of the left apex, often accompanied by a thrill. Such are the leading features. The case may get worse steadily, and even with considerable rapidity; or, as is more commonly the case, the patient is fairly well when quiet, but effort produces distinct shortness of breath, with palpitation. Anything which impairs the strength may elicit some cedema. But though the organism is crippled by the injury done to the mitral valve, the injury itself remains static, and manifests no tendency to go on from bad to worse; or if it does, it is immeasurably slowly. In such a case the administration of digitalis and iron would be likely to be of distinct service. Now, as to the mitral stenosis of the gouty heart. Here there is a permanent high-blood pressure in the arteries, leading to hypertrophy of the left ventricle, with subsequent hardening of the arteries; the cardio-vascular changes which constitute the first stage of the granular kidney, so ably described by Dr. Mahomed in his recent thesis "Chronic Bright's Disease without Albuminuria." The hypertrophied ventricle contracts with vigor, so overcoming the resistance offered by full arteries to the cardiac systole, and forcing the blood into the aorta, which on its recoil closes the aortic valves with a loud sound indicative of forcible closure; and this forcible closure frequently sets up valvu litis, with subsequent mutilation of the aortic valves. This association of aortic disease with a gouty heart is now well recognised. But the powerful contraction of the hypertrophied left ventricle causes also forcible closure of the mitral valves; they have to sustain a strain equal to the force required to overcome the resistance of a full aorta, and this strain tells upon them in time, leading to sclerosing endocarditis. Such valvulitis may give either stenosis or insufficiency of the mitral valve. When the free edges become puckered or contracted, then insufficiency with regurgitation follows; when the valve curtains are soldered together by a slow inflammatory growth extending from the attachments of the valve, then stenosis with obstruction is the result. Now, whatever the form assumed by the valvulitis, the features of the gouty heart will remain to the end; even when all the phenomena of advanced mitral disease are developed and implanted thereon. The aspect is never that of a simple primary mitral stenosis; nor does the interest centre round the murmur evoked by the morbid process, but attaches itself rather to the associated general condition of the vascular system. stage in all probability. It is no part of the design of the writer here to discuss the early stage, but to confine himself to the consideration of stenosisi. e., of a stage so advanced that it carries with it a murmur indicative of the character of the injury done. What are the features of this form of mitral stenosis? The patient is elderly; has a more or less pronounced senile aspect. The complaint is that the power to undergo exertion is impaired. There is shortness of breath upon effort. There may be nothing more. The pulse may be feeble and rapid, but there is nothing else about it, nothing characteristic. But on auscultating the heart over a very limited area, at or near the right apex, a tiny "whiff" can be caught. Only over a small spot; move the stethoscope ever so little and it is apt to be lost; certainly lost if the stethoscope be distinctly moved. Here the presence of a murmur is significant, and unmistakeable enough; at least in the majority of cases. But there is also a strong heart very commonly, and a fairly full artery-i. e., there are the associations of a gouty heart along with the mitral stenosis. Usually the nature of the cause of the murmur is clear and patent, and not a matter for reasonable doubt, as in the case given above. Here is a distinct explanation of the failure of power complained. Or there may be a more advanced condition attained before the case came under notice, and the patient is confined to bed with or without some positive patch of pulmonary congestion. But there are the significant murmur, the rational features of mitral disease, linked with the cardio-vascular changes of the gouty heart, or granular kidney, as the case may be. The diagnosis bears on the prognosis and the treatment, especially as to the administration of digitalis. Here there is not an old-standing limited injury to valves, as static and non-progressive as the scar of a burn; limiting the patient's powers, but possessing no tendency to further advance. There is a contracting or sclerosing valvulitis afoot, which tends to go on from bad to worse, because the mitral valve has to bear the strain put upon it by a hypertrophied left ventricle. It is a progressive form of valvulitis. Certainly; but granting that, at what rate is it progressing. Quien Sabe!" as the Spanish girl said when they asked her who was the father of her child." (Kingsley). One would like to know, but how can one can get to know? Only, in the language of Oliver Wendell Holmes, by "getting an arc big enough to determine the size of a circle"-i. e., getting a period A certain amount of injury to, and deformity of, of observation long enough to calculate the rate of the valves has gone on before it is sufficient to progress. This may entail personal observation, produce a murmur. But there may be the ration- or may be fairly made out by the history of the al symptoms of a mitral lesion before the ominous case. In one case there can be a definite date murmur is set up. It may be possible to "sus- made out, since which there has been such a fallpect" a mitral valvulitis before the tell-tale murmuring off in the patient as reveals pretty plainly the can