see that the effect upon the circulation would be quite as serious as in the condition just referred to-stenosis of the orifices of the heart.

it

Patients suffering from these valvular diseases, as I told you, are liable to die suddenly. But still they do live on for years, in many instances in comparative comfort, having been warned perhaps of the necessity of avoiding excesses of every kind, mental and physical, and particularly excess in eating or drinking. But many more would die early in the disease than do, if it were not for a wonderful provision of nature, a condition, which gradually develops itself, called com pensating hypertrophy of the heart-actual increase in the size of the heart, increase in the number of muscular fibres which enter into the composition of the heart walls. Hypertrophy, enlargement of the heart, in itself can hardly be called a disease. In these cases of valvular disease there is a necessity for Why should there be such a necessity? Take, for instance, stenosis of the aortic orifice, a contraction of the orifice, which prevents the contents of the ventricle-arterialized from having so recently passed through the capillaries of the lungs-from flowing with natural freedom into the aorta, to be distributed to various portions of the body The system needs this blood; not a portion of it, but the whole. If it is deprived of even a small portion of it, sufficient nourishment can not be imparted; and, aside from this, if the arteries do not contain their proper share of the blood of the entire body, the veins must necessarily contain more than their share; and this overfilling of the veins will result in serious disturbances, from a percolation of a portion of the serum of the blood through their walls, producing the condition known as dropsy; œdema, if local, and confined to the parenchyma; anasarca, if general, and still confined to the parenchyma; simply dropsy, if involving any of the shut or serous cavities. Now, if this stenosis of the aortic orifice exists, producing all these disturb ances, the effect would be: first while the heart was suffering from the inflammatory condition which produced the stenosis, if it arose from an endocarditis, to dilate the left ventricle, making its cavity larger and its walls necessarily thinner. The heart, although not increased in weight, is larger; it occupies more space in the chest cavity than is normal. But it is not hypertrophied; there is no increase in the number of its muscular fibres. Sometimes it does not become hypertrophied; sometimes its attenuated walls are ruptured; sometimes the heart, from being overloaded and overtaxed, becomes paralyzed, and the patient dies from dilatation of the heart.

If he does not die, recovery of the heart's action is produced by an actual increase in the thickness of the ventricular walls-compensating hypertrophy, increase in the number of muscular tibres; so that, with an additional amount of fibre, it has, of course, additional strength, and is able to propel nearly or quite the same amount of blood through this constricted orifice that the normal and smaller heart propelled through the normal and larger aortic orifice. So with insufficiency of the same or any of the other orifices. Blood which should be forced forward, flows back, and, in order to overcome this abnormal state of affairs, we have, as before, after the inflammatory condition from which it arose subsides, a gradual increase in the thickness of the dilated walls-compensating hypertrophy-and the heart, with its additional size and strength, sends blood in quantities sufficient to supply the wants of the system.

The patient which I now bring before you says he is about thirty years of age, a stonecutter by occupa tion; that, until the date of seizure with the illness which caused his present serious trouble, he never had a sick day in his life; always well, always hearty and strong; accustomed to, and in the habit of, lifting heavy weights. He tells us that, on a certain occasion

some three years ago, while lifting a heavy stone, he felt something give way in his chest here, and places his hand over the præcordia, the region of the heart; that he felt almost unconscious; that he had violent palpitation and pain in this region; and that for weeks he was confined to his bed, all the time suffering from pain in this locality, palpitation, and shortness of breath; that he gradually recovered till he was able to leave his bed and his room, but from that time to the present he has been unable to resume his work, owing to heart palpitation and difficulty of breathing upon making the slightest exertion; that frequently he is seized with violent paroxysms of dyspnoea,or difficulty of breathing, accompanied by rapid and irregular action of the heart.

