yet every practitioner knows that in cases of organic disease of the heart, and even in some instances of functional disorder, the pulse fails to represent faithfully the number of systoles. The failure occurring regularly with each alternate systole was the circumstance exciting wonder. The persistency of the multiplication of the heart sounds in a ratio compared with the pulse exactly double, for several weeks, without being associated with other symptoms denoting immediate danger, and the abrupt cessation of this irreg ularity, with sufficient improvement for the patient to leave the hospital, and to continue without difficulty a laborious occupation, are circumstances abundantly disproving the hypothesis last mentioned.

Finally, in view of the facts contained in the four cases of reduplication of the two sounds of the heart, which are presented in this article, it is dif ficult to settle upon a positive conclusion as to the mechanism by which this remarkable and rare form of disordered action is produced. The theory of a want of synchronism, so far as concerns its intrinsic plausibility, is to be preferred; but it is met, as has been seen, by a difficulty in its application to the instance occurring under my observation, and equally to the case reported by M. Bouillaud, which, unless disposed of in some way that I am not prepared to indicate, must invalidate its correctness, not only in this, but ¡n other instances, for it is not probable that in different cases, this feature, identical in each, and so peculiar, is to be explained differently. Nor is the second hypothesis devoid of difficulties in addition to what has been alluded to, which will readily occur to the mind of the reader.

in

These two explanations are all that have been suggested to account for reduplication of both heart sounds, and I have no additional hypothesis to offer. An analysis of a larger number of cases may develop results which will shed more light on the subject. And in dismissing the question as to the rationale, the following quotation from the treatise on diseases of the heart by M. Bouillaud, is perhaps not less pertinent than when penned by that distinguished author more than fourteen years ago: "Je souhaite que ces faits soient fécondés par quelques uns de mes lecteurs, qui, plus heureux ou plus habiles que moi, résoudront peut-être les difficultés qu'ils me semblent encore offrir, et dissiperont les obscurités dont ils sont environnée."-Tome II, page 345.

My remarks being already more extended than I had designed, I shall not prolong this article by a discussion of the causes which occasion reduplication of one only of the sounds of the heart. I will simply say that, whatever may be the true explanation in cases in which a beat of the heart is accompanied by four sounds, the same explanation will probably apply to

the instances in which the beat is accompanied by three sounds. In much the greater number of the cases of the latter description which have been reported, the second, or diastolic sound is the one doubled;* and, therefore, we may conclude, either that the two ventricles dilate separately, contracting in unison, or, that the dilation takes place, not continuously, although synchronously, but by two divided acts, each act taking place in such a manner (it must be confessed not easily understood) as to produce by a complete diastole a double sound.

Recurring to the reduplication of the two sounds, the question arises, what is its value as a diagnostic and prognostic symptom? In two of the four cases which have been given in this article, the morbid condition of the heart was determined by the post-mortem examination. The prominent lesion in each instance was different; in one consisting of aortic, and in the other of tricuspid insufficiency. In all of the four cases there was enlargement of the heart. In two cases this aberration of the heart's rhythm ceased, and improvement took place so that the patients were not obliged to remain under medical treatment; and in the case reported by me, the patient has apparently recovered good health, some enlargement of the heart doubtless remaining. In this case a bruit existed, supposed, but with some doubt, to be endocardial, and to denote mitral regurgitation, but it disappeared after recovery. In view of these facts it does not appear that the reduplication of the two sounds possess special significance either in diagnosis or prognosis, and it must be confessed that, with our present knowledge, the interest belonging to the subject, if the antithesis be allowable, is rather scientific than practical.

M. Bouillaud, basing his opinion on the case that had fallen under his observation, thinks that the sounds are never doubled except in connection with organic disease involving either constriction or insufficiency. In fact, he regards the symptom as diagnostic of valvular lesions, and, inasmuch as their existence may be determined by other criteria than this, he says it is quite superfluous so far as diagnosis is concerned. He calls it "un signe de luxe." The facts, however, contained in the history of my case tend to throw doubt on the correctness of this opinion. The existence of valvular disease in this case is not certain. A bruit supposed to be endocardial existed, it is true, but it was a matter of question, at the time, whether it was not a friction sound; and in view of its disappearance, and the present state of the

* Dr. Bellingham states the reverse of this; but he is undoubtedly in error on this point.

VOL. XI., NO. 1.-2.

heart, the supposition that it was so is perhaps more probable. That a positive opinion was not formed as to the seat of the bruit should not subject the observer to reproach, since the most experienced auscultators have acknowledged the difficulty and indeed impossibility, in certain instances, of determining whether an adventitious sound emanating from the heart be a bellows murmur or a friction sound.

The fact that reduplication of the heart sounds is a phenomenon so rare in its occurrence, goes to show that its connection with organic lesions is only incidental; and if it be true that it may occur irrespective of such lesions, it is to be regarded as a functional disorder, which, although, perhaps, in the great majority of instances associated with structural disease, is a superadded affection. But with reference to this, as to other points, farther observations are desirable before positive conclusions are admissible.

ART. II.-A few Remarks on Acute Laryngitis with Illustrative Cases. By THOMAS F. ROCHESTER, M. D., Professor of Theory and Practice of Medicine in Buffalo Medical College.

