in a corresponding situation on the left side. Now, it is often easy to determine whether the intensity of the aortic second sound is diminished and its valvular quality impaired ; and in proportion as this sound is abnormally altered in these respects, we may infer that the aortic valve is damaged. It is hardly necessary to say that, in order for this comparison to warrant the inference just stated, pulmonary disease must be excluded. A tuberculous deposit, for example, on the left side, may, by conduction, render the pulmonic apparently more intense than the aortic sound, the latter retaining its normal intensity ; the same will occur from shrinking of the upper lobe of the left lung so as to bring the pulmonic artery into contact with the thoracic walls. Under the latter circumstances the pulsation of the pulmonic artery may sometimes be distinctly felt in the second left intercostal space near the sternum. I have met with two cases during the past winter in which the pulsation of the pulmonic artery was so strong as to suggest the idea of aneurism; in both cases the patients were affected with tuberculous disease of the left lung. Alteration of the normal relation of the aorta and pulmonic artery due to enlargement of the heart, or to any of the causes already mentioned, will of course preclude a comparison of the two sounds.
With reference to the value of a comparison of the aortic and pulmonic second sound in estimating the amount of aortic lesions, the able reviewer in the Dublin Quarterly, to whom I have already referred, and for whose valuable criticisms I beg to avail myself of this opportunity of expressing my sincere thanks, remarks as follows:- —
" It is observed, to our great wonder, that if the aortic second sound retain its normal intensity and purity, it shows that the aortic valve is competent to fulfil its function, a fact which warrants the exclusion of lesions affecting it sn.fficienth/ to give rise to ohstruction." He adds, " Surely Dr. Flint must have become clinically cognizant of the fact that there is not unfrequently serious contraction of the aortic orifice producing marked obstruction and hypertrophy of the left ventricle, the aortic second sound remaining intact."
Tills criticism is not altogether just. I state that the normal intensity and purity of the aortic second sound warrant the exclusion of lesions affecting
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it, i. e., the vake, sufficiently to give rise to obstruction. I do not say that contraction of the aortic orifice may not occur without involving the aortic valve, and, in such a case, the aortic second sound may remain intact. In fact, I imply this when I proceed to say, "In a large proportion of the cases of obstructive lesions of the aortic orifice, the valve is involved sufficiently to compromise, to a greater or less extent, its function and impair the intensity of the aortic second sound." This language is equiva- lent to admitting that there is a small proportion of cases of obstructive lesions of the aortic orifice, in which the valve is not involved sufficiently to compromise its function and impair the intensity of the aortic second sound. These exceptional cases are extremely rare. Surely the able reviewer will admit that, in the great majority of cases, the valve is involved so as to impair its function to a greater or less extent.
I have lately been interested in a nice point of observation connected with the murmur under consideration, viz., the concurrence of two aortic direct murmurs, one produced at the aortic orifice and another within the aorta just above the orifice. One of the murmurs may be organic and the other inorganic, or both murmurs may be organic. At the present moment I have under observation three cases of endocarditis with rheumatism, each presenting a high pitched basic murmur when the stethoscope is placed over the sternum and a little to the right of the median line, the murmur limited to a circumscribed space, and just above this point, in the right second intercostal space, is another murmur difi'ering from the former notably in pitch, being quite low. In one of these cases there is still another murmur in the pulmonic artery. The high pitched murmur just below the second intercostal space, as I infer from the situation to which it is limited, is a murmur produced at the aortic orifice ; and the low pitched murmur just above, as I infer, also, from the situation to which it is limited, is an aortic murmur produced within the artery above the aortic orifice. I infer that there are two murmurs from the notable difference in pitch, it being by no means probable that a single sound would be so much altered within the area in which the two murmurs are heard, this area not being larger than a half dollar. That an aortic murmur is sometimes produced at the orifice and sometimes within the artery above the orifice, in different cases, is cer- tain, but I am not aware that the production of a murmur in each situation, at the same time, in the same case, and the discrimination of the two by means of the character of the sound, have been pointed out.
Aortic regurgitant murmur. — This murmur need never, as a matter of course, be confounded with the systolic murmurs, viz., the aortic direct, and mitral regurgitant, the latter occurring with the first, and the former with the second sound of the heart. In general, too, there is no difficulty in distinguishing the aortic regurgitant, from the mitral direct murmur. The former occurs with and follows the second sound, the latter precedes the
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first sound.. The one is diastolic, . the other is pre-systolic. This is a distinction, nice, it is true, but easily appreciable in practice, to which I shall recur under the heading of the mitral direct murmur.
The situation of the murmur is also distinctive. It is best heard at, and below the base of the heart. Usually it is best heard below the base to the left of the median line on a level with the third or fourth ribs. This is doubted by the reviewer in the Dublin Quarterly, to whom I have referred, but as the statement is based on a pretty large number of recorded observations, I must consider it as correct. It is not uncommon to hear this murmur distinctly, and even loudly, over the apex ; it may be diffused over the whole prsecordia and even propagated beyond this region.
An aortic murmur with the second sound of the heart, propagated below the base of the heart, necessarily implies regurgitation, in other words there must be insufficiency of the aortic valvular segments. But it is always to be borne in mind that no inference can be drawn from the inten- sity or character of the murmur, respecting the amount of insufficiency and consequent regurgitation. An extremely small regurgitant stream may give rise to a loud murmur, while a feeble murmur may accompany a large regurgitant current, as the rippling brook is noisy while the deep broad river flows silently. In a case recently under observation, there existed a loud aortic regurgitant murmur, and on examination after death the aortic segments were so slightly impaired that, on cursory inspection, they might have been considered as normal. Weakening or extinction of the aortic second sound of the heart are points of importance as showing frequently the extent to which the function of the aortic valve is impaired. Comparison with the pulmonic sound enables us to judge whether the aortic sound be impaired, provided the pulmonic sound be not abnormally intensi- fied as a result of coexisting mitral lesions. It is important to recollect that when aortic and mitral lesions coexist, the intensity of the pulmonic sound cannot be taken as a criterion for judging whether the aortic sound be, or be not weakened. This remark is equally applicable to the com- parison in cases in which an aortic direct murmur is present. It is needless to say that in comparing the aortic and pulmonic sound in connection with an aortic regurgitant, as with an aortic direct murmur, pulmonary disease is to be excluded, i. e., solidification or shrinking of the left lung will, as already stated, render the pulmonic sound relatively more intense than the aortic, irrespective of, on the one hand, any actual increase of the intensity of that sound, or, on the other hand, of any weakening of the aortic sound. It is also to be stated here, as heretofore, that an alteration of the situation of the aorta and pulmonary artery as regards the thoracic walls, due to enlargement of the heart, or other causes, will preclude a comparison of the two sounds with reference either to intensification of the pulmonic, or weakening of the aortic sound.
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Mitral systolic murmur. — I use the phrase mitral systolic, instead of that more commonly used, viz., mitral regurgitant murmur, as applied to any murmur produced at the mitral orifice and accompanying the first sound of the heart. If the latter term be applied to any systolic murmur emanating from the mitral orifice, we fall into the solecism of calling a murmur regur- gitant in cases in which there is no regurgitation. A mitral murmur may be produced by mere roughness of the valvular curtains when there is no insufiiciency of the valve. In this case the murmur cannot be correctly said to be regurgitant. A mitral systolic murmur, thus, may or may not be a regurgitant murmur, and, to express this important distinction, we may say that a mitral systolic murmur exists with or without regurgitation. The question at once arises, how are we to determine whether a mitral systolic murmur be regurgitant or non-regurgitant ? This point claims consideration.
A mitral systolic murmur, as is well known, generally has its maximum of intensity at, and the murmuring may be limited to, the situation of the apex-beat, or to the point where the intensity of the first sound of the heart is greatest. The murmur may be diffused, in the first place, within this point over the body of the heart, and, in tlie second place, without the apex over the left lateral surface of the chest and on the back. I have been led to believe that when the murmur is diffused over the left lateral surface and more or less over the back, it always denotes regurgitation, and that when the murmur is not propagated much without the apex, although it may be more or less diffused over the body of the heart, it may be produced within the ventricle and not by a regurgitant current. In the latter case I have distinguished the murmur as an intra-ventricular murmur, and not considered it as affording any evidence of insuflQciency of the mitral valve. It is this intra-ventricular, or mitral systolic non-regurgitant murmur, which generally exists in rheumatic endocarditis. The importance of the point involved is obvious, for a murmur emanating from the mitral orifice without valvular insufficiency or regurgitation, denotes lesions of little immediate consequence, and they may be innocuous, not only for the present but for the future.
The practical rule just stated, I believe, generally holds good ; but there may be exceptions. The following is perhaps an exceptional instance : a case was recently under my observation in Bellevue Hospital, in which acute rheumatism was complicated with endocarditis, pericarditis, and pleurisy, with considerable effusion, affecting the left side. This patient presented, on admission, a loud pericardial friction sound diffused over the whole prsecordia, and a loud mitral systolic murmur. The latter had its maxi- mum of intensity at the apex, but was diffused over the left lateral surface of the chest and heard on the back. After the lapse of about a week the friction sound disappeared ; but before the disappearance of the friction sound, the endocardial murmur had gradually diminished and disappeared.
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The pleuritic efifusion also disappeared, and evidence was afforded in this case of pericardial adhesions by the immobility of the apex-beat when the body of the patient was placed in different positions. The disappearance of an endocardial murmur developed by rheumatic endocarditis, so far as my observation goes, is rare, although I have met with other examples. I suppose that endocarditis does not involve actual regurgitation save as a remote consequence of lesions to which the endocarditis may give rise. 1 may be mistaken in this supposition, but, assuming that I am not, here was an instance in which an intra-ventricular or non-regurgitant mitral systolic murmur was propagated entirely around the chest.
With reference to determining the existence of either regurgitation or obstruction, or both, resulting from mitral lesions, a comparison of the aortic and pulmonic second sound, forms a beautiful and useful application of auscultation. Obstructive and regurgitant lesions, situated at the mitral orifice, involving an obstacle to the free passage of blood through the pul- monary circuit, give rise, as is well known, to hypertrophy of the right ventricle. In this way they lead to intensification of the pulmonic second sound of the heart. This effect is due, in part, to the augmented power of the contractions of the right ventricle, and, in part, to the resistance to the passage of blood through the lungs, both continuing to increase the dilatation of the pulmonary artery by the pulmonic direct current, and the consequent recoil of the arterial coats by which the pulmonic valvular segments are expanded, and the pulmonic second sound produced. But the morbid disparity between the aortic and pulmonic second sound is due, not alone to the intensification of the latter in the manner just stated. The aortic second sound is weakened in proportion to the amount of blood which fails to pass into the aorta with the ventricular systole, in conse- quence of the mitral obstruction or regurgitation. It is obvious that the aortic direct current will be lessened by the amount of blood which, in con- sequence of valvular insufficiency, flows backward into the left auricle after the ventricle contracts, and by the amount of difficulty which exists in the free passage of blood from the auricle into the ventricle in consequence of a contracted orifice. It is also obvious that, other things being equal, the intensity of the aortic second sound will be greater or less according to the quantity of blood propelled into the aorta by the ventricular systole. Thus it is clear how mitral obstruction and regurgitation lead to weakening of the aortic sound, as well as to intensification of the pulmonic sound, and both effects are abundantly attested by clinical observation.
