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the same of amnesia has been recorded illustrating degree FURTHER by Dr. P. J. Cremen,50 the essential details of which are asON( FUNCTIONAL MURMURS: A follows. CONTRIBUTION IN ILLUSTRATION OF CASE 21.-The patient, a man of intemperate habits, was admitted to THE MIMICRY OF ORGANIC HEART the Cork North Infirmary on April 10th, 1885. He was the subject of aortic and mitral disease, fully compensated, which had followed an DISEASE. attack of rheumatic fever in childhood. About October, 1883, he suddenly became giddy, with loss of speech, but no paralysis of limbs. BY DAVID DRUMMOND, M.A., M.D. DUB., D.C.L. DURH., same and five He continued to work during the day, during months SENIOR PHYSICIAN TO THE ROYAL INFIRMARY, NEWCASTLE-ON-TYNE. his speech slowly improved very much. "He now commenced to .do some light work, being able to make himself understood fairly well, occasionally using one word fo: another." About Christmas, SINCE my paper on Functional Heart Murmur appeared in 1884, on awaking one morning, he was surprised to find that he THE LANCET of July 27th, 1895, I have met with a number had lost the signt of his left eye. (This was subsequently found to be due to embolism of the central artery of the retina.) " He ofC additional cases illustrating the difficulties attending the - continued otherwise the same as regards speech, until about four weeks( of heart disease. A few of these I have selected before after a hard whilst in the act of diagnosis admission, when, day’s work, . holding a candle, he suddenly allowed it to drop and commenced to cry. 1in order to call attention once more to the frequency with His speech again became very imperfect and his face was slightly whichB functional disturbance simulates organic mischief. .drawn, but there was no appreciable paralysis of limbs." Since then no r The’ is of and I am the more change had taken place in his symptoms. On admission volitional subject great importance, ( to speech was much affected. When asked of what he complained hedisposed pursue it because of the interest shown by a pointed to his left temple and said he had a pain there, and on being numbert of thoughtful clinical observers who noticed the asked if was it constant he said not. He also pointed to the left eye, paper. I ventured to refer to three varieties of functional ,and indicated that he could not see with it. His memory of names, I the cardio-hæmic or the cardio- places, and things was very defective. He did not recollect the names murmur-namely, anaemic, of his father, mother, or other near relatives. When asked to try, hemuscularI or neuro-typtic (so-called), and the cardio- made an effort to do so, sometime3 repeating his own name instead, respiratory. To this nomenclature I am disposed to adhere, that he was When he ,evidently knowing wrong. corrected, repeated 1 I am free to admit that the offered the name distinctly, having no difficulty whatever in articulation, the though quite explanation latter being very distinct. When asked to name the organs of senseof the murmurs may not be entirely correct. In some he called the ear a " hair-pin," and named correctly the nose and respects the appended cases resemble closely those alluded tongue ; he did not recollect the name of the eye, and called this also to in my first paper; in others they differ, and chiefly in the ’’tongue"; but when corrected said, "Yes, eye; that’s right." When further questioned he became confused, calling nearly everything point of time that the murmurs occupy in the cardiac cycle. that was shown to him ",tongue." His vocabulary was, however, liable CASE 1.--A man, aged fifty-two years, a life-long neurotic, to variation from day to day. When asked to repeat the Lord’s Prayer who lived in dread of the development of organic disease, he failed to do so, but repeated another prayer instead; however, when of after loss of iven the first sentence he repeated it through correctly. His under- complained dyspepsia, pain food, flatulency, standing of spoken and written language was perfect. He could repeat appetite, some reduction in weight, palpitation, and a sense .accurately and quickly words spoken before him. Notwithstanding this of general weakness. The heart rate averaged 85 ; the apex he could read and great defect of memory of words, aloud clearly dis- beat was in the fifth about half an inch to the without a of a book from to end. The interspace, tinctly, hesitation, page beginning left of the usual On auscultation at the following composition, in which it is impossible to discover any position. apex the meaning, was written by him at my request as the history of his first sound was reduplicated ; the second part of the double .case: "Cork Molens.