be heard; there is indeed a pre-murmuric time when the lesion began to tell upon the organ 66 6 ism. In another case there will be no data point-, tainly; and therefore grave and valid doubts may A gentleman, aged sixty-seven, who had led an active life, but who latterly had pains which he called "rheumatic," though, he wrote, "his water is more or less high-coloured, and the red sediment is always round the bottom of the pot," which looked like gout-came to me for some "fluttering or palpitation" at the heart. The diagnosis then made was 66 gouty heart, with mitral stenotic murmur." He was put upon a pill containing some strychnia and digitalis. On this treatment he lost his uncomfortable sensations, and felt very nicely. He went abroad for some time, being conscious of his heart only by some shortness of breath on attempting to climb a hill. A year later he was nicely; his tongue clean, and urine clear; not perceptibly worse. This June he presented himself after an attack of bronchitis, which had pulled him down considerably. The heart was acting irregularly, and the beats were unequal in force. This was due to muscular debility in the heart, the right heart having been severely taxed by the extra demand upon it made by the bronchitis. He had been given carbonate of ammonia, nux vomica, and digitalis by his medical man, according to the formula at p. 367 of the "Practitioner's Handbook of Treatment" (2nd edition), which had suited him well. Indeed, he feels so well that he will not give the heart the rest required for it to recover itself. On his old pill he is doing well, and the muscular tone of the heart is being regained.1 Even with the recent demand upon the heart there is no evidence that the mitral lesion is perceptibly advancing. In some other cases the inactivity of the valvulitis seems about the same; but in others, again, the progress has been steadily, if not rapidly, downwards. In one case there are violent paroxysms of angina pectoris present. Το As to the treatment of these cases, the prevention of the production of uric acid by an approximate dietary and the use of hepatic stimulants, its solution by antilithic alkalies, are measures about whose adoption there can be no question. keep the blood-pressure in the arteries as low as possible means lessening the strain on the diseased mitral valves on each ventricular systole; and this is attained by reducing the amount of albuminoid waste in the blood, or dissolving it and so letting it escape by the water emunctories. So far so good. But how about the administration of digitalis? To increase the vigour of the ventricular contractions means increase of the strain on the valves. Cer I Since writing the above he has had some distinct gouty symptoms. Pro ORGANIC MURMURS OF THE HEART. CLINIC, BY AUSTIN FLINT, M.D., NEW YORK. I proceed now to the subject proper of my remarks to-day, and I will say in the outset that I assume that many of you have already given considerable attention to the study of endo-cardial murmurs; but although this is the case, I think it will be of service to you to go over the ground again, since it is important that you should have this knowledge so readily at command that you can bring it to bear in a practical way at any moment. No apology is necessary, therefore, for introducing this subject. The most important endocardial murmurs which we meet with are in connection with the left side of the heart, those of the right side being so comparatively rare that they are of much less practical significance. The murmurs which we will study to-day are four in number, two in connection with the mitral valve, and two in connection with the aortic. The first murmur to which I direct your attention is the mitral direct or obstructive. It is also called the mitral systolic from the time at which it is heard. The second murmur is called the mitral regurgitant, and signifies, as the name denotes, insufficiency of the mitral valve and consequent regurgitation from the left ventricle into the left auricle. The first murmur in connection with the aortic valve is the aortic direct. It may imply an obstruction, or if not this a certain amount of roughness of the surface over which the blood passes. The second murmur is the aortic regurgitant, which involves of necessity insufficiency of the aortic valves with resulting regurgitation from the aorta into the left ventricle. It is a matter of importance, I hardly need say, that all should acquire the ability to recognize each of these murmurs when occurring alone, and also when in combination. All four of them may be met with in the same individual, and we should be able in such a case to differentiate the several murmurs. This knowledge involves, in addition, a recognition of what these different murmurs de note. In the first place, then, how are we to distinguish the several murmurs, singly or in combination? By way of preface I may remark that every adventitious sound about the heart is called a murmur, the word murmur being always used in this connection in a conventional and technical sense. The regular heart sounds themselves, although certain modifications are noted in them also, are entirely distinct from these. These murmurs, as sounds, present differences among themselves. Thus they may be either loud or faint, soft or rough. They are said to be soft when they sound like a current of air passing from a bellows. When they have not this bellows-like character they are called rough, and if the roughness is quite marked they are sometimes designated as rasping. Again they are sometimes characterized by a distinct musical note. There are, then, three kinds of murmur as regards the matter of sound, soft, rough, and