The degree of weakening of the aortic and of intensification of the pul- monic sound will be proportionate to the amount of mitral regurgitation or obstruction, or both. We have then, in this application of ausculta- tion, a means of obtaining information respecting the extent or gravity of mitral lesions. And, in a negative point of view, this application is im- portant, viz., as a means of determining that lesions which give rise to a
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murmur are not serious ; in other words, of determining that they do not involve much, if any, obstruction or regurgitation. As enabling us to exclude obstructive or regurgitant lesions in certain of the cases in which mitral murmurs exist, a comparison of the aortic and pulmonic sound is of great practical value. But the circumstances which may stand in the way of this application of auscultation are to be borne in mind. The two sounds cannot be compared with reference to mitral, more than with refer- ence to aortic lesions, if there be coexisting pulmonary disease, nor when- ever the normal relation of the aorta and pulmonary artery to the thoracic walls is altered by either past or present disease of lungs, by deformity of the chest, or any other cause. It is also to be recollected that mere enlarge- ment of the heart may disturb the normal relation of these vessels to the walls of the chest. This application, moreover, cannot be made when mitral and aortic lesions coexist. Under the latter circumstances it is, of course, difficult or impossible to determine how far an existing disparity between the aortic and pulmonic sound is due to the aortic, and how far to the mitral lesions.
Another important point pertaining to a mitral systolic murmur is, its occurrence without any appreciable lesions. A truly mitral regurgitant murmur doubtless always involves lesions of some kind, for it is hardly probable that the papillary muscles, as has been supposed, may become spasmodically affected and thus give rise to insufficiency or regurgitation as a temporary functional disorder. But it is undoubtedly true that a sys- tolic murmur either limited to, or having its maximum of intensity near the apex, has been repeatedly observed in cases in which mitral lesions were not apparent after death. Dr. Bristowe in a paper contained in the Brit, and For. 3Ied. Chir. Review, for July, 1861, details six cases of this description. Dr. Barlow, in an article in Guy^s Hospital Reports, vol. v., 1859, states that a mitral murmur may occur (for what reason he does not state) in long-continued capillary bronchitis. I have met with some instances in which a systolic murmur, supposed to be mitral, existed, and no mitral lesions were found after death.
Case 1.* In the winter of 1859-60, 1 saw a female patient in the Charity Hospital, New Orleans, in the service of my colleague, Prof. Brickell, affected with capillary bronchitis. After several days there was improve- ment as regards the pulmonary symptoms, and then, for the first time, a s3'stolic cardiac murmur was discovered. The murmur was loudest at the epigastrium, but heard over the site of the apex, and extended to, but not above the base of the heart. The patient subsequently died. On exami- nation after death the lungs were emphysematous ; there were no valvular lesions, all the valves appearing to be sound. The foramen ovale was closed. There were no clots. The right ventricle was distended with liquid blood. The walls of the heart were of normal thickness. The valves and orifices were not measured, nor was the water test of valvular sufficiency employed.
^ Private Records, vol. xi. p. 36.
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In recording this case I have commented on the murmur as follows : "What could have caused the loud systolic murmur? I cannot say unless it was due to distension of the right ventricle and tricuspid regurgitation."
In support of the supposition that the murmur was tricuspid, not mitral, it is to be noted that the greatest intensity was at the epigastrium. It was, however, considered to be a mitral systolic murmur during life.
Case 2.* During the winter of 1860-61, a patient was under my obser- vation in the Charity Hospital, New Orleans, for four months, affected with albuminuria and general dropsy. During all this time there was a mitral systolic murmur heard at the apex and over the body of the heart, and not propagated without the apex. It was regarded as a mitral systolic, non- regurgitant or intra-ventricular murmur, and as such pointed out to several private classes in auscultation. The patient died by asthenia, and was found to have fatty kidneys and cirrhosis of the liver. On examination of the heart, post mortem, nothing abnormal was found except some enlargement, the organ weighing 12 oz., and a little separation of the marginal extremity of two of the aortic segments. The mitral valve appeared to be perfectly normal. I expected to find some roughening of the mitral valve but no insufficiency; there was, how^ever, no atheromatous, calcareous or other deposit, and the valve seemed to be sufficient. There was no aortic, nor pulmonic murmur in this case, a fact which excludes the supposition that the existing murmur was due to the condition of the blood.
Case 3.^ During the winter of 1860-61, a patient was under my obser- vation in the Charity Hospital, New Orleans, for about six weeks, affected with chronic bronchitis and emphysema of lungs. He presented habitual dyspnoea which was at times excessive, persisting lividity and anasarca. The heart was evidently somewhat enlarged. There was a loud rough systolic murmur, having its maximum of intensity at the apex propagated without the apex (the record does not state how far), and over the body of the heart. On examination after death the volume of the heart was not much increased, and its weight was 13 oz. The left ventricle was not dilated and the left auricle was small. The walls of the left ventricle did not exceed half an inch in thickness, and the appearance of the muscular tissue was healthy. The mitral valve was perfectly normal. The orifice was not enlarged, and the valve must have been sufficient. No lesion at the aortic orifice. The right cavities were much dilated. They were twice as large as the left cavities. The walls of the right ventricle were much thickened, the thickness falling but little short of that of the left ventricle. No lesion of the pulmonic orifice. The tricuspid valve was normal. The orifice was very large, admitting the extremities of all the fingers. I have appended to the record of this case the following comment : "Whence thfe murmur supposed to be a mitral regurgitant? I suspect it was a tricuspid regurgitant."
Dr. Bristowe, in the article already referred to, discusses several conditions which have been supposed to give rise to the murmur in cases like those which have just been given, viz., clots in the ventricular cavity, spasm of the papillary muscles, and enlargement of the auricular orifice so as to
' Private Records, vol. xi. p. 243. ^ Hospital Records, vol. xv. p. 423.
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render the valve insufficient. His own opinion is tliat the murmur is due to a " disproportion between the size of the ventricular cavity and the length of the chordas tendinae and musculi papillares." This disproportion he attributes to dilatation of the cavity of the ventricle. He also accepts to some extent an explanation offered by Dr. Hare, viz., that the murmur may be due to a "lateral displacement of the origins of the musculi papil- lares in consequence of the rounded form which dilatation imparts to the heart."
These several explanations may each be applicable to certain cases, but none of them, apparently, to the cases which I have given. Clots in the left ventricular cavity were not present in either of' the cases ; the murmur con- tinued too long and too persistently to be due to spasm ; the mitral orifice was not dilated, and the enlargement of the heart was not sufficient to occa- sion a notable disproportion between the length of the tendinous cords and papillary muscles, and the ventricular cavity. I am disposed to think that in each of the three cases the murmur was erroneously considered to be mitral ; that it was a tricuspid regurgitant murmur. As I have already said, I have but little practical knowledge of tricuspid murmurs. I have met with two instances in which murmur was connected with well-marked tricuspid lesions as verified by examination after death. In both these cases the murmur was heard over the body of the heart, within the superficial cardiac region. I suspect that a tricuspid regurgitant murmur is not so rare as is generally supposed, and that not very infrequently it is <?onsidered to be mitral. This opinion is expressed by Dr. Gairdner in an interesting article on cardiac murmurs in the Edinburgh Med. Monthly, Nov. 1861. According to this able clinical observer, a tricuspid systolic murmur is heard over the right ventricle where it is uncovered of lung, being but slightly audible above the third rib ; and, if the heart be much enlarged, it may be heard louder towards the xiphoid cartilage. A collection of clinical facts respecting the frequency of tricuspid murmurs, the physical conditions giving rise to them, and the means of discriminating them from mitral murmurs, is an important desideratum.
Mitral direct murmur. — This murmur is not recognized by many aus- cultators, and its existence is denied by some. It is generally confounded with a mitral systolic murmur. For many years after I had begun to devote special attention to cardiac affections, I committed this mistake, and I was sometimes puzzled to account for a supposed mitral systolic murmur rough at its beginning and soft at its ending. In my records of some cases before I had learned to separate the mitral direct from a mitral regurgitant, I have described the latter as presenting the variation just stated, the fact being that the two murmurs were present, the one rough and the other soft. It is only within the last few years that I have discriminated these two murmurs, but during this time my field of clinical observation has
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been so extensive that I have had abundant opportunities to make the dis- crimination. With regard to the frequency of the mitral direct murmur, it is by no means so rare as is generally supposed, and as I had thought some yeairs ago. At one time during the past winter, in Bellevue Hospital, I knew of six examples of it, and several also at the Blackwell's Island Hospital. When the auscultator has learned to distinguish it, he will not be long in finding it if he be in the way of seeing a moderate number of cases of disease of the heart. From what has now been said, it is obvious that an important point pertaining to this murmur is, its discrimination from other murmurs. This point will first claim consideration.
In order to comprehend this murmur, it is essential to understand clearly when the mitral direct current of blood takes place. The opportunity of observing the movements of the heart exposed to view in a living animal, conduces greatly to a clear understanding of this point. The mitral direct current is produced by the contraction of the auricles ; now, when do the auricles contract ? When the movements of the heart are observed, it is seen that the contraction of the auricles immediately precedes the contrac- tion of the ventricles. So close is the connection between the contraction of the auricles and the contraction of the ventricles, that the former appears to merge into the latter; there is no appreciable interval between the two, but the successive movements, although distinct, appear to be continuous. More- over, it is evident to the eye, and to the touch, that the contractions of the auricles are not so feeble as some seem to suppose. The mitral direct cur- rent of blood, therefore, occurs just before the ventricular systole ; it con- tinues up to the ventricular systole, and must, of course, instantly cease when the ventricles contract. The contraction of the ventricles causing the first sound of the heart, it follows that the mitral direct current caused by the auricular contractions must take place just before the first sound ; that it must continue to the first sound, and that it cannot continue an instant after the first sound.
The mitral direct murmur is produced by the mitral direct current of blood forced by the auricular contractions through a contracted or rough- ened mitral orifice. Hence, the facts just stated with regard to the current, apply to the murmur. The murmur occurs just before the ventricular sys- tole or the first sound of the heart ; it continues up to the occurrence of the first sound, and instantly ceases when the first sound is heard. It is not strictly correct to call this a diastolic murmur ; it does not accompany the second or diastolic sound of the heart. The aortic regurgitant is the only true diastolic murmur. The mitral direct is a pre-systolic murmur ; this name expresses its proper relation to the heart sounds, and it is the only murmur which does occur in that particular relation. The time of its occurrence as just explained, and as expressed by the term pre-systolic, is sufficient for its easy recognition when once it is fully comprehended. Although, when this murmur is fully comprehended, and has been repeatedly
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verified, it is more readily recognized than either of the other murmurs, there is often at first considerable difficulty in determining its existence. Let me endeavour to point out the way in which it may be ascertained. I have already said that by those who overlook this murmur it is generally confounded with the mitral systolic or regurgitant murmur. This is in consequence of its close connection with the first sound, and because it is heard at and near the apex of the heart. Now it is evident that a mitral systolic murmur cannot commence before the ventricular systole. It is equally evident that the ventricular systole and the first sound of the heart are synchronous. It is, therefore, an absurdity to suppose that a mitral systolic or regurgitant murmur can be pre-systolic in the time of its occur- rence. This murmur must necessarily accompany and follow the first sound of the heart, as clinical observation has established. We have, then, only to determine that a murmur is pre-systolic, and that it does not accompany the second sound of the heart (z. e., there is an appreciable interval of time between the second sound and the murmur), to recognize it as a mitral direct murmur. Generally it is sufficiently easy, after a little practice, to perceive that the murmur precedes the sound, but, if there be difficulty or doubt, there is a ready mode of rendering it apparent ; this Is by placing the finger on the carotid pulse. The carotid pulse is synchronous with the first sound of the heart, or, at least, so nearly synchronous, that there is no appreciable interval of time between them. Placing, then, the finger on the carotid and listening to the murmur at the apex, the murmur is found to occur before the arterial impulse and to cease instantly when the latter is felt.