A few days since I saw him in one of these paroxysms, and can truly say it was the most distressing of the kind I ever witnessed. On that occasion I took a sphygmographic tracing of his pulse, which tracing, as well as one taken over the heart, I have in my collection. Finding it difficult, owing to the weakened action of the heart, to take a tracing at the wrist, one of the internes called my attention to quite a violent pulsation in the neck, which he supposed was a pulsation of the subclavian artery. Instead of being an arterial pulsation, I immediately pronounced it a pulsation of the jugular vein, which satisfied me that there was insufficiency of the tricuspid valves. Upon each systole, or contraction of the right ventricle, the blood, instead of freely flowing into the pulmonary artery, was forced, at least a portion of it, back into the auricle; a portion of the contents of the auricle was forced into the vena cava descendens, and with every pulsation the column of blood in the jugular vein received a concussion, which was visible in the neck. This alone, without any further examination, would have satisfied me that there was regurgitation at the auricular ventricular oifice of the right side of the heart; but, to satisfy myself still further, I placed the stethoscope over the lower portion of the sternum, the spot where the sounds produced by the tricuspid valves are best studied, and then I heard a distinct blowing murmur. Of course, no doubt could now exist, but, to be still better satisfied, I listened at the left edge of the sternum, in the third interspace, where the pulmonary valves are best studied, and there I heard this same murmur, commingled with another of a grating character. I carried my stethoscope over to the left side, between the seventh and eighth ribs, about two inches to the left of the mammary line, where I could see and feel the apex beat, and there Í heard another distinct blowing murmur, which I could also hear in the third interspace, at the right edge of the sternum, the spot where the aortic valves are best studied. This murmur I could also hear posteriorly at the left of the spinal column. What was I to conclude from this examination? My conclusion was that the sickness from which this man suffered after that terrible strain, was an endocarditis involving both sides of the heart; that the acute inflammation had subsided, but a chronic valvular disease had developed, resulting in insufficiency of both the tricuspid and mitral valves, with probable stenosis of the aortic and pulmonary orifices; decidedly the most aggravated case of valvular disease of the heart it has ever been my privilege to examine. I will ask this man if he has ever suffered from inflammatory rheumatism. He informs me that he has not; that he never had a day's sickness in his life till the illness that caused his present condition. Why do I ask him this question? Simply because endocarditis is, in nearly every instance, a complication of inflammatory rheumatism. You are aware that rheumatism is a blood disease; is owing to some poison circulating in the blood, which affects by preference the synovial membranes of the joints. It is supposed that this poisoned blood, in its passage over the delicate membrane which lines the heart, has

tion.

an irritating effect, which sometimes results in inflammation of this membrane-endocarditis. So let me caution you, gentlemen, when you are treating a case of inflammatory rheumatism, always to examine the heart daily for evidences of endocardial inflammaBut this patient says he never had rheumatism; that he felt something give way upon lifting a heavy stone. I believe something did give way; I believe there was a rupture of some of the chorda tendinæ, owing to this terrible strain; that an inflammation naturally followed, which has resulted in organic disease of the heart, involving every valve. Under the action of Digitalis vnd Cictus, and a quiet life free from care and exercise, this man has been kept comparatively comfortable. But he is liable to die at any moment from a sudden overfilling of the heart resulting in cardiac paralysis, or from pulmonary hyperæmia, or congestion resulting in oedema. I shall continue the remedies mentioned, the Digitalis to be taken as a steady remedy, the Cactus during the paroxysms. The next patient which I shall present to you is, as you see, a man of more mature years; larger in frame, apparently more robust than the other, but evidently broken in health.

He complains of shortness of breath upon taking active exercise, but not so severe as in the case just before you He says his feet and legs become considerably swollen each day, but that the swelling has apparently entirely disappeared in the morning after a night's rest in bed; that his appetite is good, his bowels comparatively regular; that he ur nates about three times a day, and passes what he considers a natural quantity.

In reply to the question, have you suffered from rheumatism (which question, I told you, should always be asked in suspected cardiac difficulties)? He answers, he has; that his first attack was when he was but nineteen years of age; that he has had repeated attacks from that time on, and that the last severe attack was in 1876; that, after recovery from that attack, he commenced to feel the heart symptoms which have incapacitated him for hard work since. Upon inspection you will see a pulsation, more properly a fluttering, in the left mammary region.