-I noscent nountg ani ammbys gosisbyoyey sound was little more than an echo, and was followed - imitwats I bet me sent sml me me much yab yas you good cocleped." a well-marked which He wrote his own name and residence accurately, and could write immediately by blowing murmur, numerals to any extent without dictation. The following will ran up to the second sound. This post-systolic murmur defects in writing from dictation. When asked to write the was audible from the to the sternum and .exemplify " apex up word he wrote for for just" fugl," "subjects" "supfect," speak" to the lower border of the third rib, was lost over the aortic ’" sery," for "found" "spuut." Strange to say, when told to spell those words he did so accurately in every instance, and when asked why he valves, and was scarcely, if at all, conducted beyond the did not write them he explained that he had forgotten how to make the apex towards the left. It disappeared when the patient held ’letters. He remained in for about three and left much hospital months, a deep was intensified when he was on the improved in his speech, being able to carry on a conversation fairly well, inspiration, lying left diminished when on the though occasionally using one word for another. He could name objects side, and materially right side. ’better. Volitional writing was not improved; writing from dictation was It was also diminished on resting, but did not entirely cease. slightly better. CASE 2.-A young man, aged twenty-one years, was Apart from the marked amnesia with preservation of examined by a medical man and passed for an office under a .ability to read aloud, this case is remarkable for the gibberish public body in June, 1996, when no murmur was detected. 41haracter of the patient’s writing, combined with an ability He was examined by another practitioner within the next to spell correctly-two characters that do not often go few weeks, and a murmur found, and again with the same together. In this relation it may be mentioned that it some- result six weeks later. He was advised to consult his own times happens that the speech of patients is entirely limited medical man, who at the first examination detected the ,to a mere imitative repetition of words spoken in their hearing, murmur ; but on seeing the patient a few days later when at while they are without the power of volunteering any state- rest failed to do so, and sent him to me. The patient was ment-that is, their auditory word-centres respond only to thin and pale, and was not conscious of palpitation or direct sensory incitations, and not at all to those of an shortness of breath. He had never had rheumatism, and was associational or volitional order. In these cases (usually able to lie on either side at night. When sitting the pulse ’Included under the term echolalia ") a marked general was 126, small, regular, and compressible. When lying on mental impairment almost invariably co- exists. the back a voluminous pulsation in the precordium was visible, A defect of this kind (occurring in a woman who was with apparent displacement of the apex-beat downwards hemiplegic from cerebral haemorrhage) has been recorded byand outwards. This was, however, more apparent than real, as Professor Behier. 51 She was born in Italy, and had resided the nipple was three-quarters of an inch above its natural both in Spain and France ; of the three languages she had point. The apex was in the fifth interspace two and a half thus acquired she had completely forgotten the Italian and. inches from the border of the sternum. On auscultation, Spanish, and had only retained a most limited use of French. when standing or sitting, a short, loud, blowing, systolic In this latter language she only repeated like an eclao the murmur could be heard at the apex and half an inch to the words pronounced in her presence, without, however, left of that point. This was conducted along the fifth rib .attaching any meaning to them. nut in the case of a woman to the centre of the sternum. The murmur was intensified seen at the Salpetriere by Bateman the mimetic tendency during inspiration and was at a minimum at the end of was much stronger. She even reproduced foreign words; expiration. On drawing a long breath as the end of with which’ she had never been familiar. It is clear that in inspiration was approached it became very high in such a case as this there must have been a mental degrada-. pitch and resembled the sound caused by squeezing tion of a much wider kind than that which occurs when the air through a hole in an india-rubber ball. When he held .auditory word-centre alone is reduced to its lowest grade ofE his breath at the end of a deep inspiration the heart became functional activity. suddenly slower and two or three deliberate beats occurred which were unaccompanied by murmur. Fifteen minutes’ 50 Brit. Med. Jour., Jan. 2nd, 1886, p. 14. rest in the recumbent brought the heart down to 51 position Gazette des Hôpitaux, May 16th, 1867. 