The mitral direct murmur is to be discriminated from an aortic regurgi- tant murmur. These two murmurs may be confounded at first, but after a little practice the discrimination is easy. The aortic regurgitant murmur accompanies and follows the second sound of the heart. The mitral direct commences after the second sound. Generally there is a distinctly appre- ciable interval of time between the second sound and the commencement of the murmur. The aortic regurgitant murmur may be prolonged nearly or quite through the long pause up to the first sound ; but the intensity of the murmur diminishes with the prolongation, the murmur being insensibly lost before or when the first sound occurs. The mitral direct murmur, on the contrary, always continues up to the first sound, and instead of losing any of its intensity, it becomes more intense, and appears to be abruptly arrested, in its greatest intensity, when the first sound occurs. This is a striking characteristic. The difference in the situation in which two mur- murs respectively are heard with their maximum of intensity, is another point in the discrimination. The aortic regurgitant murmur is generally - heard at the base of the heart, and is heard loudest a little below the base near the left margin of the sternum on a level with the third intercostal space. The mitral direct murmur is heard loudest at or a little within the No. LXXXYII July 1862. 4
50
Flint, Cardiac Murmurs.
apex ; is generally confined within a circumscribed space, not propagated much without the apex and rarely to the base of the heart.
The quality of the mitral direct murmur is, in many cases, characteristic. In my work on diseases of the heart I have said that this murmur is gene- rally soft. My experience since that work was written has shown me that this statement is incorrect. The murmur is oftener rough than soft. The roughness is often peculiar. It is a blubbering sound, resembling that pro- duced by throwing the lips or the tongue into vibration with the breath in expiration. I suppose that the murmur is caused, in these cases, by the vibration of the mitral curtains, and that the vibration of the lips or tongue by the breath represents the mechanism of the murmur as well as imitates the character of the sound. At one time I supposed this blubbering mur- mur denoted a particular lesion, viz., adhesion of the mitral curtains at their sides, forming that species of mitral contraction known as the button- hole slit; but I have found this variety of murmur to occur without that lesion, and, in fact, as will be seen presently, when no mitral lesion whatever exists.
A mitral direct murmur may, or may not, be associated with a mitral systolic murmur. Without having analyzed the numerous examples which I have recorded during the last few years, I should say that, while the mitral systolic murmur is much more frequent in its occurrence than the mitral direct, the former, indeed, being the most common of all the mur- murs, the mitral direct is observed quite as often without, as with the mitral systolic. But the two frequently coexist, and then the demonstra- tion of the existence of the mitral direct murmur may be made more striking than when it exists alone, provided, as is usually the case, this murmur be rough and the mitral systolic murmur be soft. Listening at or near the apex in a case presenting a blubbering mitral direct and a soft mitral sys- tolic murmur, the former, of course, precedes the latter, and between the two occurs the first sound of the heart, the apex-beat and the carotid pulse. The first sound, the apex beat or the carotid pulse will be found to mark the abrupt ending of the mitral direct, and the beginning of the mitral systolic murmur. The different relations of the two murmurs to the first sound are distinctly perceived in such a case if the observer be prepared to perceive them by a clear comprehension of the subject. And when once the discrimination between the two murmurs has been fairly made, it be- comes sufficiently easy; indeed, the mitral direct murmur is then more readily recognized than either of the other murmurs.
The existence of a mitral direct murmur has been theoretically denied on the ground that the auricular contractions are too weak to propel the current of blood with sufficient force to give rise to a sound. It is un- doubtedly true that, other things being equal, the intensity of a murmuir is proportionate to the force of the current, and clinical observation shows that sometimes a murmur is not appreciable when the heart is acting feebly,
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but becomes distinct when the power of the heart's action is from any cause increased. But murmurs do by no means always require for the production a powerful action of the heart ; on the contrary, loud murmurs are often found when the heart is acting very feebly. For example, I have reported a case in which an aortic direct and an aortic regurgitant murmur were well marked in a patient an hour before death, the patient dying from paralysis of the heart due to distension of the left ventricle. Yenous mur- murs in the neck are often notably loud when, assuredly, the force of the current of blood in these veins is vastly less than the current from the auricles to the ventricles. The feebleness of the current in this instance is shown by the slight pressure requisite to interrupt it and arrest the murmur. It requires but little force of the expiratory current of air to throw the lips into vibration so as to produce a loud sound. Moreover, one has only to see and feel the contractions of the auricle, when the heart is exposed in a living animal (the heart's action being much weakened under these circumstances) to be convinced that the power of these contractions is not so small as some seem to imagine ; the blood is driven into the ventricles with considerable force. It is hardly necessary to say, however, that d priori reasoning with regard to the existence or non-existence of physical signs is not admissible. Their existence is a matter to be determined by direct observation. Clinical observation shows that a murmur does occur at the precise time when the mitral direct current takes place as shown by observation of the movements of the heart exposed to view in a living animal. And clinical observation shows that this murmur is not always feeble, but, on the contrary, is not infrequently notably loud.
So much for the reality of the mitral direct murmur and the means of discriminating it from other murmurs. It remains to consider another important practical point, viz., the pathological import of this murmur. As already stated, it is developed in connection with a contracted mitral orifice, and, so far as my experience goes, especially in connection with con- traction caused by adherence of the mitral curtains, forming the buttonhole slit; the murmur, then, being due, not to the passage of blood over a rough- ened surface, but to the vibration of the curtains. And the sound, as thus produced, is peculiar, resembling the sound which may be produced, in an analogous manner, by causing the lips to vibrate with an expiratory pulf. The murmur, however, may be produced by the flowing of the current of blood over a roughened surface, without contraction of the aperture. This is undoubtedly rare. As a rule, the force of the mitral direct current is not sufficient' to develop a murmur unless there be mitral contraction. Is this murmur ever produced without any mitral lesions ? One would d pri- ori suppose the answer to this question to be in the negative. Clinical observation, however, shows that the question is to be answered in the affirmative. I have met with two cases in which a well-marked mitral direct murmur existed, and after death in one of the cases no mitral lesions were
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[July
found; in tlie other case the lesion was insignificant. I will proceed to give an account of these cases, and then endeavor to explain the occurrence of the murmur.
Case 1.^ In May, 1860, I examined a patient, aged 56, who had had repeated attacks of palpitation, sense of suffocation, with expectoration of bloody mucus and a feeling of impending dissolution, but without pain, the paroxysms resembling angina, excepting the absence of pain. In the inter- vals between these attacks he was free from palpitation, did not suffer from want of breath on active exercise, and considered himself in good health. He had never had rheumatism. On examination of the chest, the heart w^as found to be enlarged, the enlargement being evidently by hypertrophy. At the apex was a pre-systolic blubbering murmur, which I then supposed to be characteristic of the button -hole contraction of the mitral orifice. At the base of the heart was an aortic regurgitant murmur, which was diffused over nearly the whole prsecordia. There was no systolic murmur at the base or apex. Three days after this examination the patient was attacked with another paroxysm, and died in a few moments after the attack, sitting in his chair. The heart was enlarged, weighing 16 J oz., the walls of the left ventricle measuring |ths of an inch. The aorta was atheromatous, and dilated so as to render the valvular segments evidently insufficient. The mitral valve presented nothing abnormal, save a few small vegetations at the base of the curtains, as seen from the auricular aspect of the orifice.
In this case it is assumed that the mitral direct murmur, which was loud and of the blubbering character, was not due to the minute vegetations which were found after death. There was no mitral contraction. The mitral valve was unimpaired, so that the murmur could not have been due -to mitral regurgitation.
Case 2.^ In February, 1861, I was requested to determine the murmur in a case at the Charity Hospital, New Orleans. I found an aortic direct and an aortic regurgitant murmur, both murmurs being well marked. There was also a distinct pre-systolic murmur within the apex, having the blubber- ing character. On examination after death, the aorta was dilated and roughened with atheroma and calcareous deposit. The aortic segments were contracted, and evidently insufficient. The mitral curtains presented no lesions; the mitral orifice was neither contracted nor dilated, and the valve was evidently sufficient. The heart was considerably enlarged, weigh- ing 17|- oz., and the walls of the left ventricle were an inch in thickness.
In the second, as in the first of the foregoing cases, it is evident that a mitral systolic murmur was not mistaken for a mitral direct murmur, for in both cases, the conditions for a mitral systolic murmur were not present. In both cases the mitral direct murmur was loud and had that character of sound which I suppose to be due to vibration of the mitral curtains. In both cases, it will be observed, an aortic regurgitant murmur existed, and aortic insufficiency was found to exist post mortem. How is the occurrence of the mitral direct murmur in these cases to be explained? I shall give an explanation which is to my mind satisfactory.
' Private Records, vol. x. p. 713.
2 Ibid., vol. xi. p. 241.
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The explanation involves a point connected with the physiological action of the auricular valves. Experiments show that when the ventricles are filled with a liquid, the valvular curtains are floated away from the ventri- cular sides, approximating to each other and tending to closure of the auricular orifice. In fact, as first shown by Drs. Baumgarten and Hamer- nik, of Germany, a forcible injection of liquid into the left ventricle through the auricular opening will cause a complete closure of this opening by the coaptation of the mitral curtains, so that these authors contend that the natural closure of the auricular orifices is effected, not by the contraction of the ventricles, but by the forcible current of blood propelled into the ventri- cles by the auricles. However this may be, that the mitral curtains are floated out and brought into apposition to each other by simply distending the ventricular cavity with liquid, is a fact sufficiently established and easily verified. ISTow in cases of considerable aortic insufficiency, the left ventricle is rapidly filled with blood flowing back from the aorta as well as from the auricle, before the auricular contraction takes place. The distension of the ventricle is such that the mitral curtains are brought into coaptation, and when the auricular contraction takes place the mitral direct current passing between the curtains throws them into vibration and gives rise to the cha- racteristic blubbering murmur. The physical condition is in effect analogous to contraction of the mitral orifice from an adhesion of the curtains at their sides, the latter condition, as clinical observation abundantly proves, giving rise to a mitral direct murmur of a similar character.
A mitral direct murmur, then, may exist without mitral contraction and without any mitral lesions, provided there be aortic lesions involving con- siderable aortic regurgitation. This murmur by no means accompanies aortic regurgitant lesions as a rule; we meet with an aortic regurgitant murmur frequently when not accompanied by the mitral direct murmur. The circumstances which may be required to develop, functionally, the latter murmur, in addition to the amount of aortic regurgitation, remain to be ascertained. Probably enlargement of the left ventricle is one condition. The practical conclusion to be drawn from the two cases which have been given is, that a mitral direct murmur in a case presenting an aortic regur- gitant murmur and cardiac enlargement, is not positive proof of the exist- ence of mitral contraction or of any mitral lesions. The coexistence of a murmur denoting mitral regurgitation, in such a case, should be considered as rendering it probable that the mitral direct murmur is due to contraction or other lesions, and not functional.