You will notice the prominence of the veins through out the entire body; the blue or cyanosed condition of the entire hand of both sides; a remarkable pallor of| the skin, showing an absence of a proper quantity of arterial blood on the surface Aside from the supra clavicular fossa on both sides being well marked, there is apparently nothing remarkable in the general appearance of the body.

Upon palpation, by which we simply mean feeling, we find that the pulsation so marked in the left mammary region is distinctly felt by placing the palm of the hand over that portion of the chest, and with the finger I can define the location of the apex beat, which in this case is between the fifth and sixth ribs, about an inch to the left of the nipple. In the other case, although the impulse of the apex was found to the left of the nipple, it was much lower than normal.

|

We will now proceed to percuss this man's chest, to see if we can find anything abnormal. Normal resonance, you will see, exists over the entire right side, with the exception of a dullness which we find along the right border of the sternum, from the upper border of the fourth rib to the end of the sternum. Percussion of the supra and infra-clavicular regions of the left side gives normal resonance, but, as you see, upon reaching the lower border of the third rib, a dull sound is imparted upon percussion. This dullness indicates the location of the upper border of the heart. As we reach the fourth rib, the sounds become absolutely flat, from the heart being in immediate contact with the chest walls. Taking the line of the apex beat, I find the dullness extends to a point corresponding to the spot where, from inspection and palpation, we found the apical impulse of the heart, which with the tape measure we find to be just four and a half inches from the median line.

What are we to conclude from this examination, so far as we have gone? Certainly that the heart is hypertrophied. But does that hypertrophy involve principally the right or the left ventricle? Most certainly the former; for if the left ventricle was princi-· pally involved, as I have just told you, the apex would be found to the left, but lower down than normal. In this case it is found decidedly to the left, but no lower than normal.

What do we find upon auscultation? A blowing murmur at the apex, with the first sound of the heart preceded by a roughened, grating sound. What are we to conclude from this? First, that there is regur gitation at the mitral orifice; second, that the auricular surfaces of the valves are roughened either by granulations or calcareous deposits.

At the lower edge of the sternum, where I told you the tricuspid valves were best studied, I hear another blowing murmur, evidently proceeding from the tricuspid orifice, upon placing the stethoscope in the third interspace to the left of the sternum. I can distinctly hear this regurgitating murmur with the first sound of the heart From this I conclude that this patient is suffering from insufficiency of both the mitral and 'ricuspid valves; the latter being more marked than the former. The second sounds of the heart, caused by the closing of the semi-lunar valves at the pulmonary and aortic orifices, I find to be normal.

As I told you in the former case, I saw a distinct pulsation of the jugular veins, owing to the tricuspid insufficiency. At present I can distinguish no such pulsation in the neck of this patient, owing probably to the feeble action of the heart.

Now, gentlemen, the valvular condition which we find in this case will account for all the symptoms we have detailed: the pallor of the skin, owing to the comparative empty condition of the arteries; the cyanosed condition of the hands; the prominence of the overfilled veins throughout the entire body; the coldness of the surface of the body, particularly the hands; the comparative shortness of breath; the feeble pulse; the oedema of the extremities-all arising from men chanical obstruction to the flow of blood. The obstruction is in the right side of the heart. The lungs are not well supplied with blood; hence the shortness of breath. The left ven ricle beats feebly and is poorly filled; a portion of its scant contents regurgiIn hypertrophy of the left ventricle the apex is found tates into the auricle, consequently but a comparative to the left, and lower down than normal. In hyper-ly small quantity of blood enters the aorta. trophy of the right ventricle it is found to the left of its normal position, but generally between the fifth and sixth ribs; sometimes even higher up than this. We find these cyanosed hands to be much colder than | the rest of the body.

You are aware, gentlemen, that in health the apex of the heart should be found between the fifth and sixth ribs, about an inch to the right of the mammary line, or a line drawn from the nipple down,

The

arteries are not well filled, sufficient nourishment is not supplied to the tissues, the pulse is rendered weak, and the skin is pale. That portion of the blood which should be in the arteries is found in the veins, producing the cyanosis, the prominence of the veins, the The pulse we find to be remarkably feeble and rap-coldness of the extremities, and the dropsy of the fee id, but regular. I have also a sphygmographic trac- and legs. ing of this man's pulse, which I took a few days ago, which confirms what I have just told you with regard to the pulse.