110, when the murmur could no longer be heard so long as : he held his breath at the end of a deep inspiration, and the area over which the murmur was heard under other condi- THE Farnham Rural District Council on1 tions was much reduced-that is to say, it was only to be - April lst granted an extra donation of .f:20 to thedetected over the immediate apex after rest. medical officer for his special services during the recent out-- CASE 3.-A woman, aged about twenty-eight years, was break of diphtheria. seen for headaches and nervous depression about four months 1018 after her first confinement. The patient was somewhat of a pain about the left nipple, which be ascribed to his anæsmic, but otherwise looked well. She was able to move heart. He had frequent attacks of palpitation with a feeling about briskly and was free from breathlessness. On examina- of intense apprehension of approaching danger, when he tion of the heart the apex beat was found to be somewhat trembled all over. The pain was worse at night. The prominent, but in its normal position. The heart sounds were heart was rapid, 100 in a minute when standing. The left clear and rather accentuated, about eighty-five in the minute. apex beat was in the nipple line between the fifth and sixth A well-marked blowing murmur was heard in the fourth ribs. In the erect posture a loud, systolic, blowing murmur interspace about one inch from the left border of the sternum. was heard at the apex, beyond which it was not conducted, It distinctly followed the first sound, and appeared to run up being limited to within a narrow circle at this point. This to the second sound, an interval occurring between the first murmur was intensified on drawing a long breath, and was sound and the murmur. The point of maximum intensity increased in loudness as the inspiration reached its termina- of this post-systolic bruit was at the place indicated, tion, but on holding a very long breath it disappeared. and it was well heard beside the sternum, but not at the After lying down for a few minutes it was no longer audible, base, and was scarcely audible at the extreme apex and A few points stand out prominently in connexion with not at all outside of it. At the end of a dep inspiration these mimetic murmurs: firstly, they occur in highly neurotic the murmur was absent. It disappeared after treatment people; secondly, they are frequently associated with vio. by rest and arsenic. lently acting ventricles independent of lung conditions;-, CASE 4.-This patient, a married woman aged forty- thirdly, they may be intimately connected with respiration one years, had been an invalid for some years. Fifteen and structural alterations in the lungs ; fourthly, they are years before ,he came under observation the ovaries not limited to any cardiac area ; fifthly, they may be sys. were removed for tubal disease. She bad not men- tolic, post systolic, or early diastolic ; and sixthly, they can struated since the operation. She suffered much from be diagnosed by an appeal to certain tests, chiefly rest, palpitation and nervousness. The pulse was regular, position, and respiratory movements. (See table at end of jerky, 100, even when lying in bed. The area of the first paper, THE LANCET, July 27tb, 1895, p. 196). cardiac was increased, and the whole of the Newcastle-on-Tyne. impulse ______precordial region heaved more or less with the systole. The extreme apex was behind the fifth rib three inches from the left border of the sternum. Notwithstanding A CASE OF PHTHISIS COMMUNICATED the excessive impulse the cardiac dulness was slightly, if at all, increased. On auscultation at the extreme FROM HUSBAND TO WIFE. apex the sounds were very loud and "membranous," and a BY WILLIAM MURRELL, M.D., F.R.C.P., short murmur the first sound. This blowing accompanied LECTURER ON PHARMACOLOGY AT THE WESTMINSTER HOSPITAL. was best marked towards the termination of the sound and increased in as the sternum was where intensity approached, A WOMAN, years, was admitted into the it became musical. It was audible as as the third aged thirty-six high Westminster from Both he1t interspace as a, musical sound, but was merged in the second Hospital suffering phthisis. interspace in a soft blowing murmur (hæmic). At the end father and mother were alive and well, and she had three of a full breath it was much diminished, and it was greatly sisters and one brother all grown up and in good health when the on her side. It exaggerated patient lay right There was no history of phthisis in her family cn either side. was not audible to the left of the apex. At times when Her husband was healthy when she married him, the was free from excitement the murmur was apparently patient but his father and one sister died from After a absent. phthisis. entirely time he a blood, and died, CASE 5.