Dr. Gairdner, in a recent article already referred to, proposes a change of name for the mitral direct murmur. He proposes to call it an auricular systolic murmur. Inasmuch as the murmur is produced by the systole of the left auricle, this name is significant. And the usual name is open to this criticism, viz. : it is not produced by the whole of the mitral direct current, but only that part of the current which is caused by the contraction
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Dickson, Smallpox.
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or systole of the auricle. From the situation of the auricles as regards the ventricles, the former being placed above the latter, and the free communi- cation by means of the auriculo-ventricular openings, the blood must begin to flow from the auricles into the ventricles the instant the ventricular con- tractions cease. During the first part of the long pause or interval of silence, i. e., the period after the second sound and before the subsequent first sound of the heart, the blood flows from the auricles into the ventricles simply in obedience to gravitation. It is not ascertained that this part of the current ever gives rise to a murmur. If it does, the murmur would follow immediately the second sound, or when an aortic regurgitant murmur occurs. I have conjectured that such a mitral direct murmur may occur, and that it is confounded with an aortic regurgitant murmur. This con- jecture is based on cases in which an apparent aortic regurgitant murmur existed, and the aortic valves seemed to be nearly or quite sufi&cient on examination after death. However this may be, the mitral direct current giving rise to the murmur which has been considered in this article, is not the current which immediately follows the second sound, and is due to gra- vitation alone, but it is the current immediately preceding the ventricular systole, and due to the systole of the auricle. Hence, as it seems to me, the name proposed by Dr. Gairdner, being more specific and accurate, is to be preferred to that in common use.
Art. III. — On Smallpox, and the Means of Pr^otection against it. By S. Henry Dickson, M. D., Professor of the Practice of Medicine in Jefferson Medical College, Philadelphia,
The exanthemata may fairly claim a high place among the topics of greatest and most constant interest to the medical practitioner. They seem to solicit attention by their marked and impressive features ; and present so many palpable, well-defined, objective phenomena, that we feel always as if on the point of receiving some clear and instructive develop- ments from the study of the facts observed in their history and progress. At first sight their origin appears to be plainly traceable, their diagnosis distinct and easy, their nature obvious. But a closer examination will soon convince us that our knowledge of them is by no means so satisfactory as we had imagined, and that the field is still open for further and more minute exploration.
Three of the class of diseases to which the name has been attached ex- hibit in common certain striking characteristics, exclusively their own, and therefore well deserve to be set apart from all others, and arranged together. Smallpox, scarlatina, and measles are all of them eruptive affections, py-
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Dickson, Smallpox.
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rectic, contagious, self-limiting, and self-protective. They stand alone as to the concurrence of these conditions, one or more of which may belong to certain maladies, but all of them to none beside. Thus, hooping-cough, with no cutaneous eruption, is pyrectic, contagious, self-protective, and somewhat vaguely self-limiting. Dengue is irregularly eruptive as to con- stancy, characteristic appearance, and periods, though contagious and pro- bably self-protective. Erysipelas is neither self-limiting nor self-protective ; and the same negatives are true of varicella. It is perhaps worthy of remark in this connection, that all maladies which attack the human sub- ject but once, and are in this sense self-protective, have been by various authorities regarded, and with some ,show of plausibility, as among the exanthemata. Pertussis is so considered by Watt ; typhus and typhoid by many pathologists ; Hildebrand ranges yellow fever thus in the catalogue, and several of our American brethren have confounded it with dengue, which has vastly better, though still insufficient, claims to that position.
The well-arranged, carefully prepared, and valuable " Report on Meteor- ology and Epidemics for 1861," read by Dr. Jewell before the College of Physicians of Philadelphia on the 5th of February, 1862, and published in the last (April) number of this Journal, contains some appalling statements in reference to the three pestilential affections there exclusively denominated exanthems. We learn from it that in the city of Philadelphia, containing 568,034 inhabitants, there died within twelve months from smallpox 158 persons; from scarlatina 1190 ; and from measles (of which it should be recollected that the fatal results are in great proportion indirect and masked under other names) 14. With most commendable industry, and with an intelligent zeal which entitles him to the thanks and highest respect of our profession. Dr. Jewell has collated, tabularly and otherwise, a large mass of useful facts and observations, in addition to the mere statistics of his report. Going back to 180T, he places before us a comparative view of the annual mortality of the most loathsome and destructive among them. We find it recorded of smallpox, which has figured largely in the bills of mortality for several years past, that the next highest number of deaths took place in 1852, 421 ; in 1856, 390 ; in 1824, 325. This terrible pes- tilence was, last year, about twice as fatal as at any time during the current century, with the exception of the year 1852, when the difference, 331, was not far below the greatest amount of mortality in the worst other year of the century. We cannot avoid being shocked at this retrograde exhibition, and shrinking from the acknowledgment of professional failure and defeat which it seems to imply. We are apt to take for granted — nay, I will maintain it to be positively true— that, fatal as this disease is even now, its proportional mortality has been vastly reduced. Fewer of those attacked die of it than formerly by a great difference, and we have occasion to notice much less deformity and mutilation by it. Allowing, then, for this dimin- ished violence and destructiveness, we contemplate with horror the im-
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Dickson, Smallpox.
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mense mass of suffering which must in this community have overwhelmed the multitudes of miserable sick who passed through its wretched stages of varying infliction, recovering finally ; many of them, doubtless, through tortures far worse than death itself. If we carry out our thoughts to the soldiers of the great armies now in the field, and the camp followers, and attendants, and refugees of all sorts, upon whom this scourge is widely and heavily laid, we shall shudder with quivering sympathy, and painfully lament the woes of our frail and afflicted race. And yet farther ; when we reflect that all these horrors were preventible, and ought to have been prevented, our sympathy will be freely mingled with shame and remorse ; shame, that in the light of advancing civilization, governments and law-makers should not have accepted, instituted, and enforced the proper means of preserva- tion from such evil ; and remorse at our remissness as a professional body, intrusted with the care of the physical well-being of our fellow-men, in not having urged, with unceasing and irresistible importunity, measures at once so important and so feasible. Dr. Jewell quotes and adopts the re- mark of an English writer, " that the absence of an efficient system of protection should be considered a national disgrace ; almost a national crime and we must all acquiesce in and feel deeply the truth of the im- putation.
I have read with much pleasure the observations made by Dr. Nebinger before the Philadelphia County Medical Society, on the 13th of ^^ovember, 1861, on the subject of this essay, and given to the public in the Fhil. 3Ied. and Surg. Reporter, of March 29, 1862. I have already stated my accordance in his opinion that smallpox is better treated, and more suc- cessfully, now than in the days of Sydenham. During a long course of practice, I have myself lost so small a proportion of my variolous patients, that I am fully prepared to accept the favourable view he presented of his own good fortune. The data he then offered will assist us to estimate — approximately — the number of sick who suffered, but did not die. This is an essential element to a fair appreciation of the real value of prevention. I have always considered it a matter of great regret that we have no re- cord of the extent of actually existing disease; its frequency; its dura- tion ; its degree ; its calamitous privations and inflictions. Such a register is a necessary complement to the bare ''bills of mortality," useful and instructive as these have become in the hands of Dr. Jewell and his colla- borators.
Dr. Nebinger had seen more than 30 cases : he had among them 5 con- fluent ; but one death occurred from them all. He ascribed this large success to his energetic efforts to sustain the strength of his patients dur- ing the progressive stages of maturation, suppuration, desquamation, and redintegration of cutis.
In a report prepared by Drs. Bell and Mitchell, of this city, we have a table of 248 cases given, of which 89 died — in the epidemic of 1823-24.
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I saw smallpox prevailing extensively in New York during 1848 and 1849. Many of the members of the medical class in the University in which I then held the chair of the Practice of Physic, were attacked ; of these, 50 or more in number, only 2 died. Averaging these three state- ments, each of which is extreme, two of them in good fortune, and one in the reverse, we have 1 death in about 3 J cases, reaching a total of 2653 sick.
Gregory estimates the average mortality all over the world as 1 in 6. In Dr. John Davy's Notes and Observations on the Ionian Islands and Malta, there is an interesting history of "the Variolous Epidemic of 1830-31, in Malta." The deaths were llt2 out of 806Y cases reported ; " many cases occurred which were not reported ; of the mildest kind, pro- bably." These proportions would give us about 5000 cases of smallpox in one year in this favoured city. If we take from the very happy rate of success announced by Dr. Nebinger, fully two-thirds — and we should re- member that both Drs. Burns and Remington ''fully agreed with him, and added their testimony as to the good results of his mode of treatment" — if we admit, I say, that Dr. N. was singularly fortunate, and subtract two- thirds as approaching the more general average, making the deaths 1 in 10 of the whole aggregate of cases, we shall find our sick amounting to 1580. What an accumulation of anguish ! What an infinite sum of wretched- ness ! Pew of them could have been ill a shorter time than a week, in greater or less degree ; at least half of them would be in an invalid con- dition, and in a state of feeble convalescence for two and three weeks, many even more than this ; and although two-thirds of them were young chil- dren, yet they would require, each of them, an adult attendant. Putting the average duration of illness, then, at ten days, 15,800 days of useful life would be lost to the individuals ; of ordinary labour to the community — more than two hundred years of privation, suffering, and sorrow !
This calculation would be irrelevant and useless, if we were treating of an inevitable form of calamity; but I hold the contrary to be positive truth here. I believe it to be in the power of all civilized and well governed communities to confine within very narrow limits, or rather to exterminate the pestilence under discussion. I contend that it is their bounden duty to set about this purpose at once and without delay, and to press the effort with energetic constancy. It is hardly requisite, I presume, that I should explain my meaning in the use of the words ''extermination" and "extir- pation." I surely have not conceived the idea of physical annihilation of the virus of smallpox, or the disease variola, ontologically or dynamically considered. What I intend and aim at is its extinction as an epidemic, as a pestilence; its obliteration from the bills of mortality. It will be seen that the course which I am about to propose with this view implies the constant employment, and of course the preservation of smallpox matter, as we now keep up and preserve the vaccine. It may happen, which
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Dickson, Smallpox.
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Heaven grant ! that this dreaded virus may hereafter become difficult to procure, and a supply will need to be sought out of the bounds of civiliza- tion and well-ordered governments. Such a supply will always doubtless be within reach, among the barbarous hordes of Africa, Asia, and South America.
But if we may trust in familiar observation and repeated tabular state- ments, we are possessed of means of defence against the spread of this repulsive malady, and also against its fatal violence, which may be made available to an extent as yet matter only of reasonable calculation and hopeful estimate. Very few deaths proportionally or absolutely occur from inoculated smallpox ; very few from smallpox after vaccination : it will be seen that I would combine universally and regularly the modifying and palliative influences of the two, by inoculation superimposed upon vaccination. In two out of three cases hereafter referred to, the result of such inoculation was "local affection without any fever or eruption; in the third, local affection without fever, but with papular eruption on the seventh day, not advancing to vesicles." It remains to be ascertained whether such effects as these would comprise the general history on a great scale ; and whether the influence exerted on the constitution would be as thoroughly protective as I am disposed to anticipate. Should there be no disappointment in these respects, surely it is not visionary to hope for as few deaths from smallpox in the next generation as now from vaccine.
