fibrous, in which state it is quite impossible to determine their thickness with accuracy.

Notwithstanding the greater variation which occurs in the different measurements of the thickness of these large cartilages than of others, it will be found that there is nothing, either in these or in the smaller variations, observed in the other instances, nor yet in the whole series of measurements, which will warrant the conclusion that these structures become gradually thinner as life advances, nor even that they are thinner in the aged than in the young person.

From a conversation with Mr Toynbee on the statement made in his paper before referred to, I found that his evidence on this matter had been derived from the observations and statements of others, rather than from measurements or observations of his own, and thus I believe that he has been thrown off his guard, and made to appear as the author and supporter of a statement which, under other circumstances, his habitual care and anxiety to arrive at the truth, would effectually have prevented from being made in so definite a

manner.

In conclusion, I may state my conviction, founded on the measurements indicated in the table appended, that articular cartilages do not become gradually thinner as life advances, and that they are not uniformly thinner in aged persons than in early life. I may also remark that, in endeavouring to estimate the thickness of articular cartilages at different periods of life, I have had presented to me a large amount of evidence in addition to that which I formerly made public, that, as life advances, these structures, and especially those of certain joints, change their elementary characters, and become fibro-cartilaginous, or altogether fibrous. This change has its analogues in the conversion of the costal cartilages into bone, of tendons into fibro-cartilage and bone, and in those changes which age induces in the bones generally, in the cornea and other tissues. It may not improperly be styled senile degeneration of cartilage.

ARTICLE V.-Remarks concerning the Diastolic Mitral Murmur. By W. O. MARKHAM, M.D., Assistant Physician to St Mary's Hospital.

It has often been to me a matter of surprise that a diastolic mitral murmur should be freely admitted as a well established and frequently met with fact, by writers on the Continent, and that our own authors upon diseases of the heart should either have placed it aside, as being of excessive rarity, or have altogether denied its existence. Dr Latham speaks of such a murmur as a sort of clinical curiosity; and he observes "that it would almost seem that the

mitral orifice could be the seat of only one murmur, and that murmur the systolic ;" and his opinion is more or less typical of the opinion of those of his countrymen who have followed or preceded him. Lænnec, Bouillaud, and the best observers in France and Germany, on the other hand, admit the existence of the murmur without hesitation, and write of it as a thing regularly established in the clinical history of disease.

Three cases of cardiac affections have lately come under my notice in which I have been compelled, after the most careful and oft repeated examinations, to assign the origin of the morbid sounds heard to the mitral orifice, and their coincidence in time to the diastole of the heart. These cases I will briefly relate, premising that, in every instance, I did not trust to my own ear alone, but obtained the assent of other capable observers; the difficulties of auscultation being, in my judgment, of much too overwhelming a character ever to warrant any ordinary observer speaking freely upon his own authority of a disputed point in stethoscopy.

The first case was that of a man who had long suffered from rheumatic gout. A soft murmur, distinctly falling in with the heart's diastole, was heard over the left side of the heart, beneath and to the outer side of the nipple; the sounds over the aortic valves and along the aorta, and down the sternum, were distinct and clear and natural. The murmur was permanent, for it remained when the symptoms for which he had presented himself for treatment had disappeared, viz., dropsical effusions and short breath. Am I not justified in attributing such a murmur to some roughnesses about the auricular surface of the mitral valves, or to some contraction of the mitral orifice? What other account can be given of it?

The second case is of a still more positive nature, inasmuch as the pathological conditions discovered after death fully bore out the diagnosis made during life. It is interesting also in another sense, because I think it perhaps gives some explanation of the reason why the murmur I am writing of is so seldom recorded; a reason to be found in the extreme difficulty of, and caution requisite in, its diagnosis, and particularly as regards fixing it to its proper coincidence with the diastole of the heart. I have, on more than one occasion, seen experienced observers mistake the first for the heart's second sound, when the action of the organ was great, and its sounds unnatural, and have frequently fallen into the same error myself. If the heart's beats exceed a certain number in a minute, I believe it is almost impossible, without at the same time feeling the arterial pulse in the neck, or the impulse of the heart's apex, to say which is the systolic, and which the diastolic sound; what the number of the heart's pulsations is, which so confounds the sounds and perverts the periods of their intervals, it is not possible to state, for it naturally has a relation to a variety of circumstances to which I need not here refer, and may be therefore greater or less.