musical. The sound of the murmur, however, gives us no information as to its origin. Any of the four murmurs pointed out may partake of either of these characteristics. Let us proceed, then, to inquire by what points we may recognize the several murmurs, and differentiate them when they are found in combination. This inquiry can be best answered, I think, by a reference to the case of the woman whom I now bring before you. In commencing an examination of the patient, I will call your attention first to the marked pulsation noticeable in the arteries of the neck. This sign, I may say, in passing, indicates, as a rule, aortic regurgitation, but we need not, of course, base our diagnosis on this alone. In auscultation of the heart the stethoscope is better than the unaided ear, as it serves to localize the sounds more satisfactorily. Now placing the stethoscope at the second intercostal space on the right side of the chest, but quite near the sternum, I get a distinct rough murmur. My first inquiry in connection with it is, With which of the two heart sounds does it occur? I find that it is connected with the first sound, and it is therefore a systolic murmur. Suppose, now, that I had some difficulty in determining the heart sounds, which might occur, for instance, with great rapidity and irregularity of action. In that case I might place my finger over the carotid artery while listening to the heart, which would give me the desired information, since the carotid pulsation corresponds with the first sound of the heart. Or I might place my hand over the apex of the heart, and if I could then connect the murmur with the heart impulse, which is synchronous with the first sound, I would know that it was systolic. On further auscultation I find that this murmur cannot be heard much below the base of the heart, but when I carry the stethoscope up to the neck I get a murmur which corresponds exactly to that heard. at the second intercostal space. We have, then, a rough murmur at the base of the heart, which is systolic, and which is propagated to the carotid artery. The diagnosis, therefore, is a direct aortic murmur, due either to obstruction or to roughening about the aortic orifice. It is possible, however, that this may be an inorganic murmur, due to some abnormal condition of the blood, but as we shall not have time on the present occasion to enter into a discussion, we will assume that it is organic in character. While listening to the heart in this same situation I recognize a second murmur, which I can very readily distinguish from the other because it follows the latter, and that not continuously. There is a little break between the two, and I find no difficulty in determining that this last murmur is coincident with the second sound of the heart. If, as is sometimes the case, the second sound could not be made out, the interval would be sufficient to indicate that it occurred at the time when the second sound was to be expected. I find, furthermore, that the murmur is propagated almost down to the apex, which shows that it is due to an insufficiency of the aortic valve. If the valve is sufficient or adequate, as we say, there can, of course, be no regurgitation, but if there is regurgi tation the blood in thus flowing back always give patient. Here, as before, the loudness and quality murmur. I next go down to the apex, wherever that may be. The rule is, that the point where the lowest appreciable impulse is found is the location of the apex; although it is often the case that we get a stronger impulse at other points than this when the heart is enlarged and the shape of the organ altered. One reason for this is that as the heart enlarges it pushes away the lung, and so comes nearer to the chest wall. You must bear in mind, however, that the lowest point of impulse is always the apex, whether it is in the normal position for the apex or not. As you are aware, we listen at the apex for mitral murmurs, and now placing the stethoscope at the apex in this case, I find a murmur which occurs just before the first sound of the heart. There is no difficulty in determining its relation to the first sound, since the latter is always synchronous with the impulse. This murmur is short, rough in character, and can be heard only over a very circumscribed space. It is worth while to note also that it ends abruptly with the first sound of the heart. From these points I know that I have here a mitral direct, obstructive, or presystolic murmur. This is a murmur which precedes the first sound of the heart, and is usually rough; the roughness being of a peculiar quality, which is described as vibratory. This vibratory character is due to the causes of the murmur, which we have not time to investigate minutely at present. I can only allude in passing to the fact that there are usually adhesions, which produce certain changes about the orifice. Moreover, while listening to the apex I get still another murmur. This one begins with the first sound of the heart, and is of a soft and blowing character, so that it is readily differentiated from the other. An additional characteristic of it, in contradistinction to the latter, is that it is propagated laterally around the chest as far as the scapula. From these points we diagnosticate a mitral regurgitant murmur, so that we find all four of the murmurs which I have mentioned, present in this There is one point to which I will now call your On There are some points of interest in connection with the history of the case to which I will now direct your attention. The patient is a native of Ireland, twenty-eight years of age, and she is an embroiderer by occupation. She was admitted to the hospital two days