The majority, even of my professional brethren, may perhaps continue to think that I exaggerate the competency of the means proposed : yet no one will doubt or deny that much, very much of what is contemplated, may be done by their vigorous and unremitting application. In order properly to appreciate, however, the value and probable efficacy of our means of restriction, prevention, and extirpation, we must carefully con- sider the modes of origin and propagation of the disease we are to contend with.
1. D©es variola ever arise spontaneously, or from ordinary contingencies, or under any known or suggested circumstances of defective or vicious hygiene ?
2. Does it arise from degradation or intensification of any other known forms of disease, which may themselves originate spontaneously or acci- dentally? Or,
3. Does it always require a specific infection, an implantation, or efficient impression from a previous case fully and characteristically developed? There are no other imaginable alternatives, I believe ; and it is not easy to obtain an answer perfectly satisfactory to either of the above questions, although we may reach a fair practical result.
1. I will not venture to deny the possibility of "spontaneous generation" of smallpox. It came into existence once, and therefore logically may again occur, provided the same conditions coincide again to produce it. Nor am
1862.]
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I unaware that there are several instances on record, in which the breaking out of the disease has been totally unaccountable. Nay, I hare myself met with and published a history of one of the strongest and strangest among the cases that have been observed. I need not say that such rare facts ought to be studied with the admission that our knowledge of the entire range of details must always be incomplete, and that it will be safest and most reasonable to follow the patent and obvious course of known ana- logies in forming our opinions. Ordinary pollutions of the atmosphere produce their known effects ; none have been defined or even conjectured of a nature causative of variola. It is easy to enumerate and imagine obscure and extremely varied modes of its infectious communication wher- ever social and commercial intercourse obtains. "We know the tenacity of its contagion, and shall treat of its great diversity of vehicles. We have no account of its outbreak where such conveyance was not demonstrably possible at least ; and if possible, it at once becomes more probable and presumable than the vague hypothesis of "spontaneous generation." Be- sides this, speaking practically, such instances will be amenable to the same methods of prevention that will affect, as we hope, all the others, and even in special degree. For there is no alleged example, among all these strange seizures, of persons protected, either by vaccination or previous attack, having been the subjects of obscure invasion. These yield only to the more vehement impressions of obvious and definite exposure.
2. The second inquiry presents some intrinsic difficulties, and is not readily disposed of. We might at once cut the Gordian knot, and pro- nounce dogmatically with Copeland and Gregory that "the whole confusion arises from mistaken diagnosis but I will not think or speak thus lightly of the observations and opinions of such men as Howitz and Bateman, and Hennen and Thomson. The very authorities above quoted admit "that there is a form of smallpox w^hich may be mistaken for varicella;" Gregory makes indeed a class of "varicelloid cases." The true question is whether or not they actually run into each other, and are capable of mutual generation. Of the difficulty of clearly distinguishing them, every prac- titioner should be cautiously aware. Dr. Davy tells us of the Maltese epidemic of 1830-31, that "in most instances when the disease occurred after vaccination, it was mild and short in its course, often resembling chicken-pox rather than smallpox. Chicken-pox was at the same time common, ninety-one cases being reported." He regards the diagnosis as doubtful, and mentions a case occurring three months after the last report of smallpox, which he "thought to be genuine variola, though mild. It was among some cases of chicken-pox that it happened." Gregory, dwell- ing on the capricious mingling of the severe and slight varieties of small- pox, says, "A confluent case shall give origin to a varioloid, and a mild distinct, and even a varicelloid case ; and these shall generate in their turn malignancy and confluence."
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Tlie spontaneity, that is, the independence of any specific sources of pro- duction of varicella is universally taken for granted. It has never been proved, nor, on the other hand, so far as I know, questioned. Yet it has clearly, a very relevant and important bearing upon our main subject. Enough has been said to show the danger of error here. ^Nevertheless, and in spite of all these warnings, fatal mistakes continue to be made by experienced physicians. On three occasions I have known smallpox to spread from infection communicated by cases pronounced to be varicella ; the first and introducing instances being slight and of mild character, fol- lowed by development of marked cases of violence and malignity. I have now before me a melancholy ''appeal to the public" of a city into which the writer had been the unhappy agent of importation of smallpox, quite recently. The disease spread and prevailed epidemically in a very fatal form, and he became odious under the imputation, as his printed statement expresses it, of "recklessly sowing the seeds of the most contagious and loathsome of maladies, by freely mingling with the people while knowing that he carried the deadly infection about his person." He affirms that he returned home from New York in perfectly sound health ; that being attacked a few days after with a slight illness, accompanied by an eruption on his face and body, he consulted an "eminent physician," who unhesitatingly pronounced the eruption to be chicken-pox, and told him he might resume his business without fear. "Nor did the idea of smallpox once cross my mind until, after my own child had caught the infection in an aggravated form and fallen a victim, the physicians began to whisper the dreaded name."
The preponderance in number of what are called "negative facts," ex- amples of innoxious presence and prevalence of varicella, should never be allowed to lull our caution to sleep. No prudent practitioner will fail to watch attentively the course of chicken-pox in any group or collection of unprotected subjects. I do not believe it to be possible to diagnosticate from it by any definable marks some of the irregular varioloid affections, which yet are potential in spreading smallpox ; and even those who con- tend most peremptorily for precise distinctions, allow that we do meet with a "confounding" similarity. Where there exists any doubt, we should have prompt recourse to the most immediate protective measures.
Nor must we entirely pretermit the consideration of another possible origin or development of smallpox. Its identity with vaccine is at the present day the received doctrine with the majority of our profession. I will neither affirm nor deny it, but proceed, ex ahundante cautela, to draw from it a practical inference. If it be true that vaccine is a modified or degenerate variola, altered in its features and history by transmission into and through organisms of lower type, it would be difficult to imagine why it should not, when restored to its original nidus and pabulum, resume, under fostering contingencies, its orif^inal characteristics. Some startling
1862.] Dickson, Smallpox. 61
examples have occurred, as not long ago at Richmond, of the introduction of smallpox with matter supposed to be vaccine, and the explanation has been accepted that an unfortunate accidental mixture of the two contagious viruses had taken place. No one now doubts that vaccine may arise spon- taneously in the cow; Jenner thought, erroneously, that it depended upon an equine affection, "the grease ;" Baron and Ceeley have attempted to prove that they are both variolous. And even if with Gregory we dissent from their conclusions, and accept with him the views of Greaser, we do not escape from reasonable fear of possible danger : if "a, morbid poison applied to different animals produces, not a similar and specific disease, but the disease to which the animal from constitution and structure is predis- posed." ''Equine matter, vaccine lymph, variolous matter — each, when applied to the vessels of the cow, develops vaccinia," says Gregory. It would be difficult to show, upon this view, why, when applied to the vessels of the human subject, they should not develop smallpox.
And what shall we say of cases in which " there is a general eruption of Yaccine Vesicles over the body, resembling, in some patients, those of Varicella," as we find it stated in the notes to Gregory's excellent work on Eruptive Fevers. To the small number of these hitherto recorded, I will add one from the pen of a physician, himself the subject. It is described in the following extract of a letter to me from Dr. Henry H. Cone.
I was inoculated in the year 1815, by Dr. Samuel B. Woodward, of Weathers- field, Conn., immediately after having been somewhat exposed to the contagion of smallpox. The vaccine matter was inserted in two places, about the middle and anterior part of the left arm. At the usual time the genuine symptoms of cowpox made their appearance, such as the gradual formation of pustules which continued to increase until they had attained the usual size. Along with the two pustules, which formed at the places where the virus was inserted, were three others on different parts of the body, which were a day or two later, according to the best of my recollection. One of these was situated on the right arm at its upper and anterior part, forbidding the possibility of its coming in contact with or originating in the direct application of the virus ; another was situated on the right thigh ; the third on the parietes or surface of the abdo- men. The three last mentioned pustules were in no respect different from those which formed at the places where the matter was inserted, neither are the remaining cicatrices, all of them being marked with small pits or depressions near their margins. There was some symptomatic fever ; though not so much as to deter me from my ordinary pursuits.
In two of the instances from Gregory, the matter of the extra pustules was experimented with and genuine vaccine resulted. I will confess to some apprehension, that in examples of this constitutionally eruptive im- pression of vaccine, and especially where the pustules resembled varicella more or less, there would be a risk of arousing the ''varioloid predisposi- tion" of Gregory and Greaser. A " very curious case" indeed is given in the notes above referred to, of a "constitutional vesicle" breaking out at a distance from the points at which the matter vras inserted ; the " three incisions" made there healing up without effect. An instructive example
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is given in the same place, of the similarity of various eruptions, enough, surely, to account for much "confusion" and many mistakes.
A child eighteen months old, vaccinated a fortnight before, had well charac- terized vaccine vesicles on the external labia, and also on the perineum and about the anus. The vesicles bore some resemblance to certain forms of vene- real eruption appearing about those parts in children and the case was carefully examined in reference to this point.
All such irregularities deserve special study. So also does the retarda- tion of the vaccine influence within the system, where it sometimes remains, holding by a tenure very obscure. Not to dwell on mere delay of the local and general effect of the insertion of the virus, which is stated in various instances to have lasted from 1 4 days to six months ; we may refer to an example of very peculiar character, related in detail by Dr. Ruprecht, of its renewal or relapse after several years' interval.
A girl of 14, being seized with influenza, complained of pain in each arm at the spots where, when an infant, she had been vaccinated ; and in these locali- ties vaccine vesicles became perfectly developed. An elder sister was revac- cinated with the lymph hence obtaioed; beautiful vesicles formed, and ran a normal course. — Yide Brit, and For. Review, April, 1850.
3. When smallpox shows itself without obvious infection derived from a specific instance previously developed, the apparent exception must come under one of the heads already discussed. It does not seem to me to affect the question, if we admit the fullest efficiency that has ever been supposed to belong to what is called "Epidemic influence," unless this influence can be shown to act independently of the presence of a case or cases previously devel- oped. Nothing can be more vague than the familiar use of the above phrase. Every one is aware that all diseases prevail with greater promptness, their causes known and unknown act with greater efficiency, over wider spaces, and include larger numbers, at certain periods than at others. It is pro- bable, indeed, that any malady may find in atmospheric contingencies favouring elements ; but these are favouring, fostering, not generative. We must not confound the parent with the nurse. Diseases both conta- gious and non-contagious thus become epidemic. It is noticeable, too, that epidemics vary, at different times, in their degree of malignity or propor- tional mortality, which is not, by any means, in uniform correspondence with their extent or sway over numbers. Prof. Wood has pronounced it "highly probable that the epidemic influence maybe alone sufficient to produce smallpox, scarlatina, and other contagious eruptive affections, without the co-operation of the specific contagion." Even if the idea be correct, the expression here used is too strong. It can hardly be said that anything is highly probable, unless some good reason can be given for the belief that it has once occurred. I have admitted the possibility of such an event ; but it would be an incident both rare and mysterious. No one would say that he expected or anticipated it under any contingencies which he could describe or define. Epidemic influences, ex vi termini, act upon a
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great many simultaneously. Influenza, cholera, &c., are known to affect numerous subjects at once. On the contrary, the obscurely induced attacks of smallpox have always at first, and generally altogether, been confined to a single individual, with whom the affair may end ; or it may subse- quently spread more or less widely. We have agreed to stigmatize "the absence of an efficient system of protection as a national disgrace, almost a national crime." The appropriateness of this sentiment, it ought to be added, must entirely depend upon the feasibility of such protection. If the origin and spread of smallpox be probably ascribed to any unintelligible and uncontrollable mode of causation, and such are all epidemic influences, then there is neither disgrace nor crime in the failure to protect. Believ- ing, however, as I do, that the introduction and propagation of this pesti- lence are well enough understood for all practical purposes, I do regard all governments as responsible for the institution of proper and relevant efforts at prevention and circumscription, and deeply guilty when this is neglected.
