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MEDICAL SOCIETY OF LONDON. SATURDAY, MARCH 28TH, 1857.
Mr. Hawkins as to the after-results of the system. He had the operation performed in six cases. In two instances it was upon the elbow-joint after a fracture of the internal condyle, in two or three upon the hip-joint, and in one or two upon the knee-joint. In none of these cases did a bad symptom present itself. The patients were placed fully under the influence of chloroform, and in one instance the operation was performed a second time.he In consequence of the successful issue of these operations, (Mr. Wells) had been encouraged to resort to the proceeding in a case in which the internal condyle and the humerus having been fractured; the limb was firmly flexed upon the arm. It yielded, however, to extension, and motion was re-established without any ill consequences
by
seen
whatever. Mr. HUTCHINSON bore testimony to the little danger which was incurred in breaking down adhesions of the knee-joint-an operation frequently performed in the larger hospitals of London. In only one or two cases had he seen any considerable amount of inflammation follow the proceeding. He could not give a decided opinion as to whether the plan recommended any material advantages over the one in common use at the Orthopaedic Hospital. He thought, however, in his own practice that he should prefer the latter mode of dividing the tendons, and procuring gradual extension by an apparatus. Mr. Brodhurst had referred to excision in some of his casesan operation which had never suggested itself to him (Mr. Hutchinson)-an operation, in his opinion, only justifiable when acute disease was going on, as the alternative of amputation. Mr. BRODHURST had brought the subject before the Society, in consequence of a statement made at a medical meeting in Vienna by Baron Dumreicher, that the division of tendons was necessary, and that extension alone was required in cases of partially anchylosed joints. He believed, from the cases of Langenbeck and Louvrier, that the tendons ought to be divided in cases where great rigidity existed. He had seen no evil effects from extension, except a rather serious inflammation in one case; but this subsided, and motion was established. The author had not found it necessary to divide the ligaments, though there might possibly be cases in which that operation would be expedient. He should hesitate to extend the limb immediately after the use of the knife. He had only had thirteen cases, all of which had terminated successfully. In one of his cases resection had been suggested, and it was on that account that it came under his care.
offered
MEDICAL SOCIETY OF LONDON. SATURDAY, MARCH 28TH, 1857. MR.
HIRD, PRESIDENT,
Mrp. BRODHURST read
a
IN THE
CHAIR.
paper
ON THE TREATMENT OF LATERAL CURVATURE OF THE SPINE.
The author commenced by stating the various causes of lateral curvature, and he showed that some varieties of curvature are alone amenable to treatment; he affirmed that it was not difficult to discover the cause of curvature, and he pointed out the means by which an accurate diagnosis might be made. These several points were elucidated by means of casts. He then alluded to primary and secondary curves, and explained how to distinguish the primary curve. Through ignorance of these questions, it was customary to treat the dorsal curve alone,
whether
a
the lumbar
primary
or a
secondary
curve;
and, consequently,
the spinal apparatus and its action as follow :-" The instrument consists of a band fitting accurately to the pelvis, from which rise two lateral uprights, the heads of which rest in the axillae, and support the shoulders. These uprights elongate, so that they may be raised to any desired height; they also move in the segment of a circle at their junction with the pelvic band: consequently one or both may have a perpendicular or an oblique direction. Springing from the centre of the pelvic band is a perpendicular steel bar, (vertebral stem,) which rises to the upper extremity of the dorsal curve. This stem is united by a transverse band, (scapular band,) with the crutches. Thus a solid frame is produced, which cannot be tilted by any amount of pressure. The vertebral stem supports three levers, all of which are moved by rack-and-pinion joints. The lowest of these gives attachment to the lumbar webbing band; to the middle lever is attached the dorsal webbing band, and the upper lever is connected with the shoulder ring. The lumbar and dorsal webbing bands are further attached in front to two perpendicular levers, which are placed on the anterior surface of the pelvic band, and which, as the other levers, are moved by rack-and-pinion joints. Now, when the lumbar is the primary curve, its concavity is supported by the lowest webbing band, and the dorsal band is applied obliquely in such a manner that it shall act on the inferior extremity of the dorsal curve by uplifting it. This action of the instrument will tend to depress the pelvic band. A webbing band, fastened to a lever in front, and to the pelvic band behind, passes over the highest ilium. This, by its action on the lumbar curve, tends to restore the horizontal position of the pelvis; and the combined action of these four bands is to unbend the lumbar curve. When the dorsal is the primary curve, its convexity is also supported by a webbing band, while the lumbar band is applied to the upper extremity of the lumbar curve to act upon it obliquely in a downward direction, and the upper extremity of the dorsal curve is equally acted on by the shoulder sling, which, embracing the scapula, and lying upon the ribs which correspond to the extremity of the dorsal curve, acts upon them to unbend the curve. Thus the convexity of the curve being firmly fixed, there is power to uplift and depress the extremities of the curve, which cannot fail to unbend it if the positions now laid down are attended to. When much rotation of the vertebras is superadded to lateral curvature, a metal plate, movable with rack-and-pinion joints, is attached to the perpendicular vertebral stem of the instrument ; by means of which adequate pressure can be made from behind