The relative infrequency of Acute Laryngitis, as compared with the other inflammatory affections of the air passages, is justly esteemed a most providential exemption from disease. For as surely as inflammation of a severe grade attacks the voice seat, so surely, unless promptly recognized and readily arrested, does it lead to a rapid and fatal termination. As the disorder is seen but rarely, it seems scarcely possible to urge too forcibly the importance of distinguishing between the various modes of attack, of determining whether it be simple or complicated, and if the latter, of deciding upon the nature of the complication. Spurious or simulated Laryngitis is also to be borne in mind. The sex of the patient will often reveal this at once, (hysteria morborum omnium simulator,) as well as the knowledge of the fact, that males are more frequently than females the subjects of the inflammatory seizure. It is proposed in this communication, to submit to the readers of the Journal, a report of a few cases that have recently been presented to the observation of the writer, and it is hoped that if no new ideas of either pathology or treatment are advanced, that at least a candid statement of facts may not be without interest or value.

CASE I. Miss L-aged 17 yrs., native of Buffalo, person well developed, health vigorous, menstruated at 15. On the evening of Sept. 13th,

1854, she was overtaken by a rain storm and was much wet; on reaching home, she changed her garments and felt none the worse from the exposure. Retired about 10 P. M. quite well. Awoke at 3 A. M., feeling hot and thirsty, pain in back and limbs, throat sore and voice hoarse, cough slight and without expectoration. Sept. 14th, 9 A. M., I was called to see her. I found her quite anxious and excited, pulse 95, full and hard, tongue slightly coated, bowels confined, surface of body hot and dry, eyes bright, cheeks flushed, voice husky, cough hoarse, spasmodic and frequent, respiration hurried and incomplete. Fauces intensely red but no tonsilitis; I could not obtain a view of the epiglottis; examination was however made freely with the finger, and detected a constantly upright position of the epiglottis, but without positive induration or oedema. No pain was experienced on pressure from without, except over the thyroid cartilage; there it was decided, and to the same locality was also referred pain in deglutition; all attempts to drink induced cough, a portion of the fluid probably passing into the glottis, on account of the immobility of its protective valve. Physical exploration of the chest detected insufficient inspiration, and consequent slight pulmonary inflation-there was great heaving and shoulder raising, but no full, deep inspiration; every effort at this was spasmodically arrested. DiagnosisAcute uncomplicated Laryngitis.

I directed the feet to be soaked in a hot mustard bath, and three Swedish leeches to be applied along the trachea, for I fancy the objection to their use in such cases, as urged by Watson, to be entirely theoretical and quite groundless but admitting that serous infiltration of the cellular tissue may result from the leeching, surely acupuncture will at once relieve it. After the foot bath I prescribed ol. Ricini 3ss, succi Limonis 3ij, to be taken at one dose. This formula is, I believe, much used at the Massachusetts General Hospital; the lemon juice covers the taste of the oil and at the same time increases its cathartic action. I also prescribed-Ant. et Pot. Tart. grs ij. Morphiæ Muriatis gr. iss. Syr. Limonis 3jss. Dose to 1 teaspoonful, to be given sufficiently often to maintain nausea but to avoid emesis.

2 P. M. Patient much relieved; the bowels have moved twice freely; the blood is still oozing from the leech-bites; the tartar emetic produces very slight nausea; pulse 90 and less hard; countenance still anxious; cough has almost ceased; respiration less jerking and irregular; voice remains husky and unchanged; pain diminished both in swallowing and on pressure. Tartar emetic and morphine to be continued; hot poultice of bran and hops to be applied to throat.

9 P. M. Patient about the same as at 2 P. M. Has had four prolonged

spasmodic attacks of coughing during the evening, but unattended with expectoration. I directed the stimulating pediluvium to be repeated, and the vapor of warm water to be inhaled if, on trial, it was found to relieve the spasmodic coughing; discontinue the Tartar emetic and to take Pul. Ipecac. comp. grs. x every four hours.

Sept. 15, 9 A. M. Patient has slept well; has taken but two of the Dovers Powders-found the inhalation of the warm vapor very grateful. Pulse 80 and soft. No pain in swallowing and scarcely a perceptible amount on pressure; cough and voice both slightly husky. Respiration unembar. rassed; countenance cheerful; the redness of the fauces diminished. No serous infiltration from the leeching. No further general medication seemed necessary, but I judged that topical applications would now be of service; the fauces and rima glottidis were accordingly lightly touched with a sponge moistened with a solution of Nitrate of silver, grs. xxx to 3j of distilled water. This produced coughing, followed by mucous expectoration, and effected a decided and instantaneous improvement in the quality of the voice. The sol. of Nitrate of silver was applied every morning for three successive days, and Miss L was discharged, quite well. It may be asked, why was not this topical treatment resorted to at the commencement of the attack? With respectful deference to those of an experience more extended than my own, I would answer, that as a sedative and antiphlogistic, I have not found the Nitrate of silver to sustain the favorable reports of its advocates; on the contrary, in several cases of acute Tonsilitis, in which I applied it, it certainly increased the inflammation, and in two instances great oedema of the uvula immediately followed its use. I have seen many cases of tonsilitis at once arrested by the lunar caustic, but I think I have seen more failures than successes. In several instances it aggravated the inflammation, in two it produced positive oedema. When it does afford relief, it is so speedy and so effectual, that I think it should always be tried, where it can be used with safety, as in Pharyngitis, Tonsilitis, and perhaps membranous croup. In the two former affections aggravation of the inflammation would scarcely ever place life in jeopardy, but in Laryngitis, attended with high febrile movement, and with' unmistakable evidence of intense local excitement, the chances of the production or of the increase of oedema are certainly equal to those of preventing or of allaying it. In Laryngitis accompanied with secretion, the employment of the Nitrate of silver, as a stimulant and alterative, does not seem to be either dangerous or objectionable, and as a stimulant, it is doubtless a valuable agent in restoring tone and vigor, in cases such as Miss L—'s, when the inflammation is subdued.