Smallpox propagates itself, or is propagated, 1. By actual inoculation, insertion of the virus. 2. By contact with the sick. 3. By near approach or immersion in polluted air. 4. By fomites, either applied directly to the surface, or acting through the air about them. 5. By diffusion of infec- tious matter through the atmosphere to an undefined extent ; which con- stitutes, doubtless, the chief, if not the exclusive, element, in epidemic dissemination. This is obviously more effective in certain atmospheric conditions, known and unknown, often or generally observed to be associated with ochlesis, the crowd-poison, which also gives force to the third mode, or, indeed, ail of them. Many unfavourable hygienic conditions act rather on the constitutions of the subjects, than by multiplying or concen- trating or intensifying the subtle virus engendered by the pestilence.
Inoculation of smallpox is prohibited by law in Great Britain, and has fallen into disuse in our own country. Contact with the sick is more diffi- cult to be prevented than one would think. It is not known how soon the subject becomes a dangerous centre of evil, nor for how long. Near ap- proach by accident must often happen, while those ill of mild attacks, or convalescent, are permitted to make use of public vehicles and common paths. Civilization renders impossible the abandonment of the miser- able sick, under any circumstances ; but it is always easy to find nurses hardened against infection by previous attacks. Fomites are sources of widest danger, because they are of such vast variety, and often, therefore, unsuspected. We may refer to all garments, bedclothing, textile furniture, such as carpets, curtains, stuffed and covered chairs, &c. The tenacity with which such objects retain their evil potency is remarkable. A story is told by Mills of a child dying of smallpox in its cradle. The bedclothes were carefully washed and put away ; a year after they were brought out for the use of another infant, born to occupy the same cradle ; this new-comer soon took smallpox, and also died, no other instance of the disease being known
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to exist anywhere else in that region of country. Carriages, both public and private which have been used for conveying the sick, are dangerous fomites. Bank-notes handled by them are very reasonably denounced also by Dr. Buckler, of Baltimore. The dead body itself may act very effi- ciently as fomites. I remember a case which appears strongly in point. During the winter of 1848-49, a young man, a member of the medical class of the New York University, died suddenly and unexpectedly in the night, under the care of a physician who had not thought him seriously ill. I was invited to the autopsy, and observed, when the corpse was un- covered, a few dark-red spots on the surface, which were supposed to be petechial ; the principal symptoms of his attack having been gastric, with great debility, as we were informed. The coffin was taken home to a New England village, for burial ; where, at the funeral, some of the relatives approached and opened it, to see the face of the deceased, before it was inhumed. Of this number, eight were attacked with smallpox,, no other persons in the neighbourhood being assailed. It was afterwards thought probable that the youth had attended the wards of some hospital in the metropolis, and had been affected with the disease which at that time was in existence there.
I have omitted to speak under this category of books, paper, letters, solid wooden articles, and the walls and floors of houses, as disputable ; although there are instances, repeated often enough on the records, to ex- cite caution at least, of the reception of the contagion through the post ; by handling walking sticks and other implements ; and by inhabiting apart- ments in which the sick had lain long ago, and from which all suspicious furniture had been removed. Atmospheric diffusion is, however, by far the most injurious method in which this, like other forms of pestilence, propa- gates itself. Nothing in nature can be more obscure or hard to apprehend than the varying conditions which surround us, all of them comprised under the familiar phrase "constitution of the air," though we know not whether they are telluric or astral, electric, or thermal; unappreciable diver- sities, at one time indifferent to the presence of a contagious malady, at another opposed or unfriendly, or unadapted to its spread ; again, giving it wings, as it were, and aiding its extension ; exhibiting an evil influence by rapid increase of the number of subjects attacked on certain occasions ; and on others, by impressing a peculiar character of violence and malig- nity upon a narrower range of prevalence. Against this danger, so stealthy, so impalpable, no ordinary precautions are of any avail, whether personal or hygienic. Of the first forty cases which I saw in New York during the epidemic of 1848-49, there was not one who was conscious of having approached a patient affected with the disease, or who, upon close inquiry, such as it was my habit to make, could be brought to recollect having placed him or herself in circumstances of any imaginable suspicion of risk.
#-
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Happily, we are provided with special and relevant means of defence, applicable alike in all the varying conditions above enumerated and alluded to, and available against all the several modes of extension or propagation. Among the strongest points of contrast in the histories of disease, none is more striking than this : that certain individuals on the long catalogue create in the constitution which they intrude upon, a propensity, or, to speak technically, a predisposition to be more readily' affected by them a second and a third time, and so on indefinitely ; thus it is with malarial fevers, erysipelas, gout, rheumatism, &c. ; while certain others exhibit a directly opposite tendency, being, as I have styled them, self-protective ; and giving to any constitution over which they have once prevailed, a strange immunity against their recurrence. This is the rule — broken doubtless by exceptions — but it is the undenied rule. "Upon this peculiar characteristic belonging to the exanthemata, is based the hope as to all the three, the certainty as to the one under discussion, of being able to circumscribe, restrain it, reduce it to subjection, and, if we desire, to extir- pate it entirely.
The most ingenious speculators have offered us no plausible explanation of this curious and fortunate fact or law. Of the various conjectures thrown out, it may suffice to mention two wild and inconclusive hypotheses, which have been suggested by the analogies of vegetable life and growth : one, that every human being is born with certain elements of organic composition, which afford opportunity or pabulum for certain morbid changes. The pabulum of each morbid affection being once consumed, is not again reproduced, and the changes in which that consisted cannot again take place ; and thus, hooping-cough and measles, scarlet fever and small- pox, and perhaps some others defend against themselves. The other hypo- thesis is equally fanciful, and assumes that, in the course of certain mala- dies, new products are evolved, which are permanently retained in the sys- tem, preventive of the same actions which originated them ; as the roots of a vegetable are supposed by some to leave in the soil where it has grown certain effete matters or exuviae, unfriendly to its life, whence the necessity for a rotation of crops ; or as animals even in health, fill any confined space around them with noxious efifiuvia, demanding perpetual change of air and involvements. The well-ascertained law or fact suffices for our cherished purpose.
Again, it has been long known also that smallpox, which, taken "in the natural way," either by contact, near approach, from fomites, or when epidemically diffused, is one of the most fatal as well as repulsive of human disorders, puts on a far milder and less malignant character when introduced into the system by a wound in the skin, "inoculation." Asia and Africa, the most ancient seats of this terrible pest, have long known and still avail themselves of this mode of palliation. England resisted it obstinately, yielded to it reluctantly, and has now fatuitously prohibited it. No. LXXXYIL— July 1862. 5
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We have been indifferent to it, and act as if averse on principle to any interference with every man's right to be poisoned at his own will. Inocu- lation was first practised by civilized hands at Constantinople, in 1700; it was introduced to the English and brought across the Atlantic twenty-one years after ; and so completely superseded by Jenner's vaccination, promul- gated in 1798, that in 1840 it was "declared illegal by the British Parlia- ment, and offenders sent to prison," says Gregory, "with a good chance of the treadmill." Its alleged influence in lessening the mortality of smallpox is indeed marvellous, and scarcely credible. The author just named tells us that "with ordinary precautions, not more than one case in five hundred will terminate unfavourably." He denies positively, and opposes strongly, both by fact and argument, the assumption which has prevailed widely, and is maintained by Sir Gilbert Blane, that "it disseminated the virus, increas- ing the foci of contagion ; and thus favoured the spread of the disease," demonstrating, I think, its falsity. Indeed, so much are the violence, the suffering, and the proportional mortality of smallpox diminished by inocu- lation, that I would advocate unhesitatingly the propriety of universal inoculation at as early a period of life as was ascertained by repeated and careful experiment to be safe and allowable. I would have such inoculation repeated at short intervals, until in every subject the point of absolute inca- pacity to receive the infection was fairly reached. This would happen in a majority of instances with the first eflScient incision of the virus ; it would probably take place in the rarest exceptional cases of renewed susceptibility, after a very few repetitions. Those who had gone through this process would be proof for the future against the pestilence, and as to them it would be annihilated, virtually exterminated. And as all constitutional peculiari- ties are hereditarily transmitted, whether of original organization or in any way acquired, so this anti-proclivity or acquired immunity would go down increasing in force with every generation, until the whole race would be- come insusceptible of this horrid mode of dying. But this is only half my plan.
However palliated by inoculation, smallpox would still demand and engulf a certain proportion of victims ; and besides, would inflict in its course a considerable amount of unavoidable suffering. With grateful exultation we may reflect that we have in our hands a means of still reducing, to a minimum yet more remarkable, the evil against which we are contending. For this purpose we confidently resort to the vaccine. Whether of identical origin with variola or not ; whether primarily a human disease altered in course and history, clipped and abridged of its first atrocious properties by transmission through some of the lower organ- isms ; or primarily an equine or bovine distemper, genially adapted to the service of our dominant race, vaccine exhibits a close and most beneficial relation with smallpox. An enviable immortality glorifies the name of Jenner, as having made known this invaluable relation. Although not
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self-protective, it protects in a remarkable degree against smallpox. This protection we have learned is far from being absolute, though Jeniier thought and pronounced it so. In his petition to Parliament (1802) it is stated that he "had discovered a means of rendering through life the person protected by it, 2Derfectly secure from the infection of smallpox." For some time the public indulged the same sanguine anticipation, which, I need not say, is now universally abandoned. I have myself attended a pretty severe case of variola — or as some would insist on terming it, vario- loid, in a lady vaccinated by Dr. Jenner with his own hands. In Davy's tabular view of the Maltese epidemic, out of 8067 reported cases, 2720 are set down as "supposed vaccinated," and 390 as "well vaccinated." But I will not dwell on this point. As a protective, vaccine employed alone has failed. Perhaps the same failure may be as truly affirmed of inoculation employed alone. In Davy's tables, 97 are set down as "having had small- pox before." He mentions as authentic the case of "a lady, mother of ten children, who had smallpox eleven times ! first in infancy, and afterwards when each of her children had it; these last being as severe as the first." The books abound with similar statements. It is certain that particular constitutions admit one or the other of these analogous affections, and yet not both. A case is mentioned in the British and Foreign Review, October, 1859, where vaccination was attempted many times in vain ; the patient had smallpox severely at the ages of twelve, forty-three, and forty- five. What would have been the effect in such an instance of early inocu- lation, repeated, as I have proposed, at short intervals, to exhaust the proclivity or susceptibility? There is a difference in this respect in races as well as individuals. The Easterns are very susceptible of smallpox ; but I have heard one of the American missionaries to Siam assert that for seventeen years they were foiled in every attempt to introduce vaccine among the willing people. Some systems repel both contagions. I vac- cinated many times and inoculated repeatedly with variolous virus, all in vain, a young lady. She afterwards nursed with impunity a sister ''sup- posed vaccinated," who died of confluent smallpox ; this latter had never been my patient.