plained
forwards. Mr. HU1’T observed, that the age had not been mentioned by Mr. Brodhurst at which he believes treatment to be no longer practicable; and he inquired the ages of the several patients to which reference had been made, and from whom the casts which were exhibited had been taken. Mr. HARRISON remarked, that it had been stated by the author of the paper, that three-fourths of the cases of lateral curvature of the spine arise from increased muscular action, and from debility; and inquired if such cases could with safety be treated at any period without mechanical support, or, if not, how soon support ought to be employed. Dr. RYAN had used a similar instrument to that now exhibited with great advantage, and he remarked that the health of the patient was not injuriously affected by a portable instrument, as was too often the case when the recumbent position was long maintained. Mr. ADAMS doubted whether spinal instruments of any kind were useful after twenty-six years of age; and he believed that a pliable curve could alone be acted on by mechanical He had no faith in any power to unbend a rigid means. curve, or to act upon such a curve by lateral pressure; and he thought that gymnastic exercises and the recumbent position were more useful than any instrumental means that might be adopted. Yet he admitted that cases existed in which sup-
increased by attempting to He showed that a comremove a compensating dorsal curve. pensating curve was an effort of Nature to restore equilibrium, and that though it were removed, the primary curve and the cause of distortion would remain. Much scepticism, he said, port was necessary to relieve pain; and he cited a case in existed with regard to the utility of spinal instruments, which which considerable pain had been relieved by uplifting the dehad been occasioned by the of instruments to every pressed ribs. He doubted if pressure could ever be borne in form of curvature, without inquiry being made as to the cause the axilla, for he had always found that such pressure was folof distortion, as though every form of spinal curvature could be lowed by swelling of the extremity. He observed that the removed. He alluded to the unphilosophical mode of at- instrument now exhibited was different to that originally contempting to removearigid spinal curve by lateral pressure, structed by Mr. Errard, and inquired whether the alterations and asserted, that to overcome such a curve by such means was B had been made by Errard. a physical impossibility. The result of such treatment was to Mr. PoTTS could not subscribe to the opinion of Mr. Adams, induce flattening of the ribs, but no diminution of the spinal that instrumental interference was useless. He had seen cases, curve. Instead of lateral pressure alone being employed, he especially from fifteen to twenty years of age, in which great showed that it was necessary to unbend a spinal curve ; and advantage had been derived from the use of spinal instruments. Mr. ADAMS remarked that slight pliable curves might be rethat although slight curvature might be removed by support only, a rigid curve required to be unbent. The author then moved by means of apparatus, and reiterated his opinion that described the manner in which this was to be effected, and ex rigid curves could neither be unbent nor affected bv lateral curve was
frequently
application
347
pressure. He stated that he had lately examined a spine in which four curves existed, where neither pain nor other inconvenience had ever been experienced. The treatment with which he should be content, in the instance of a single curve, would be, if possible, to transform it into four short curves. He thought that, if such a result could be obtained, more benefit would be derived than from any other mode of treatment. No ill result could occur except some shortening of the trunk. Dr. CHOWNE was sorry to have heard so much said against the utility of spinal instruments. He had seen much advant tage from their use, and thought that, although the correcform of apparatus might not yet perhaps have been discovered, that apparatus was likely to prove most useful which encased the patient in the most efficient manner, and which afforded the most support. Mr. BRODIIURST replied that the ages of the cases to which he had referred varied from sixteen to thirty-eight years, and that the three cases to which he had especially directed attention were taken at eighteen years of age, twenty-three years, and thirty-two years respectively. The improvement which had taken place in these cases was shown by the photographs which had been subsequently taken, after eight months and after fourteen months of treatment. These cases were instances of very severe distortion, and yet it was shown what treatment had been able to effect. He was surprised to hear the opinion expressed by Mr. Adams with regard to the benefit which might be expected from mechanical treatment, and expressed his belief that, when the several curves were properly acted on, distortion might generally be overcome, but that distortion could not be removed by acting only on one curve. Support could not be applied too early when a spinal curve had been formed; but it was not necessary to use an elaborate instrument when curvature was very slight. Support to the spine and to remove the weight of the shoulders was in such cases sufficient. All the cases referred to had been treated on the principle of unbending the curve, by means of an instrument of excellent construction made by Mr. Bigg. This instrument was elaborated from one far less perfect, which was constructed by Mr. Errard. Age was a very imperfect indication as to the rigidity of spinal curves. At sixteen, or even earlier, much rigidity might exist; whilst, on the other hand, a curve might remain pliable until thirty or thirty-five years of age. Pain also was very variable; it existed both with long ancl with short curves.
