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APPRENTICESHIP AND CONSCRIPTION.
149
ventricular orifice,
that a tricuspid bruit becomes established. To the Editor of THE LANCET. It is in his discrimination of a tricuspid from a SIR,-May I draw the attention of your readers to mitral systolic bruit in mitral stenosis that the a pamphlet which I have written, entitled Apprenchief clinical interest of Sir James Goodhart’s ticeship v. Conscription," which purports to show paper consists. The tricuspid, like the pulmonary " how we can save our youths, the future " English arterial area, but less so, lay long in the region of race," from growing up untrained, undisciplined, romance," but the power of the right heart to and often in consequence vicious and criminal. generate a bruit of tricuspid regurgitation must he Any of your readers who care to write can obtain a admitted. I have myself followed such a bruit copy free from Messrs. Stanbrook and Sons, Herne from its genesis to its extinction. The case was Bay. one of sarcoma of the heart published in Although written some years ago, the present THE LANCET of Jan. 9th, 1909, in which the neotime and the next year or two is the opportunity to first fixed the atrio-ventricular ring or a plasm be preparing for " after the war." Old conditions part of it, when a loud and rough systolic bruit as are changing, new ideas are developing, the land is harsh as any mitral murmur was established and being ploughed more deeply than ever before, and was traceable round the right chest, just as a when the longed-for peace arrives and reconstrucloud mitral bruit may be to the left, and later, tion begins some definite plan must be ready when the right ventricle became fixed by the to our hand or we shall sink back to lack of was altogether abolished, the patient living disease, method, and instead of progress the present wicked for a considerable length of time on her left waste of our children and youths will be perheart alone. petuated.-I am, Sir, yours faithfully, In pointing out the silence and displacement of R. C. T. EVANS. Herne Bay, July 12th, 1915. the mitral area in some cases of leftatrio-ventricular stenosis and the occupation of the left praacordium THE RIGHT-SIDED MURMURS OF MITRAL by a systolic bruit of tricuspid origin Sir James STENOSIS. Goodhart has done good. service. If not altogether To the Editor of THE LANCET. new, this is, as he remarks, "an old wine that a SIR,-In what he terms his "old-fashioned paper," good many apparently have not had the pleasure of which appears under the above title in THE LANCET of tasting." As he also states, it is important for theraJuly 3rd, and for which no apology is necessary on peutic reasons. When such a bruit is established account of its maintenance of a clinical method the aspiratory forces which assist the circulation only too rarely seen of late, Sir James Goodhart, through the venous heart are impaired. The speaking with authority and from a ripe experience, pulmonary arterial circulation is impeded by the refers to many points, both interesting and valuable, checked outflow of the pulmonary venous circulawhich will repay study. The comparative rarity of tion and rendered still more tense by the exaggerdextral valvular lesions not of congenital origin is ated aspirative action of the lungs on the rightof itself a matter of interest. Indeed, those who heart blood. The initial failure is in left-heart discussed the subject were at one time accused of aspiration and propulsion and the vicious cycle entering upon a " region of romance." The quality established in pulmonary stasis, dextro-cardiac of the blood and the nature of the circulation in repletion, and impeded venous return. As Withering remarked when writing of digitalis, the venous heart must be the factors which secure it is more difficult to narrate the effects of a remedy a comparative immunity of the adult right heart from valvular disease, and of these the nature of than to describe a disease, but there has for long the cicculation is probably the more important. been an impression that the digitalis group has For such non-congenital lesions as are met with in not fulfilled expectations in certain conditions of the right heart are chiefly due to infection, and the disease of the right heart and also in some comparative frequency of congenital disease occurs phases of aortic regurgitant disease. There are at a time when the right heart is the chief driving no doubt many cases both of mitral stenosis power in the circulation. With the establishment and of aortic regurgitation which are saved by It would occupy too of aerial respiration the right heart is relieved of the bold use of digitalis. much of its labour and the lungs themselves much space to deal with this matter fully here, become an important factor in promoting the but there are unquestionably other cases of both
APPRENTICESHIP AND CONSCRIPTION.