Now, if the reader has given me his patient attention, he will, I am dis- posed to think, agree with me that each of these two inestimable methods of protection is unfortunately imperfect, insufficient when employed alone, and undeserving of our full confidence. Regarding them as complements, each of the other, I would institute the employment of them both. Vac- cine is the most certain in its action as a modifier. In all the tables we find the proportion of deaths in smallpox after vaccine set down as smaller than among those who are marked as "having had smallpox." Yariola is, on the other hand, the more efficient preventive or protective. By the resort to both of them, we obtain the double advantage of uniform pallia- tion, and more certain protection, or obliteration of original susceptibility.
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Gregory tells us that smallpox in the unvaccinated is five times more fatal than it is to those who have previously undergone vaccination." The latter should, therefore, precede the former. Revaccination, at distant intervals, better regular, of course, than irregular or capricious, can have no advantage over the plan proposed. It is uncertain whether it ever does away the susceptibility to its own reception. Many series of experiments are required to decide this point, and I know of none but those made by Dr. Darrach, of this city, which have not been repeated. I think we have reason to doubt whether in all individuals any number of revaccination s w^ould be securely protective ; wisdom inculcates the course of greatest safety, which consists in following up vaccination by inoculation, especially if we repeat the latter to exhaustion of susceptibility. The experienced practitioner last quoted, and so often referred to as high authority, goes on saying, "I inoculated three of my own children, at the ages of twelve, thir- teen, and fourteen, after successful vaccination in infancy, and the result was as follows : in two, local affection, without any fever or eruption. In the third case, there was local affection without fever, but with papular eruption on the seventh day, not advancing to vesicles. I firmly believe that these children are now and will remain through life unsusceptible of smallpox." In this belief I fully accord with the writer, and entertain strongly the opinion that there is no other way of obtaining such complete security.
Let me refer again to the "report" of Dr. Jewell. "In a former report," says Dr. J., "I have alluded to the inadequacy of voluntary provision to secure us from the ravages of smallpox, and I have elsewhere asserted that nothing less than a compulsory law, with a penalty attached for its viola- tion, would prove an effectual barrier, &c." What then shall be done?
There are two difficulties in the way of efi&cient action here. The first is the universal vis inertise, opposed not only to all innovation, but to all movement of any kind. Yet if the medical profession were as a body to engage with earnestness and zeal in their duty, the great inert public might be roused, and much good be effected. But at best this would be only a partial success. I am satisfied that the inattention, indifference, and inac- tion of even the most enlightened communities as to this matter, are owing to their want of clear conviction, their imperfect trust in the security attain- able by the measures urged ; and this is the second and greatest difficulty before us. Nor can such incredulity be considered unreasonable, when we reflect upon the vacillation, the avowed scepticism and open opposition of experts, and men of weight, influence, and knowledge, both in and out of the profession. Recollect that opportunity has never been given for the attainment of confidence, Chatham's "plant of slow growth," in any of the means brought to their view. Inoculation was from the first unpopular and scouted by those who feared to try a new method, involving a reluctant familiarity with a dreaded enemy. When it had just outlived opposition,
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it was supplanted by vaccination, which promised so much, and was at the beginning so fortunate. But soon, very soon, this good fortune came to an end, and the exaggerated promises were found to be unfulfilled ; and disappointed faith shrunk into doubt and disbelief. I do not despair of reviving the spirit of earnest inquiry and active experiment. The evil is so great in the present, and so menacing for the future, that if physicians will everywhere unite upon some system, we may reasonably hope to obtain from the constituted authorities the inauguration of some effective measures of coercion. A sense of the necessity of harmony among ourselves should lead to rational compromise and unity of effort. There are among us some who place little reliance upon the protective power of vaccine ; there are some who dread the presence, in any form, of variola. None of us, so far as I am acquainted with my brethren and their opinions, none of us doubt the self-protective immunities of smallpox, or the happily palliative, modi- fying tendency of vaccine. Let us then with energy, perseverance, and unanimity recommend to all civilized governments the combined employ- ment of these two safeguards. Let us procure that it shall be ordained that every child shall undergo vaccination by some expert within a month after birth ; that as soon as the constitution shall have gone through its influence, inoculation with variolous virus shall be performed, and that this latter operation shall be repeated again and again at brief intervals, until all reasonable satisfaction has been attained, of the entire extinction of the susceptibility to smallpox.
I am aware that there are some, even among my friends, who will regard all that I have written as mere Utopian speculation. Others will foresee invincible obstacles in the details necessary to carry out any plan which may be instituted. To the former I offer my entreaties that they would lay aside their inactive scepticism and join in the labours of more hopeful or sanguine philanthropists. I might say to the latter that I have not found it difficult to prepare a series of ordinances, which I refrain from presenting to them, partly because it would occupy too much time and space ; but for the still better reason that when it is once determined to act in the premises, the first step of such action ought to be a careful and deliberate consultation as to the modus operandi. I shall consider myself one of the most fortunate and happiest of men, if I prevail in arousing my medical brethren and my fellow citizens to some determined and general effort at the restriction, palliation, and extermination of one of the most enormous evils which afflict our common humanity.
TO Lente, Amaurosis and other Disorders of the Eye. [July
Art. IY. — Amaurosis and other Disorders of the Eye, resulting from Injury of the Terminal Branches of the Fifth Pair of Nerves. By Frederic D. Lente, M. D., of Cold Spring, New York.
That lesion of the fifth pair at some point within the skull, or of that portion of the cerebral substance from which they take their origin, will cause a disturbance, more or less serious, of the organ of vision itself, sometimes in its function, sometimes also in its structure, terminating occa- sionally in its total disorganization, is a fact established as well by the experiments of Magendie and other physiologists, as by the observations of various pathologists in diseases of the brain.
A number of cases of traumatic amaurosis arising apparently from injury of the external parts adjacent to the eye, which have fallen under my observation from time to time, have induced the conviction that disturbance of vision, resulting in asthenopia, or in amaurosis, may ensue as well from injury of the terminal branches of the fifth pair, as from that portion which forms a part of the encephalon.
The consequences which follow injuries about the orbit, as affecting the eye, are referable to three heads : First, concussion, or other injury of the brain or eyeball; secondly, development of inflammation, or other disease within the eye, resulting in gradual impairment, or loss of vision, sometimes even in destruction of the eye; thirdly, a sympathetic or reflex influence on the retina or optic nerve, developed sometimes immediately, sometimes after a longer or shorter interval, as a result of the direct lesion of the nerve filaments, or in consequence of processes of repair succeeding the injury. Diseases also of the periorbital region have been followed by phenomena that have been referred to the last two heads.
Modern writers on diseases of the eye devote but little attention to this subject, and generally refer the disturbance of sight and other sequelae to the first head — that is, direct injury of the eyeball or brain ; in some instances also, to the second head. Thus, Lawrence, Middlemore, Sichel, Tyrrell, Wharton Jones, Haynes Walton, Mackenzie, all seem to be more or less inclined to this opinion. The latter, who enters into the discussion of this subject, especially in his later editions, more extensively than the others, after relating many instances, as we shall presently see, very plainly indicating the nervous injury as the direct cause of the affection of the eye, yet concludes his remarks by saying that "the consideration of these facts naturally leads us to regard with still greater doubt the alleged occurrence of purely sympathetic amaurosis from slight injuries of the fifth pair, and to suspect that, in the supposed cases of this sort, there has been, in addi- tion to the external injury, either concussion of the eyeball, or disease excited within the cranium." The first case which we shall relate, and
1862.] Lente, Amaurosis and other Disorders of the Eye. 71
which occurred nearly twelve years ago, during my residence as house sur- geon in the Xew York Hospital, led me to adopt a different opinion; and a further investigation of the matter only confirmed this opinion. My attention has lately been recalled to this subject by the publication, in the American Medical Times for March 15, by my friend Dr. Noyes, of the New York Eye Infirmary, of a similar case, to the extremely interesting history of which I shall hereafter advert ; also by some interesting com- mentaries on this case in a succeeding number of the same journal, by M. Echeverria. The matter has been invested with a medico-legal interest in consequence of the publication of the report of a trial in the last edition of Walton's Treatise on the Eye. Dr. Walton and several other surgeons of note were employed by the London and Northwestern R. R. Co., who were sued for heavy damages by a watchmaker, who had received a very trivial injury about the eye, but who subsequently became in a measure incapacitated for his particular occupation in consequence, as was alleged, of this injury. ** The question of amaurosis, depending immediately or ultimately upon injury of the nerve, was raised by the patient's counsel." I am now quoting from Dr. Noyes' article: "Mr. Walton testified that in his opinion ^mere injury of the nerve-branch on the head can have no effect on the function of the retina; that loss of sight, when associated luith such lesion, is due to coincident lesion of the eyeball.^ The plain- tiff's counsel referred to numerous cases recorded by authorities, disproving this opinion, and the chief justice seemed to be particularly severe on these records. The medico-legal bearing which, as we see, this question may assume, would, of itself, render a full investigation important; for, the cases recorded in this paper, taken in connection with the evidence scattered among the various authors on diseases of the eye, which we shall presently endeavour briefly to collate, will, in our opinion, go far towards invalidating, if indeed it does not completely annul this decision of Mr. Walton. But, we shall also find that the discussion will have a practical bearing on the treatment of certain affections of the eye. We indulge the hope, therefore, that though this paper may prove tedious in some of its details, it may not be entirely unprofitable.
-Case I. Antoinette H., 11 years of age, an interesting and intelligent girl, was brought to me at the hospital as an out patient on the 6th of July,. 1850. On the 4th a boy snapped a percussion pistol near her; and, a fragment of the copper cap flying off, struck her in the face. There was a small wound on the left side of the forehead near the median line, which bled freely for a time, but caused little pain. But little concern for the injury was felt at the time; but, on the day following, the little girl com- plained of severe pain in the right eye, and around the right orbit, of a "numbness^^ extending from the ivound on the left side of the forehead as far as the right temple, and also of dimness of vision of the right eye. All
1 The words are Dr. Walton's ; tlie Italics are mine.
72 Lente, Amaurosis and other Disorders of the Eye, [July
these symptoms have been increasing to the present time, especially the last. The right eye is now amaurotic, patient having but little more than the perception of light; being unable to distinguish with it even large objects near her; patient seems rather disinclined to face the full light of day. • The pain in and around the eye is quite severe, and is much increased hy pressing upon the seat of the wound of the forehead. At this point, vy^hich is a little to the left of the median line and about half an inch below the line of the hair, there is the appearance of a slight abrasion of the cuticle, and a small circumscribed induration, as if from effusion of lymph ; no foreign body can be felt. There is a slight redness of the right eye. Patient is of nervous temperament, and in rather feeble health; was in Paris during the late revolution there, and her nervous system received a shock from which it has not yet recovered. Judging that a piece of the copper cap had lodged in the forehead, and had originated and was main- taining the amaurotic symptoms, I determined, with the concurrence of my colleague, Dr. W. H. Church, now one of the surgeons of Bellevue Hos- pital, and medical director in the Army, to search for and remove it. After making an incision, and searching for some time, we found, imbedded firmly in the pericranium, a jagged fragment of cap, w^hich we removed. During the somewhat protracted exploration of the wound, patient complained of very severe pain extending from it, towards the right eye, and in the right eyeball itself. Immediately after the removal of the fragment the pain abated, was less than before the operation, and vision was in a great mea- sure restored, patient distinguishing even small objects without difficulty. Both Dr. Church and myself were much surprised and gratified at the un- expected success of our little operation. Directed quietude, low diet, a gentle laxative, and the application of a cooling lotion to the eye.