PATHOLOGICAL SOCIETY OF LONDON. DR.
WATSON, PRESIDENT,
Dr. MARKHAM exhibited
a
IN THE
specimen
CHAIR
of
OPEN’ FORAMEN OVALE.—LOUD CrSTOLIC BRUIT : WHAT WAS ITS CAUSE? TUBERCULOSIS OF THE LUNGS.
The little girl, a delicate child, aged four, in whom these conditions were found was seen’by him on Feb. 8th. He heard then a loud cystolic bruit along the base of the heart, in the whole sub-clavicular region, but it was scarcely audible below the nipple. On the 17th the child was seized with violent convulsions. The following day the bruit was heard louder and rougher than before; it was now audible over the whole precordial region, and up the right of the sternum, also over the upper half of the interscapular space on both sides of the spine. The respiratory murmur was everywhere loud and clear; the percussion good; no râles perceptible. The respiration was easy, the skin hot, the pulse rapid; there were convulsive twitchings of the left shoulder and arm; the child was drowsy and stupid. The mother now said that the child had been always subject to cold, bluish feet, and pointed out some bluish veins around the finger-nails. These were the only symptoms, very slightly marked, of cyanosis. Necropsy showed that the heart was perfectly sound, save in respect of having an open foramen ovale. Was this opening the cause of the bruit ? The question excited some discussion. Drs. Quain and Peacock knew of no case of open foramen ovale in which a bruit had been heard during life where some other abnormal condition-e. g., constriction of pulmonary artery-had not co-existed. They could give no account of the bruit; it seemed anomalous. Dr. Markham argued that the bruit was formed at the open foramen ovale, and that the fact was not to be rejected simply because such a bruit had not yet been recognised in auscultation. His reasons were: that there was no other cause to which the bruit-on several occasions most carefully observed-could be attributed; that there was nothing in the formation of the Darts involved repugnant to
348
the idea of the formation of such a bruit. Thus, the bruit being coincident with the cystole of the ventricles, necessarily occurred during the diastole of the auricles. Certainly such a bruit could not conceivably arise during the auricular cystole, for the foramen ovale being open, the blood in both auricles would then be subjected to a like pressure, and therefore no intercurrents could occur; but during the diastole, the blood, rushing into the auricles from the large venous trunks, might readily pass through the abnormal opening, and throw the valve into such vibrations as would occasion an audible murAnd the valve, in this case, had this peculiarity : it was mur. attached to the upper and lower parts of the opening, on the left side of the septum, but was free elsewhere, and would allow a current of blood to pass readily from the right to the left auricle, and then be thrown into vibrations. The objection that the current of the blood in such case would not be strong enough to produce a bruit, is answered by the fact, that weak currents of blood will occasion loud bruits under certain conditions; witness the occasional roaring bruit produced by the gentlest pressure of the stethoscope on the cervical veins of the auasmic, and witness also the loud bruit sometimes heard even over the radial artery. That such a bruit is so rarely heard during life may be explained by the fact, that where other abnormal states of the heart do not co-exist, there is no cardiac disturbance, and therefore no examination is made of the heart during life to ascertain the fact. And why, again, should it be assumed that in cases of open foramen ovale, associated with other defective states of the heart, in which murmurs were heard during life, that the murmurs always have their origin in those other defective conditions, and never in the open foramen ovale ? For such reasons, Dr. Markham thought it more rational to attribute the bruit to the open foramen ovale than to acquiesce in the proposition that some inexplicable mystery involved the subject. Another fact of great interest was observed in this case in connexion with the lungs: seventeen hours before death a most careful examination could ascertain nothing abnormal in their condition, and yet miliary tubercles were found thickly scattered through every lobe of each lung. The possibility of such a thing is