-A twelve with a nervous developed cough, spat ultimately boy, aged years, history, it stated on the certificate that the cause of death was often had attacks of the nature cf He com- being hysteria. the last seven months of his life he was of and some shortness of breath on phthisis. During plained giddiness too weak to go out, and his wife nursed him incessantly. exertion. He had never had rheumatism. On examination had one small room, and the fire was of the heart there was a tumultuous The They only kept burning heaving impulse. and He a great deal, and no was a little below the normal there was no day night. expectorated apex position ; directions were given her as to the use of Soon thrill. A murmur could be heard to the antiseptics. loud, short, systolic after his death she noticed that she had a bad and left of the sternum. It was best marked about the fifth cough, when she came under observation it was found that she had rib and was not audible at the immediate There apex. cavernous breathing with whispering pectoriloquy at the were no basic murmurs. The heart beat was 120, and jerky apex and dulness and at the left. She The murmur became much more localised after right crepitation regular. stated that she was no worse off in consequence of her even the number of heart beats was not resting, though husband’s death, but that, on the her means had reduced to extent. On a breath the contrary, any drawing deep as her husband’s illness she had to him. murmur was absent at the end of On on improved, during keep inspiration. lying Remarks.--This case is of no interest in itself, the side the murmur was first intensified the move- particular right by but it is so when taken in with similar cases but after a few minutes conjunction ment, disappeared altogether. recorded in THE LANCET of and a similar CASE 6 -A had suffered from May 22nd, 1880, man, aged twenty-nine years, series of cases Dr. in THE and some emaciation for three or four published by Reginald Thompson cough, night-sweats, LANCET of Nov. 6th of the same year, as the change He was nervous and somewhat short of marking months. highly of opinion respecting the contagiousness of phthisis which breath. The chesti was flat beneath the clavicle, right has taken since that time. Sixteen years ago such cases where the note was dull. When a place relatively standing, loud, were with and their excited diastolic murmur could be heard to the of the regarded suspicion publicatim short, right hostile now are so common that excite sternum. The of maximum was above criticism ; they they point intensity just but little comment. Dr. Hermann Weber details of the but it was audible from the clavicle to the 1 gave dght nipple, wives who became infected from fifth rib. Tne heart beat was and nervous in the thirty-nine marrying jerky (120 and in several cases the husband but after ten minutes’ rest came down to 90 and the phthisical husbands, minute), infected more than one wife. The reason the husband infects murmur It also on the disappeared. disappeared patient the wife more than the wife the husband is a breath and it. Over the same area a frequently drawing long holding explained by the fact that when the husband is ill the wife well-marked systolic cardio murmur was heard respiratory nurses him, but when the wife is ill the husband from the a but this was distinct during quiet deep inspiration, quite increased demands on his resources has to closer attention from the sound referred to. The was small pay already pulse to business and is less at home than usual. In connexion and but not of rapid, suggestive Corrigan’s. with the of the of it is CASE 7.-Another case, the was subject contagiousness phthisis closely resembling above, difficult to avoid reference to the risk which is run that of a man, who was admitted by healthy aged thirty-eight years, on sea if to the same into the in for people long voyages compelled occupy Royal Infirmary, Newcastle, December, 1896, cabin with from advanced The and There was some retraction of the patients suffering phthisis. cough hæmoptysis. cars which numbers of and evidence of There was a sleeping convey large phthisical right lung early phthisis. short, to the Riviera and other health resorts at diastolic murmur which terminated patients popular whiffing, early abruptly certain of the are not above and much in the second sound. It was best heard between the and periods year suspicion, apex care should be taken in them aired and the sternum the fifth It was loud on excite- greater having along interspace. disinfected than is at the case. ment, but on or on the breath. present disappeared resting holding Welbeck-dreet, W. CASE 8.-A man, aged twenty-nine years, of habitually .nervous tendency, had complained for upwards of three yean 1 Transactions of the Clinical Society, vol. vii.