The subject of this case, a girl about 17 years of age, was for

many months previous to her death constantly under my observation. She had long suffered from difficulty of breathing, and throughout her illness this was her prominent source of suffering; slight exertion increased the accustomed violence of the heart's action and the force of the respiratory movements. The signs I am about to relate were constantly present, but in a more or less marked degree, according to the action of the heart; a strong and prolonged vibration was felt where the heart's apex beat (which was to the left of the nipple), producing a distinct frémissement cataire. There was a loud and prolonged murmur over the precordial region, loudest over the left side of the heart, and most concentrated at its apex, becoming weaker as the stethoscope was removed further from that spot. This murmur was sometimes high-pitched and musical, as though produced by the continued tension and vibrating of a membrane, sometimes it was deeper and rougher, and this, I think, generally when the heart's action was slower; no bruit was heard along the aorta, and its sounds were audible. The rhythm of the heart's movements was entirely perverted, the movement, associated with the murmur, occupied nearly the whole of the time of the systole, the diastole, and the interval; the impulse-that is, the first sound-immediately followed the cessation of the murmur, or rather seemed to be its conclusion, and suddenly to wind it up; it was brief and instantaneous, and, after a very short pause, followed by the recommencing murmur. My examination of this case was very frequent, and careful, and minute, and I therefore speak with some confidence as to the correctness of the facts observed; and I will add that others, among whom it is sufficient to mention the name of Dr Sibson, admitted the propriety of the murmur being considered diastolic, though expressing differences of opinion as to the morbid state producing it-my own diagnosis, resting on the general symptoms and local signs, was contraction of the mitral orifice. The rapidity of the heart's action necessarily rendered the investigation difficult, but if we are to take as a settled canon that the impulse of the heart's apex is coincident with the first sound, and this we must do, unless we reject one of the best established facts in physiology, then I see not how we can for a moment refuse to admit that a murmur which precedes that beat must of necessity be diastolic. In this case, however, therapeutics came to the aid of diagnosis. Under the influence of digitalis, and through a moderate dose of it, her pulse fell to about 40; and now there was no difficulty whatever in analysing the sounds and murmurs of the heart, and the diastolic nature of the murmur was placed beyond doubt. I should mention that the frequent attacks of hæmoptysis to which the girl was subjected, and the constant oppression of the lungs, reasonably confirmed my diagnosis, by indicating the immediate nature of the impediment to the flow of blood from the lungs; the freedom from dropsical symptoms also suggested that the impediment was most probably not on the right side of the heart.

The girl, at her own request, left the hospital; but the exertion of removal overcame her, and she died a few hours after reaching her home. Mr Trotter, the house-surgeon of St Mary's Hospital, obtained her heart, and gives this account of its state: the mitral orifice was represented by a small slit-like opening, the segments of the valves being thickened and adherent; the aortic valves were healthy; the heart large; the right ventricle hypertrophied and dilated; the left dilated, but its walls not thickened.

The third case, which I have still under observation, presents general symptoms very similar to those in the last case, but in a much less marked degree. There is a slight frémissement perceptible at the heart's apex; the bruit heard immediately precedes the heart's impulse, this seeming to conclude it; it is not heard along the aorta, or over its valves; the pulse in the carotids and its branches is very weak. This girl I have still under observation; and I should observe that, in her case, difference of opinion has been held as to the nature of the murmur, though none as to the fact of the bruit preceding the beat. Slight exertion produced difficulty of breathing; and, lately, hæmoptysis has taken place. If this be not a diastolic mitral murmur, it seems to me impossible to give any account of it. A consideration of these cases, of the pathological states which produce the murmur under discussion, and of the unhesitating manner in which some of the best continental writers speak of it in their text-books, has inclined me to the belief that there must be something erroneous in the views which we take of it in this country; and I will presently suggest what are, in my opinion, the possible sources of the error.