admitted, but its demonstration is rare. "Solitary tubercles,’’ saysSkoda, ’’ of themselves produce not the slightest change in the percussion-sound; we can only surmise their existence." The fact is readily explicable. The percussion sound is unaltered because healthy, air-containing tissue intervenes between the tubercles; the respiratory murmur is clear because the air enters freely; there are no rales because there is no exudation yet thrown out. The case therefore proves that the absence of physical signs is no proof of the absence of tubercle in the lungs, and consequently condemns as hypothetical the existence of so-called pre-tubercular stages of phthisis, and the deductions drawn therefrom. It seems also to prove the existence of a species of cardiac bruit hitherto unrecognisecl by auscultators. Dr. THEOPHILUS THOMPSON asked if there was any blueness of the surface ? Dr. MARKHAM.-The child had always cold feet 113 d blueness of the nails, and some degree of cyanosis. Dr. CAMPS had a case of cyanosis, some years ago, in a girl twelve years old, with a marked and constant bruit. Dr. OGLE had examined 100 children, and found the foramen ovale open in the greater number; there was no cyanosis in these cases. The PRESIDENT asked if the miliary tubercles were the same as is ordinarily seen. Dr. MARKHAM said there was no doubt of it. Dr. HEWETT confirmed Dr. Markham in the difficulty of diagnosing tubercles in children. Dr. QUAIN said the bruit in cyanosis would depend upon the cause producing it. He heard with consternation that such a quantity of tubercle could exist without physical signs. Dr. THEOPHILUS THOMPSON, on looking at the lung, thought there was an average quantity of air present, which would give fair percussion, but he was surprised the respiration sounds were perfectly natural. The presence of an open foramen ovale is not enough to produce a bruit; anything else obstructing the blood will do it. He doubted if the mere passage of blood through the foramen ovale could produce such a loud bruit as described by Dr. Markham. Dr. HARE read a similar case, with normal resonance on percussion, and a like condition of lung. Dr. PEACOCK said that after the length of time which the discussion of Dr. Markham’s communication had occupied, he would trespass on the time of the Society only for a very short period. Cases like that mentioned by Dr. Camps, in which there was intense cyanosis, were, in a very large proportion.
by
seen
whatever. Mr. HUTCHINSON bore testimony to the little danger which was incurred in breaking down adhesions of the knee-joint-an operation frequently performed in the larger hospitals of London. In only one or two cases had he seen any considerable amount of inflammation follow the proceeding. He could not give a decided opinion as to whether the plan recommended any material advantages over the one in common use at the Orthopaedic Hospital. He thought, however, in his own practice that he should prefer the latter mode of dividing the tendons, and procuring gradual extension by an apparatus. Mr. Brodhurst had referred to excision in some of his casesan operation which had never suggested itself to him (Mr. Hutchinson)-an operation, in his opinion, only justifiable when acute disease was going on, as the alternative of amputation. Mr. BRODHURST had brought the subject before the Society, in consequence of a statement made at a medical meeting in Vienna by Baron Dumreicher, that the division of tendons was necessary, and that extension alone was required in cases of partially anchylosed joints. He believed, from the cases of Langenbeck and Louvrier, that the tendons ought to be divided in cases where great rigidity existed. He had seen no evil effects from extension, except a rather serious inflammation in one case; but this subsided, and motion was established. The author had not found it necessary to divide the ligaments, though there might possibly be cases in which that operation would be expedient. He should hesitate to extend the limb immediately after the use of the knife. He had only had thirteen cases, all of which had terminated successfully. In one of his cases resection had been suggested, and it was on that account that it came under his care.
offered
MEDICAL SOCIETY OF LONDON. SATURDAY, MARCH 28TH, 1857. MR.
HIRD, PRESIDENT,
Mrp. BRODHURST read
a
IN THE
CHAIR.
paper
ON THE TREATMENT OF LATERAL CURVATURE OF THE SPINE.