ventricular orifice,
that a tricuspid bruit becomes established. To the Editor of THE LANCET. It is in his discrimination of a tricuspid from a SIR,-May I draw the attention of your readers to mitral systolic bruit in mitral stenosis that the a pamphlet which I have written, entitled Apprenchief clinical interest of Sir James Goodhart’s ticeship v. Conscription," which purports to show paper consists. The tricuspid, like the pulmonary " how we can save our youths, the future " English arterial area, but less so, lay long in the region of race," from growing up untrained, undisciplined, romance," but the power of the right heart to and often in consequence vicious and criminal. generate a bruit of tricuspid regurgitation must he Any of your readers who care to write can obtain a admitted. I have myself followed such a bruit copy free from Messrs. Stanbrook and Sons, Herne from its genesis to its extinction. The case was Bay. one of sarcoma of the heart published in Although written some years ago, the present THE LANCET of Jan. 9th, 1909, in which the neotime and the next year or two is the opportunity to first fixed the atrio-ventricular ring or a plasm be preparing for " after the war." Old conditions part of it, when a loud and rough systolic bruit as are changing, new ideas are developing, the land is harsh as any mitral murmur was established and being ploughed more deeply than ever before, and was traceable round the right chest, just as a when the longed-for peace arrives and reconstrucloud mitral bruit may be to the left, and later, tion begins some definite plan must be ready when the right ventricle became fixed by the to our hand or we shall sink back to lack of was altogether abolished, the patient living disease, method, and instead of progress the present wicked for a considerable length of time on her left waste of our children and youths will be perheart alone. petuated.-I am, Sir, yours faithfully, In pointing out the silence and displacement of R. C. T. EVANS. Herne Bay, July 12th, 1915. the mitral area in some cases of leftatrio-ventricular stenosis and the occupation of the left praacordium THE RIGHT-SIDED MURMURS OF MITRAL by a systolic bruit of tricuspid origin Sir James STENOSIS. Goodhart has done good. service. If not altogether To the Editor of THE LANCET. new, this is, as he remarks, "an old wine that a SIR,-In what he terms his "old-fashioned paper," good many apparently have not had the pleasure of which appears under the above title in THE LANCET of tasting." As he also states, it is important for theraJuly 3rd, and for which no apology is necessary on peutic reasons. When such a bruit is established account of its maintenance of a clinical method the aspiratory forces which assist the circulation only too rarely seen of late, Sir James Goodhart, through the venous heart are impaired. The speaking with authority and from a ripe experience, pulmonary arterial circulation is impeded by the refers to many points, both interesting and valuable, checked outflow of the pulmonary venous circulawhich will repay study. The comparative rarity of tion and rendered still more tense by the exaggerdextral valvular lesions not of congenital origin is ated aspirative action of the lungs on the rightof itself a matter of interest. Indeed, those who heart blood. The initial failure is in left-heart discussed the subject were at one time accused of aspiration and propulsion and the vicious cycle entering upon a " region of romance." The quality established in pulmonary stasis, dextro-cardiac of the blood and the nature of the circulation in repletion, and impeded venous return. As Withering remarked when writing of digitalis, the venous heart must be the factors which secure it is more difficult to narrate the effects of a remedy a comparative immunity of the adult right heart from valvular disease, and of these the nature of than to describe a disease, but there has for long the cicculation is probably the more important. been an impression that the digitalis group has For such non-congenital lesions as are met with in not fulfilled expectations in certain conditions of the right heart are chiefly due to infection, and the disease of the right heart and also in some comparative frequency of congenital disease occurs phases of aortic regurgitant disease. There are at a time when the right heart is the chief driving no doubt many cases both of mitral stenosis power in the circulation. With the establishment and of aortic regurgitation which are saved by It would occupy too of aerial respiration the right heart is relieved of the bold use of digitalis. much of its labour and the lungs themselves much space to deal with this matter fully here, become an important factor in promoting the but there are unquestionably other cases of both
APPRENTICESHIP AND CONSCRIPTION.