How can be reconciled the statement of Dr Walshe, "that he does not ever remember to have observed cardiac thrill synchronous with the ventricular diastole," with the history of two of the cases I have described, and with the statements of men like Hamernjk, and Skoda, and Corvisart? "When the contraction of the mitral orifice is great," says Hamernjk, "the second murmur is long and loud; and some portions of it are louder than others, producing the hum of a spinning-wheel, and so has been taken for a double sound. Such a second (diastolic) murmur is protracted, and ends in the systole; there is a distinct pause between the systole and the diastole of one complete heart's movement, but none between the diastolic and recurring systolic murmurs." How exactly does this account agree with the description of the second case given! "It is especially," says Skoda, "in cases like these that vibrations are felt when the hand is laid upon the precordial region-the frémissement cataire described by Lænnec." "It is a common opinion," says Professor Jacksch of Prague," that a fremitus which is felt at the apex of the heart, and which accompanies the diastole, is a pathognomonic sign of an obstructed mitral orifice."

Corvisart speaks, when relating of contracted mitral orifice of the "bruissement particulière, difficile à décrire, sensible à la main ap

pliquée sur la région précordiale,” etc. Are all these authorities mystified?

Now, I will venture to offer, as explanatory of such great contrarieties of opinion on a matter of fact, two suggestions which seem to me reasonable. The first is, that, from the rapid and tumultuous action of the heart in advanced conditions of the disease, from the complete change in the rhythm of its movements, from the altered character of its sounds, and from not fixing the exact time of the heart's systole by feeling its beat, a diastolic has been often mistaken and set down for a systolic murmur. The next suggestion is, that we have approached the subject with preconceived physiological ideas, and have prejudged the question, and wrongly." Thus," writes Dr Latham," the blood glides into the ventricles without any impelling force from behind," and therefore the onward current of blood is still without noise. Dr Williams, who says that the murmur is of excessively rare occurrence, explains it by supposing the left ventricle to be much thickened, and so to have gained diastolic elasticity, and "to suck the blood from the auricle with some force;" but, in one case I have related, the left ventricle was not thickened, though the diastolic murmur was exceedingly loud. Few persons will, I suspect, accept this explanation. The want of an impelling force to drive the blood through the contracted orifice has likewise been, with many other writers, a generally adopted axiom, by which observers have manifestly allowed their judgments to be guided; is it a true one? It is impossible to discuss the question here; but I will remark that Hamernjk, in his "Researches," etc., has proved to my mind beyond all doubt, by his observations and lucid reasonings, that the actions of the respiratory forces are, especially in cases of impeded circulation, and therefore markedly in contraction of the mitral orifice, brought to bear with great energy upon the movement of the blood, and are quite sufficient to account for that character of the murmur which gives to the ear the idea of fluid being forcedly driven through a narrowed aperture. I cannot but think that further investigation will show, that in this instance, as in so many others, the philosophic thought of Corvisart has found an exemplification: "à combien d'erreurs, même grossières, ne serait pas continuellement exposé celui qui atteindrait ainsi les phénomènes morbifiques aux notions de la physiologie, et qui trouveroit sans cesse dans ces notions, trop souvent hypothétiques, la connaissance des phénomènes qui doivent charactériser telle ou telle affection!"

It may perhaps be suggested, that, after all, it is a matter of little consequence in practice whether the murmur heard be systolic or diastolic. To this I will answer, that diagnosis cannot be too minute so long as its minuteness is capable of distinct appreciation, as I affirm it is in the present case.

As a resumé, I maintain,

1st, That a diastolic mitral murmur is not so rare a phenomenon as it is generally held to be.