The author commenced by stating the various causes of lateral curvature, and he showed that some varieties of curvature are alone amenable to treatment; he affirmed that it was not difficult to discover the cause of curvature, and he pointed out the means by which an accurate diagnosis might be made. These several points were elucidated by means of casts. He then alluded to primary and secondary curves, and explained how to distinguish the primary curve. Through ignorance of these questions, it was customary to treat the dorsal curve alone,
whether
a
the lumbar
primary
or a
secondary
curve;
and, consequently,
the spinal apparatus and its action as follow :-" The instrument consists of a band fitting accurately to the pelvis, from which rise two lateral uprights, the heads of which rest in the axillae, and support the shoulders. These uprights elongate, so that they may be raised to any desired height; they also move in the segment of a circle at their junction with the pelvic band: consequently one or both may have a perpendicular or an oblique direction. Springing from the centre of the pelvic band is a perpendicular steel bar, (vertebral stem,) which rises to the upper extremity of the dorsal curve. This stem is united by a transverse band, (scapular band,) with the crutches. Thus a solid frame is produced, which cannot be tilted by any amount of pressure. The vertebral stem supports three levers, all of which are moved by rack-and-pinion joints. The lowest of these gives attachment to the lumbar webbing band; to the middle lever is attached the dorsal webbing band, and the upper lever is connected with the shoulder ring. The lumbar and dorsal webbing bands are further attached in front to two perpendicular levers, which are placed on the anterior surface of the pelvic band, and which, as the other levers, are moved by rack-and-pinion joints. Now, when the lumbar is the primary curve, its concavity is supported by the lowest webbing band, and the dorsal band is applied obliquely in such a manner that it shall act on the inferior extremity of the dorsal curve by uplifting it. This action of the instrument will tend to depress the pelvic band. A webbing band, fastened to a lever in front, and to the pelvic band behind, passes over the highest ilium. This, by its action on the lumbar curve, tends to restore the horizontal position of the pelvis; and the combined action of these four bands is to unbend the lumbar curve. When the dorsal is the primary curve, its convexity is also supported by a webbing band, while the lumbar band is applied to the upper extremity of the lumbar curve to act upon it obliquely in a downward direction, and the upper extremity of the dorsal curve is equally acted on by the shoulder sling, which, embracing the scapula, and lying upon the ribs which correspond to the extremity of the dorsal curve, acts upon them to unbend the curve. Thus the convexity of the curve being firmly fixed, there is power to uplift and depress the extremities of the curve, which cannot fail to unbend it if the positions now laid down are attended to. When much rotation of the vertebras is superadded to lateral curvature, a metal plate, movable with rack-and-pinion joints, is attached to the perpendicular vertebral stem of the instrument ; by means of which adequate pressure can be made from behind
plained
forwards. Mr. HU1’T observed, that the age had not been mentioned by Mr. Brodhurst at which he believes treatment to be no longer practicable; and he inquired the ages of the several patients to which reference had been made, and from whom the casts which were exhibited had been taken. Mr. HARRISON remarked, that it had been stated by the author of the paper, that three-fourths of the cases of lateral curvature of the spine arise from increased muscular action, and from debility; and inquired if such cases could with safety be treated at any period without mechanical support, or, if not, how soon support ought to be employed. Dr. RYAN had used a similar instrument to that now exhibited with great advantage, and he remarked that the health of the patient was not injuriously affected by a portable instrument, as was too often the case when the recumbent position was long maintained. Mr. ADAMS doubted whether spinal instruments of any kind were useful after twenty-six years of age; and he believed that a pliable curve could alone be acted on by mechanical He had no faith in any power to unbend a rigid means. curve, or to act upon such a curve by lateral pressure; and he thought that gymnastic exercises and the recumbent position were more useful than any instrumental means that might be adopted. Yet he admitted that cases existed in which sup-