since. Ten years ago she had a very severe attack of acute articular rheumatism (the first in her life, as far as we are able to ascertain), and since then the attack has been repeated regularly every spring, although with diminished intensity. About five years ago she began to suffer from palpitation, and more recently from dyspepsia, which has increased very much during the past year. Her feet have been swollen at times, and she has also suffered from dimness of vision. Her urine is now of a specific gravity of 1010, and contains no albumen. Of course, it is impossible to say with which of the attacks of rheumatism she had endocarditis. This certainly occurred with one of them, and may possibly have done so with all. As this complication is most apt to occur with a severe attack it is probable that she had it with the first. Another thing that renders this probable is that the symptoms of which she now complains commenced five years ago, and, as a rule, endocarditis does not produce these symptoms of distress until several years have elapsed. A few words now as to the subsequent history of the case. Although the patient has the 1 four heart murmurs, I think the reason that she is suffering more than usual at present is because her general health is run down to a considerable extent. Perhaps there is no condition in which the system is so tolerant (if otherwise in good conditlon) as organic disease of the heart; and I think that after this woman has enjoyed a season of rest, with the best nourishment and appropriate tonics, she will feel wonderfully better in every way. This is an important practical point, but I cannot enlarge upon it at present. Our next patient, a man in advanced life, as you see, has another serious trouble besides that of the heart, namely, locomotor ataxia; but I do not propose to discuss the latter on this occasion. I believe, if I remember rightly, that he has all the four murmurs also. On applying the stethoscope to the second intercostal space, a little to the right of the sternum, I find, as before, two murmurs, one with the first, and one with the second, sound of the heart. He has, therefore, both aortic obstruction and regurgitation. Again, at the apex there are the same two murmurs as in the other patient; so that here is a second instance of all the four murmurs existing in combination. I will call your attention in passing to the fact that notwithstanding he has all these murmurs the patient suffers very little from the condition of the heart. What gives him all his trouble is the locomotor ataxia.-Boston Med. Journal. ARTHRITIS OF THE TEMPORO-MAXILLARY ARTICULATION. Dr. Goodwillie, of New York, Archives of Medicine, gives the following history and treatment of this affection : Arthritic inflammation may be of a local or constitutional character. The former may be excited by dislocations, blows, luxations, or any lesions in neighboring parts. In the latter by some blood poison, viz.: syphilis, rheumatism, gout, scrofula, etc., and as such must have disease medicines that are antidotes or specifics to the particular blood poison. It is my desire to call attention to my method of producing extension in acute inflammation of this joint from either of the above causes. A. P. B., of Hanover, N. H., 60 years of age, was brought to me by the late Prof. A. B. Crosby, M.D. He had been a man of very robust constitution, but for the past two or three years had suffered with attacks of gout, and was now certainly an object of pity to look upon. The gout from which he had suffered came with terrific violence in both temporo-maxillary articulations, and when he came into my office his teeth were chattering, like one in a malarial chill, from excessive irritation and spasm of the muscles of the jaw. This caused great pressure on the inflamed articular sur faces, and gave him excruciating pain, so that he got no relief except from the effects of morphine, hypodermically administered. The arthritis was preceded by neuralgia of the inferior maxillary nerve. On examination of the mouth, I found that his teeth had no decay in them, but some were very much worn by mastication upon the crowns, and some pulps (nerves) were exposed, and in consequence he had pulpitis, causing neuralgia that was followed by acute arthritis. In the treatment nothing could be done with him except under the effects of morphine and an anaesthetic. On entering my office, a hypodermic dose of morphine was administered, and when under the effects of the drug, he was given nitrous oxide as an anesthetic. This relieved him from pain, while consciousness to some extent remained. The pulpitis. the exciting cause of the facial neuralgia, was removed by protecting the exposed dental pulps (nerves) from the air and attrition by means of gutta-percha and an interdental splint. The principle of the treatment of arthritis in these joints is the same as in others, differing only in the method of application. I do not know that any extension appliance has ever been used for the relief of arthritis of this joint. The method that I employ is as follows: In this case the patient was under the anaesthetic effect of morphine and nitrous oxide. If there is any rigidity of the muscles, cautiously force open the mouth and take an impression of either the upper or lower teeth, and a rubber splint is made from the cast to cover over all the teeth in one jaw. Upon the posterior part of this splint is made a prominence or fulcrum (D), so that when the mouth is closed the most posterior teeth close upon it, while all the anterior teeth are left free. The next step is to take a plaster of Paris impression of the chin, and from this make a splint (A). On each end of |