July t. The "numbness" complained of as affecting the right side of the forehead, has there abated, and has extended to the left temple. The left eye also is painful, slightly injected, and vision somewhat impaired. The inflammatory symptoms of the right eye have much increased; the pain in the globe is deep seated, and increased by pressure; vision of this eye still better than it was before the operation, but not so good as it was just after it. Skin and pulse natural; bowels open. Directed leeches to temples, and mercurial and anodyne ointment around orbits ; rest in bed in a mode- rately darkened room.
8^/?.. Slept little last night. Complained of increased pain in right eye, and around the orbit; complains also of "soreness" over the whole scalp. There is now only very slight anaesthesia on right side of forehead, and that on the left side has not increased. Directed emplast. lyttae post dext. aur. Anodyne at bedtime.
9)th. In the early part of the evening the pain became much aggravated, extending over the forehead, scalp, and right side of the face; the right cheek also, over the lower jaw, became swollen, and tender to the touch. The pain was repeatedly relieved by the tinct. aconite. Anodynes rejected by the stomach. During the night, complained of coldness and numbness of the extremities; this was relieved, after a time, by sinapisms, and she slept during the latter part of the night. This morning, feels tolerably comfortable. Pulse and skin still natural. Has now no uneasy sensations in the left eye, and vision with this eye nearly perfect. The anaesthesia on this side has also nearly disappeared. The pain in right eye and around orbit increased; vision about the same. The tumefaction about the lower jaw still exists to some extent. Continue treatment.
1862.] Lente, Amaurosis and other Disorders of the Eye. 73
llfh. Was called to patient last evening, and found her apparently suf- fering greatly with neuralgic pains in the face, neck, and chest; the slightest pressure on the integument aggravating the pain. The pain in the back of the neck is described as being the most severe; and there is inability to flex the head; jaws swollen slightly, and spasmodically closed; skin hot, pulse frequent; some difficulty in micturition; had vomited several times ; complained also of her hands being asleep. Ordered sinapisms to feet ; tinct. opii camph. with valerian pro re nata. This morning is quite com- fortable. Fell asleep after one dose of the medicine, and rested quietly. Pain in the eye much abated ; no pain elsewhere : skin pleasant, pulse natural.
12th. Improving; no exacerbation of pain last night. Can read tole- rably fine print with the right eye.
13th. Last evening was again attacked with the neuralgic symptoms ; temperature of skin not much increased; pulse slightly accelerated. Ap- plied the aconite, and gave one dose of the antispasmodic mixture, when she fell asleep. Tongue much furred ; is quite feeble ; has a voracious appetite, but is not indulged. Chicken soup, with farinaceous food, R. Hydr. submur. gr. v hor. s. ; ol. ric. mane; quiniee sulph. gr. i ter die.
14^7?. Better; "quite welF' s/?e says. Has been moving about the house, against orders. No pain in eye. Directed some meat, and quin. sulph. gr. V, at 2 o'c. to ward off another paroxysm. Hor. som. hydr. c. creta gr. V ; ol. ric. mane.
16th. Had a slight exacerbation last night ; complained of pain in the right eye, but it extended no further. Eye looks perfectly natural, with the exception of slight injection of the sclerotica, which is fast disappear- ing. Some asthenopia, and increased lachrymation.
11th. Last night had another violent attack of pain in the eye, but no other neuralgic symptom. The quinia was omitted by mistake yesterday afternoon. The eye looks much worse, and vision is much impaired. R. Leech to Schneiderian membrane.
19//?,. Doing well ; repeat leech.
21st. Eye now appears to be normal, but is weak. Continue quinia and wear a shade over the eyes.
30//?. Health improving ; vision perfect ; pupil acts well.
December 14. My little patient called on me to-day. Seems quite well ; the eyes have a perfect appearance, but she has, with the right, visus dimi- diatus. Lost all traces of her after this date ; heard that she had removed to Philadelphia.
Taken in connection with the above, the following cases, reported in 1842-43 in the London Medical Gazette, by the late Dr. W. C. Wallace, a skilful and well-known oculist of New York city, which I take the liberty of transcribing entire, are extremely interesting : —
Case II. Patrick Burns, 35, stonecutter, on the 8th Oct. was attacked by seve- ral men, knocked down, and wounded over the right foramen infra-orhitarium. The wound gave so little trouble that in two days he went to work. Ten days after, the vision of this eye became indistinct; and, imagining that the dimness was occasioned by the scab, he picked it off, though without the least improve- ment. He was soon obliged to abandon .work altogether. The sight of the affected eye became so obscure that he could not make out an object; though, when the hand was passed across the eye, he could tell that there had been something before it. On the 13th November, when I first saw the patient, I dissected out the cicatrix, which was unusually prominent ; and, on cutting it
Y4 Lente, Amaurosis and other Disorders of the Eye. [July
open, I observed in the centre a small piece of steel. R. Strych. gr. vj : alco- holis ^ij ; acid. acet. gss. M. Fricentur tempera m. et n. Pil. cal. et colocynth. 17th, wound nearly healed, and vision much improved. He can now see the fingers held before the eye. He can, but with much difficulty, distinguish large letters, and expresses himself as relieved of uneasy sensations about the side of the head.
Case IH. John Williams, 25, butcher. On the 8th of November, during an election riot, received, from an unknown weapon, a wound on the right lower eyelid, helow the edge of the orbit, and midway between the foramen infra-orhit- arium and tendon of orbicularis palpebraru7n. According to his own account, both eyes immediately became blind, and he had to be led home. As, on the second or third day, the vision of the right eye was perfectly restored, he thinks that the temporary deprivation of sight was caused by the tumefaction of the lids. Since the injury, the left eye has been completely amaurotic. With this eye he cannot recognize the least ray of light, and is even insensible to the glare of a magic lantern. The iris is somewhat expanded, and totally immovable when the other eye is closed, but when both are open, their motions perfectly correspond. With the exception of the cicatrix under the right eye, and the total loss of vision in the left, there is no appearance of disease. With great difficulty I persuaded the patient to allow me to remove the cicatrix, which was found to contain a smcdl foreign body. But, by no entreaty could I persuade him to allow me to bring the edges of the wound together by stitches. Although he promised to return, he never afterwards made his appearance, and I have not been able to find any traces of him.
Happening to mention these cases to the late Dr. J. Kearney Kodgers, then one of the surgeons of the New York Hospital, and one of the founders of the New York Eye Infirmary, he related a case in point, which had fallen under his own care. The notes of this case I have unfortunately lost, and cannot therefore give its very interesting history with accuracy; but, as I now remember it, the substance was the following : —
Case IY. A little girl, five or six years old, the child of a friend of the doctor, was playing under a table ; and, on rising up suddenly, struck her head against the edge of the table. Some time after this it was noticed that vision of one eye was becoming very imperfect, and Dr. Rodgers was con- sulted. The blow on the head was not, at that time, considered by the parents as having any connection with the disorder of vision, and was therefore not mentioned. But the doctor, on running his hand over the head of the child, in examining the eye, noticed that she flinched w^hen he touched a particular spot of the scalp ; and the mother then said that, in combing the hair, the child often cried when the comb came in contact with this spot, and then related the history of the accident. On closer exami- nation a cicatrix was discovered, and was excised. After the wound had healed, vision was either much improved, or rendered perfect, I cannot distinctly remember which. But the doctor regarded it as a remarkable circumstance.^
' These cases, and others wliicli will be alluded to, bear out one of the conclu- sions arrived at by Doctor Skokalski in bis investigations concerning the functions of the fifth pair, viz., that "sight does not depend solely on the retina, but on a combined action of the retina and fifth pair." Comparative anatomy also furnishes us with the important fact that, in s'ome animals, whose visual apparatus is -but slightly developed, the optic nerve is wanting entirely, and its place supplied by a branch of the fifth pair ; as in the mole tribe ; but most unequivocally, in the proteus anguinus.
1862.] Lente, Amaurosis and other Disorders of the Eye. 75
Remarhs. — Hippocrates remarks, ''The sight is obscured in wounds in- flicted on the eyebrow, or a little higher" (Middlemore). Beer makes a similar observation, and relates several cases in support of his opinion. He says that ''he has had frequent opportunities of accurately observing and curing amblyopia and amaurosis, occurring in consequence of wounds of the eyebrows." Also, that "where such wounds are judiciously managed, and speedily healed by adhesion, no bad consequence ensues ; but when suppuration occurs, followed by the granulating process necessary for secondary union, the divided nerves are involved in the inflammation, and subsequently included in the hard cicatrix, and, as he conceives, compressed and irritated.'" Larrey seems to have had the same idea, for he says, "In incisions about the orbit, we should avoid, as far as possible, injury of the ramifications of the frontal nerve; or, if we injure it, we should be careful to make a complete section." And, as Middlemore remarks, "few surgeons have had a greater extent of experience in this particular form of injury." Middlemore himself records a number of interesting cases of amaurosis from orbital wounds ; though he appears to be somewhat sceptical as to whether it should in general be attributed to the lesion of the nerve. He says, "Amaurosis may arise during the period of dentition ; it may take place from the irritation of a carious tooth ; from laceration, or other injury of the supra-orbitary nerve." He relates a case in which Mr. Howship removed an encysted tumour from the scalp, which produced ^'marked and permanent improvement in vision.^'' Another case, in which M. Demours removed a tumour from the neighbourhood of the eye, and thus produced amaurosis. Another from the Edinburgh Medical and Surgical Journal, "which would appear," he says, "to prove that wounds of the infra- orbitary nerve may restore the sight of an eye which has long been lost from an amaurotic affection." "A man was affected with perfect gutta Serena of the right eye, and had the sight of the eye restored, he thinks, in consequence of receiving a smart blow in the neighbourhood of the infra- orbitary nerve of the right side of the face." Another still more striking case, in which a person received "a wound just above the right eyebrow from a piece of glass, which was removed immediately after the accident." When the wound had healed, "the sight of the right eye was very nearly lost; he had a painful sensation in the neighbourhood of the cicatrix, and a singular sense of creeping, and pinching and quivering of the upper eyelid and the integuments of forehead." "I made a free incision of the cicatrix down to the bone, and all uneasiness at once ceased, and the eye, shortly after, assumed its healthy character and functions, and vision was perma- nently restored.''^ Lawrence, after relating two or three cases of amaurosis following wounds and the formation of cicatrices over the brows, remarks, "It is still a matter of doubt whether injury of the frontal nerve may cause
' Lawrence, American edition, 1854, p. 124.
76 Lente, Amaurosis and other Disorders of the Eye. [J^ily
amaurosis." Aud yet, he adds, "injmy or other irritation of the trigeminus may bring on impaired vision or amaurosis." "The sympathy between the trigeminus and the immediate nervous apparatus of vision affords the only explanation of some apparently obscure cases, in which amaurosis seems