increased by attempting to He showed that a comremove a compensating dorsal curve. pensating curve was an effort of Nature to restore equilibrium, and that though it were removed, the primary curve and the cause of distortion would remain. Much scepticism, he said, port was necessary to relieve pain; and he cited a case in existed with regard to the utility of spinal instruments, which which considerable pain had been relieved by uplifting the dehad been occasioned by the of instruments to every pressed ribs. He doubted if pressure could ever be borne in form of curvature, without inquiry being made as to the cause the axilla, for he had always found that such pressure was folof distortion, as though every form of spinal curvature could be lowed by swelling of the extremity. He observed that the removed. He alluded to the unphilosophical mode of at- instrument now exhibited was different to that originally contempting to removearigid spinal curve by lateral pressure, structed by Mr. Errard, and inquired whether the alterations and asserted, that to overcome such a curve by such means was B had been made by Errard. a physical impossibility. The result of such treatment was to Mr. PoTTS could not subscribe to the opinion of Mr. Adams, induce flattening of the ribs, but no diminution of the spinal that instrumental interference was useless. He had seen cases, curve. Instead of lateral pressure alone being employed, he especially from fifteen to twenty years of age, in which great showed that it was necessary to unbend a spinal curve ; and advantage had been derived from the use of spinal instruments. Mr. ADAMS remarked that slight pliable curves might be rethat although slight curvature might be removed by support only, a rigid curve required to be unbent. The author then moved by means of apparatus, and reiterated his opinion that described the manner in which this was to be effected, and ex rigid curves could neither be unbent nor affected bv lateral curve was
frequently
application
347
pressure. He stated that he had lately examined a spine in which four curves existed, where neither pain nor other inconvenience had ever been experienced. The treatment with which he should be content, in the instance of a single curve, would be, if possible, to transform it into four short curves. He thought that, if such a result could be obtained, more benefit would be derived than from any other mode of treatment. No ill result could occur except some shortening of the trunk. Dr. CHOWNE was sorry to have heard so much said against the utility of spinal instruments. He had seen much advant tage from their use, and thought that, although the correcform of apparatus might not yet perhaps have been discovered, that apparatus was likely to prove most useful which encased the patient in the most efficient manner, and which afforded the most support. Mr. BRODIIURST replied that the ages of the cases to which he had referred varied from sixteen to thirty-eight years, and that the three cases to which he had especially directed attention were taken at eighteen years of age, twenty-three years, and thirty-two years respectively. The improvement which had taken place in these cases was shown by the photographs which had been subsequently taken, after eight months and after fourteen months of treatment. These cases were instances of very severe distortion, and yet it was shown what treatment had been able to effect. He was surprised to hear the opinion expressed by Mr. Adams with regard to the benefit which might be expected from mechanical treatment, and expressed his belief that, when the several curves were properly acted on, distortion might generally be overcome, but that distortion could not be removed by acting only on one curve. Support could not be applied too early when a spinal curve had been formed; but it was not necessary to use an elaborate instrument when curvature was very slight. Support to the spine and to remove the weight of the shoulders was in such cases sufficient. All the cases referred to had been treated on the principle of unbending the curve, by means of an instrument of excellent construction made by Mr. Bigg. This instrument was elaborated from one far less perfect, which was constructed by Mr. Errard. Age was a very imperfect indication as to the rigidity of spinal curves. At sixteen, or even earlier, much rigidity might exist; whilst, on the other hand, a curve might remain pliable until thirty or thirty-five years of age. Pain also was very variable; it existed both with long ancl with short curves.
PATHOLOGICAL SOCIETY OF LONDON. DR.
WATSON, PRESIDENT,
Dr. MARKHAM exhibited
a
IN THE
specimen
CHAIR
of
OPEN’ FORAMEN OVALE.—LOUD CrSTOLIC BRUIT : WHAT WAS ITS CAUSE? TUBERCULOSIS OF THE LUNGS.