I told you these cases were peculiar. Why are they peculiar? Because the complicated condition we find

of is a rare one. Why is it rare? Because endocarditis enlarged last winter during an attack of cough, and rarely involves the right side of the heart in extra remained so for a couple of months. Never had uterine life. Mitral and aortic insufficiency and sten- jaundice. No œdema. 20osis is common enough, but it is exceedingly rare that To we meet with a case of cardiac disease involving the right side of the heart.

It is exceedingly rare that you meet with a case of → valvular disease of the heart that has not been preced Iled by an attack of inflammatory rheumatism, In the first case which I brought before you, the endocarditis, which was the undoubted cause of the valvular condition we found, was produced by an injury, a probable Orupture of some of the chorda tendinæ of the heart, owing to a terrible strain which overfilled the ventricles, bringing pressure to bear upon the valves sufficient to Is rupture some of these delicate tendinous chords, pro Jducing an endocardial inflammation, which resulted in chronic valvular disease. The same remedies which I gave in the first case, Cactus and Digitalis, have proved equally efficacious in this. These remedies

will be continued.

By G. C. BROWN, M.D., NEW YORK,

The post mortem showed a liver contracted to twothirds the normal, the right lobe marked by three prominent cicatrices, cutting into which, the knife passed through syphilomatous nodules of half an inch in diameter. Fully one-half the right lobe was thickly studded with smaller similar nodules, giving the characteristic appearance of syphilitic liver. Uterus a little enlarged with a fibroid in the fundus.

The lining membrane of the stomach gave marked evidence of ulcerative processes; pyloric orifice contracted; spleen slightly enlarged.

The intestines showed points of infiltration corresponding to the localized pain. The condition of the rectum was normal. Objections were made to a more complete examination. 100 to „ium s WITH COMPLICATION OF THE AXILLARY

SCIRRHUS OF THE LEFT MAMMÆ,

GLANDS.

BY PROF. C. H. VON TAGEN, M. D., CICAGO, ILL. Was consulted January 1877, by Mrs. Svi; aged Mrs. A., 51 years of age, was taken suddenly ill, 32, of nervo-sanguine temperament, medium stature, having the following symptoms: severe pain in the somewhat disposed to hysteria, and of English birth. stomach and bowels, attended with nausea, vomiting, She complained of a swelling in the left breast, accomand diarrhoea The matter vomited was green and panied with severe lancinating pains, always sharp watery, and very bitter; the fecal matter was dark and shooting, aggravated by damp weather,and brown and watery. The diarrhoea ceased in about worse at night; so much so as to disturb her rest, Ve sixteen hours; the nausea continued for four or five and prevent sleep. These pains extended up to the days. The stomach rejected all nourishment, and corresponding shoulder, and throughout the length of even the smallest dose of medicine would cause vom- the arm to the tips of the fingers. She first noticed iting, ice being the only substance tolerated. Hie-a small, hard lump, about eighteen months prior cough was a constant symptom; there was constant to the time stated; on questioning her as to the pain, located chiefly in the region of the stomach and cause, she stated she had received a blow on the part in and along the colon. There was moderate tympan some three months prior to the last period mentioned. itis. The highest temperature 102, in the after It was then about as large (the time she first noticed noon; lowest, 99, in the morning. Pulse never it) as a hazel nut, and was painless. It gradually above 104, and most of the time between 90 and 98; and steadily assumed larger proportions, until it the mind was clear to within a few hours of death; became about the size of an English walnut, when she the heart's action was good until within thirty-six experienced slight, pricking pains, and she likened hours of death; urine free and clear, and correspond-them to the sticking of needles, which increased in ing in quantity to the amount of ice eaten; the patient severity as the tumor grew larger, and as well at each lived eight days, nourishment and medicine being returning menstrual period. The period occupied by administered per rectum. these changes ranged over a term, as she stated, of about six months, when she conceived, carrying the foetus until this time. Premature birth occurred; the child lived only three weeks, dying of starvation, as the mother termed it, meaning the child could take no nourishment and digest it. She was confined to her bed from the effects of this pregnancy over seven weeks; was very much prostrated; her breasts secreted milk in slight quantities, and could not be made to do so sufficiently to nourish the child. Slowly but steadily the tumor in the breast increased, as also the symptoms in severity Within two months or thereabouts of the birth of the last child, she conceived again; while in the second month of this pregnancy, she accidentally injured the breast again, after which it took to growing so rapidly that the tumor attained the proportions of a small nutmeg melon Within ninety days later, all the symptoms increased in severity proportionately. This was the first time the writer saw the case, viz, January, 1877, when it presented the following general appearance: the patient looked caroworn, as if she had suffered severely gromplained of great nervousness of the entire system, loss of appetite. The tumor was red, inflamed, and sensitive to manipulation, slightly movable; nipplet retracted Slight nodulated appearance was apparent about the surroundings of this part, which bore the appearance of a threatening open ulcerationio Examination of the corresponding axilla novealedi implica eluq ft of

