On the Value of Quinine and Some of Its Congeners as Parturients
Authors: A. Mullan
Journal: BMJ (1885)

eaiks of ther first sound, s;h-erdi to the 'left df thi hoidcartilA asoften present.An interesting fact Was Aoticed p Iy, nail1ely, tie disappearance of the Tkdlplication while the patient hed hi teath, although he could only do so for a-vry-short tinie, owing to the dyspncea from which he suffered.Occasionally, le had' suffered -fromn attacks of bronchitis.During his stay,, the respiration approached at times the Cheyne-Stokes type he had no hemopt'y8is.The urine was albuminous aad scanty.The' patie6tt face was habitually florid, but appeared unduly congested.When, with all this, the limbs begat to Swell, Us thev did soon after admission, the idea of mitral disease was most strongly suggested to the mind.But the murmur, instead of being systolic or presystolic, was obviously diastolic; a pretty long, soft, or whiffing murmur, running off from the second sound, which could 'still be heard at the aortic cartilage with a booming quality.The murmur itself was audible both at the aortic cartilage anl at the very tip of the riphoid cartilage, perhaps most plainly at the lower half 6fthe sternum.The idea of mitral disease, and the improbability of aortic incompetency, were so strongly impressed on my mind, that I considered again and again if this murmur could not be the diastolic portion of a prolonged murmur of mitral stenosis; but its! complete dissociation from the first sound seemed to negative this conclusively.On trying the pulse critically, both with the finger and with the ephyg- knograph, no characteristics of the aertic regurgitant pulse were found.The idea of its being due to disease in the aorta, similar to the case alteady reported, next suggested itself; although it was a very un- likely occurrence to have another such case so soon after the fint, it was di'scussed with the students in attendance.In this second case however, we had only one murmur-not two as before-and it was of diastolic rhythm.Now, so far as I had seen the records of the kind of cases referred to, there had always been two nmurmurs found; or if one only existed, it was systolic; and the explanation offered by Dr.Bellingham sand others, as to the production of the murmur, rendered it very unlikely that a diastolic murmur could be produced by a rough dilated and rigid aorta without a systol-ic'murmur being present also.'Witl this' in view, I listened again and again for & systolic nvtrmu at the base, but had' to' enter 'in the notes that lio sibh tnurmur tonl&d;.e heard.The patient lived about six weeks in the *td, with hierelsing dyspnena and diopsy; this, ihdeed, became extreme.The ttal duration of the illness was about six er seven months.He died Buddenily, apparently from syncope.The post mortem examination showed the heart greatly, enlarged, 'the right side 'even more than the left;, weight, 20 ounces.Before opening the organ, the aortio valve was tested with water, land found 'perfectly competent.;The valvular structures were not thickened any 'where, but the mitral and tricuspid orifices'were enlarged.The ao2rta *as much d-ilated, and higlhly atheromtLtous, with calcareous plates and deposits of fibrine.A large thrombus occupied the right auricle, penetrating into the auricular appendage.Haamorrhagic.infarctions 'Were present in-both lungs.The spleen,.liver, and 'kidney ~had the appearance of chronic congestion./'i These two cages afford, to my mnind, conclusive evidence ifo the existence of a double murmur, and particularly of a diastolic murmaur, of aortic origin, apart from aneurysm and apart from valvular incom- petency.-'Of course, it may be contended that, with a dilated, aorta, tlbe valves were inadequate to prevent regurgitation during.life.In reply tb this, I can only say that the valves and aortic orifice appeared to the pathologist and 'myself,' during 'the testing, so completely adapted to each other that, with every desire to do so, we were un- -*ble to adifit such an explanation.