The little girl, a delicate child, aged four, in whom these conditions were found was seen’by him on Feb. 8th. He heard then a loud cystolic bruit along the base of the heart, in the whole sub-clavicular region, but it was scarcely audible below the nipple. On the 17th the child was seized with violent convulsions. The following day the bruit was heard louder and rougher than before; it was now audible over the whole precordial region, and up the right of the sternum, also over the upper half of the interscapular space on both sides of the spine. The respiratory murmur was everywhere loud and clear; the percussion good; no râles perceptible. The respiration was easy, the skin hot, the pulse rapid; there were convulsive twitchings of the left shoulder and arm; the child was drowsy and stupid. The mother now said that the child had been always subject to cold, bluish feet, and pointed out some bluish veins around the finger-nails. These were the only symptoms, very slightly marked, of cyanosis. Necropsy showed that the heart was perfectly sound, save in respect of having an open foramen ovale. Was this opening the cause of the bruit ? The question excited some discussion. Drs. Quain and Peacock knew of no case of open foramen ovale in which a bruit had been heard during life where some other abnormal condition-e. g., constriction of pulmonary artery-had not co-existed. They could give no account of the bruit; it seemed anomalous. Dr. Markham argued that the bruit was formed at the open foramen ovale, and that the fact was not to be rejected simply because such a bruit had not yet been recognised in auscultation. His reasons were: that there was no other cause to which the bruit-on several occasions most carefully observed-could be attributed; that there was nothing in the formation of the Darts involved repugnant to
348
the idea of the formation of such a bruit. Thus, the bruit being coincident with the cystole of the ventricles, necessarily occurred during the diastole of the auricles. Certainly such a bruit could not conceivably arise during the auricular cystole, for the foramen ovale being open, the blood in both auricles would then be subjected to a like pressure, and therefore no intercurrents could occur; but during the diastole, the blood, rushing into the auricles from the large venous trunks, might readily pass through the abnormal opening, and throw the valve into such vibrations as would occasion an audible murAnd the valve, in this case, had this peculiarity : it was mur. attached to the upper and lower parts of the opening, on the left side of the septum, but was free elsewhere, and would allow a current of blood to pass readily from the right to the left auricle, and then be thrown into vibrations. The objection that the current of the blood in such case would not be strong enough to produce a bruit, is answered by the fact, that weak currents of blood will occasion loud bruits under certain conditions; witness the occasional roaring bruit produced by the gentlest pressure of the stethoscope on the cervical veins of the auasmic, and witness also the loud bruit sometimes heard even over the radial artery. That such a bruit is so rarely heard during life may be explained by the fact, that where other abnormal states of the heart do not co-exist, there is no cardiac disturbance, and therefore no examination is made of the heart during life to ascertain the fact. And why, again, should it be assumed that in cases of open foramen ovale, associated with other defective states of the heart, in which murmurs were heard during life, that the murmurs always have their origin in those other defective conditions, and never in the open foramen ovale ? For such reasons, Dr. Markham thought it more rational to attribute the bruit to the open foramen ovale than to acquiesce in the proposition that some inexplicable mystery involved the subject. Another fact of great interest was observed in this case in connexion with the lungs: seventeen hours before death a most careful examination could ascertain nothing abnormal in their condition, and yet miliary tubercles were found thickly scattered through every lobe of each lung. The possibility of such a thing is admitted, but its demonstration is rare. "Solitary tubercles,’’ saysSkoda, ’’ of themselves produce not the slightest change in the percussion-sound; we can only surmise their existence." The fact is readily explicable. The percussion sound is unaltered because healthy, air-containing tissue intervenes between the tubercles; the respiratory murmur is clear because the air enters freely; there are no rales because there is no exudation yet thrown out. The case therefore proves that the absence of physical signs is no proof of the absence of tubercle in the lungs, and consequently condemns as hypothetical the existence of so-called pre-tubercular stages of phthisis, and the deductions drawn therefrom. It seems also to prove the existence of a species of cardiac bruit hitherto unrecognisecl by auscultators. Dr. THEOPHILUS THOMPSON asked if there was any blueness of the surface ? Dr. MARKHAM.-The child had always cold feet 113 d blueness of the nails, and some degree of cyanosis. Dr. CAMPS had a case of cyanosis, some years ago, in a girl twelve years old, with a marked and constant bruit. Dr. OGLE had examined 100 children, and found the foramen ovale open in the greater number; there was no cyanosis in these cases. The PRESIDENT asked if the miliary tubercles were the same as is ordinarily seen. Dr. MARKHAM said there was no doubt of it. Dr. HEWETT confirmed Dr. Markham in the difficulty of diagnosing tubercles in children. Dr. QUAIN said the bruit in cyanosis would depend upon the cause producing it. He heard with consternation that such a quantity of tubercle could exist without physical signs. Dr. THEOPHILUS THOMPSON, on looking at the lung, thought there was an average quantity of air present, which would give fair percussion, but he was surprised the respiration sounds were perfectly natural. The presence of an open foramen ovale is not enough to produce a bruit; anything else obstructing the blood will do it. He doubted if the mere passage of blood through the foramen ovale could produce such a loud bruit as described by Dr. Markham. Dr. HARE read a similar case, with normal resonance on percussion, and a like condition of lung. Dr. PEACOCK said that after the length of time which the discussion of Dr. Markham’s communication had occupied, he would trespass on the time of the Society only for a very short period. Cases like that mentioned by Dr. Camps, in which there was intense cyanosis, were, in a very large proportion.