The patient's history previous to the fatal attack was one of long complaining, the symptoms ever changing, ever new; had been an invalid for twentyfive years; was married, and had five miscarriages and ... one child; patient contracted syphilis from husband over twenty years ago; two members of her family died of cancer.

She had tried physicians of all schools, change of climate, clairvoyants, and domestic remedies; ad in finitum, but slowly and steadily declined in health. Change of life took place between the age of 48 and I 50 years. About ten months ago she had a severe and protracted uterine hemorrhage; she was under old : school treatment for two weeks without relief. Sabina relieved entirely between 3 and 10 o'clock, and the hemorrhage never returned. Two years ago she had rheumatism in the knees and pains in both tibiæ, which were relieved by iodide of potash. Since then she has complained of chills, coming irregularly, and usually followed by fever, sometimes slight and sometimes quite pronounced. Her appetite was variable, and she always complained that a few mouthfuls of food filled her up. Her bowels generally regular; color of * skin, ashen; lips and tongue, rod; there was a gradual * loss of flesh during the past year. At times there have been pains in the right and left lumbar regions of the abdomen, so that the only position in which she could lie down was on the bank The cervical glands were

་

a marvelous change already apparent, the patient the erysipelatous condition entirely gone; suppuration having been unable, prior to the ten days of the pre- and pus laudable; re touched what was left of the paratory treatment referred to, to retain any food very slight points of attachment that still looked a of zinc. Reupon her stomach, from severe morning sickness that little suspicious, with the chlori she previously labored under. Her bowels, which dressed, using carbolized oil the same manner as formerly were very costive, were now disposed to before, giving Hepar sulph., 30th trit., internally; diet move regularly. There being no special symptoms re- generous. quiring treatment, excepting the dyscrasia, or taint of the system that induced the diseased condition, Conium mac., 30th trit. was ordered to be given every fourth or fifth hour, with a view to modify the pre-existing influence.

On the second day following operation, called again. Patient rested well during the previous night. Pulse 99, temperature 100,50, skin slightly feverish, tongue furred, other functions of the body normal (urine and stool), slight feeling of discomfort about the regions operated on. Dressings were removed, wounds thoroughly bathed with warm, carbolized The cut surfaces water, two grains to the ounce. presented a favorable appearance; symptoms of suppuration were present, and presented a healthy condition. Re-touched all the suspicious points with the chloride of zinc, and re-dressed same as before. With a view to promote healthy granulations, Hepar sulph., 30th trit., was ordered to be given every fourth hour throughout the day; diet continued as before.

Third Day.-Nothing of import to state, as matters generally were unchanged, as compared with the day before; treatment and diet continued; dressings were not disturbed.

10

Fourth Day-The patient complained of headache; slight thirst; pulse 101, temperature 102 5; sense of uneasiness; and general restlessness, accompanied with nervousness which the patient ascribed to a terrible dream she had the night before; otherwise she slept well; urine and stool normal; removed dressings, and found the wound presenting an erysipelatous blush at their margins, accompanied with burning sensation. Suppuration was proceeding favorably, no unpleasant odor being emitted. Bathed the parts freely with a solution of Sulphide of soda, ten grains to the ounce, and re-dressed with the same, ordering the parts to be kept constantly moistened; likewise gave same rem edy internally, 3d trit., a dose every three hours prepared in water.

Fifth Day.-Called at two P. M., and the following is the report for the day. The patient had passed a restless night, had much thirst, pulse 110, temperature 103°, skin hot, respirations 24 per minute, bodily functions otherwise favorable. Patient complained of burning and itching about the sore parts, which she attributed to the dryness of the dressings, the nurse having neglected to re-apply the solution as was ordered the day previous. Re-dressed after cleansing the wound in the same manner as before, renewing the internal remedy, and gave strict orders for the ful fillment of our instructions, believing that the aggra vations of the symptoms were due to the want of proper care on the part of the nurse.

Sixth Day-Called at 10 A. M.; found patient much improved; upon inquiry ascertained that our instructions had been literally fulfilled; this was also evident, judging from the improved state of affairs. Pulse 101, temperature 995, respirations nineteen per minute; skin moist, and nearly normal to sense of feeling; less thirst, and the wound was looking better; the local conditions were manifestly better. Renewed local and internal treatment same as the day before; diet same as before, except the addition of a small piece of rare, broiled steak and mashed potatoes, which articles the patient seemed to long for.

Seventh Day.-Patient and wound doing remarkably well; all seems to be going well; general condition about the same as the day before, rather better. Pulse 95, temperature, 98, respirations 18 per minute;

This treatment was continued day by day for a period of nearly two weeks, without any further important change to report, excepting a marked improvement in the patient's general health, and the wound, which we re touched every second or third day, at the points heretofore referred to, with the chloride of zinc. The wounded parts healed rapidly, filling in with healthy granulations, with laudable pus throughout, cicatrizing handsomely on the twentyfourth day after the operation.

The patient's health improved in the same ratio, gaining in strength and weight, and from all we could learn by physical examination, gestation was proceeding very favorably at this time. The patient was now put upon Conium mac., 200th, with a view to overcome what remained of the cancerous diathesis.

As time wore on, and the period of confinement had arrived, the general health of the patient improving meanwhile, she bore a healthy looking and well developed child, passed through her after-confinement illness without any drawbacks, and up to this present period, August, 1879, after the lapse of two years and seven months, there has been no vestige of a return of the malady. Both mother and child are still enjoying good health.

It is a fact worthy of note in this instance that the right breast of the patient (this is not the first or only case in the writer's experience) assumed double its former proportions during the period of lactation, and furnished sufficient nourishment for the wants of the child; for, be it remembered here that in her former pregnancy, and before her left breast was invaded to any extent, both breasts failed to secrete to any extent. Up to present date of writing, October 4, 1879, both mother and child are enjoying good health.

REPLY TO DR. W. C. GOODNO'S CRITICISM
OF" FRACTURES OF THE FEMUR," Etc.

BY PROF. C. H. VON TAGEN, M. D, CHICAGO. Dr. Goodno, in his article in the Hahnemannian Monthly, entitled "Fractures of the Shaft of the Femur, Etc.," which appears to be a criticism of an essay of mine upon the same subject, says:

I object, first, to the adoption of, and rigid adherence to, any single method of treatment of fractures of the femur, or of any other bone, as unscientific and unsurgical."

In reply to this objection-when a method presents itself which fulfills the indications and requirements of one or many cases, and terminates satisfactorily with more favorable results than is attained by any other method, especially when all other plans are familiar and have been witnessed with not such satisfactory effects, he who resorts to any other is a base experimentalist, and the charge of unscientific" and "unsurgical" recoils upon the author of the assertion. The old adage of "letting well enough alone" is a good one, and we propose to abide by it until a better one with more favorable results is presented.

To the second objection, which, for its lengthiness. we will not quote here, we reply: the gentleman had better refresh his memory; when he states that the semi-flexed position on a double inclined plane dates back to the time of Hippocrates, or that Pott had any thing to do with it, he is incorrect. Sir Charles Bell, one of Old England's best and most noted surgeons, as we distinctly stated in our article, and will adhere