BY A. R. MORGAN, M. D., SYRACUSE, N. Y.

On Monday forenoon, 9th December, 1861, was called to see F. H., boy aged ten, inmate of the Onondaga Co. Orphan Asylum. He awoke about midnight with retching and vomiting, high fever, thirst and inability to sit up without aggravating all his symptoms. Upon examining what had been voided from his stomach, found an Ascaris lumbricoides. Fever unabated, starts and jerks during sleep. Aconite⁶ and Cina³⁰ alternating them two hours apart, until an amelioration of symptoms occurred, then lengthen the interval.

10th. Upon entering the room, my attention was instantly attracted by the violent and tumultuous action of the carotids. Auscultation revealed a loud, rude and continuous “bruit de souffle” occupying the time of both beats of the heart and completely supplanting them, something between the gentle blowing sound and the rough or grating sound. This “blowing” or gushing (perhaps expresses it better) was distinctly audible in the carotids, scarcely distinguishable in remote portions of the lungs, uniformly loud and distinct all over surface of the heart; complains of uneasiness in region of the heart. Anxious expression of countenance; less fever than yesterday; nausea and vomiting continued, aggravated by eating and drinking; face and eyes red and swollen; pulse rapid and feeble; respiration accelerated and moaning, murmur distinct not abnormal. The least movement, such as turning over in bed or rising up, aggravates all the symptoms. Complains of excessive soreness of flesh, outside right thigh near the knee; also a spot upon radial side of the left fore arm, near the wrist. No redness of the skin in these localities. General turgescence of the veins, mottled and blue appearance of the skin on the extremities. Says never had rheumatism. Diagnosis, Carditis with constriction of aortic orifice. Aconite⁶ four doses, half an hour a part, followed by Ars. ⁶ every two hours.

11th. Dr. Wm. A. Hawley, of this city, saw the patient with me. Symptoms about the same as yesterday, except a slight second sound of the heart could be distinguished through the continuous blowing sound. Pulse less frequent, feeble; tongue red; papillae elevated; face and eyes red and swollen; painful deglutition; complains less of soreness of flesh, but of occasional erratic sharp pains in the extremities. Can't bear to be moved, stiffens himself out “like a log” upon an attempt to move him. Nausea, moaning and sighing respiration; restless fretful. Mind wandering; talkative delirium, particularly on first waking; anxious, troubled expression of countenance; mottled appearance and blueness of skin increased; veins distended. Bell.⁶. Lach.³⁰, alternate every two hours. If fever arises, discontinue and give Acon.⁶ every half hour until it subsides and return.

12th. No particular change. Continued medicine at lengthened interval.

13th. Dr. H. again in consultation. No better. Great prostration; nausea; sighing; laborious respiration; pulse very feeble; extremities cold and blue; cyanosis. Heart's action slow and labored; eyes dull and fixed; brows knit; bellows sound continuous and loud; cold perspiration on moving him. Says he feels pretty well. Ars.², trituration, every hour. He continued gradually sinking and expired at ten o'clock, p.m.

Autopsy. — Blood had gravitated to a very unusual extent, rendering about one-half of the body a dark blue, gradually increasing in color until reaching the back, where it was a very deep blue black.

Lungs thoroughly engorged with black blood. Upon opening the pericardium we found about two table-spoonfuls of a sero-purulent fluid. The surface of heart gave evidence of severe inflammatory action, more intense towards its base. Two or three dark ecchymosed spots were found on the auricles and one nearly encircling the aorta at its origin, that tube being constricted to two-thirds its normal size.

The walls of the left ventricle were hypertrophied to about one-half an inch in thickness, indicating that the constriction of the aorta was not of recent occurrence. A stout fibrinous mass was found in the right ventricle, distending one of the tricuspid valves and firmly attached to the septum ventriculorum. We were surprised at not finding more decided evidence of acute inflammation of the heart itself.

After a long examination, completely puzzled by the strange incompatibility between the symptoms and pathological condition, unable to account for the phenomena existing before death and unwilling to adopt the humiliating conclusion that the pathological evidences were insufficient to satisfactorily account for the boy's death, we concluded to make one more effort to discover the cause.

The left ventricle had been laid open through its middle, so that upon separating the edges of the incision, one of the mitral valves remained extended upon the septum. We, having found the valves normal, had not disturbed them farther.

Upon carefully lifting this valve upon the handle of the scalpel, we discovered an orifice perforating the septum, opening through into the right ventricle, coming out directly under the tricuspid valve; a slight but firm tendinous band extended from the superior surface of the opening in the right ventricle, and attached itself to the under surface of one of the tricuspid valves.

This opening, twice the diameter of an ordinary goose-quill, afforded a direct communication between the two ventricles, so as to easily embarrass the actions of both mitral and tricuspid.

I have not been able to find an autopsy reported, where this continuous “bruit de suffle” had been observed.

This was unquestionably a congenital malformation permitting under certain circumstances a mixture of venous and arterial blood, for although the boy had been considered healthy, yet it had been frequently observed that his face would become “flushed” to a very unusual degree, upon over-exertion or upon mental excitement.

A reprimand by his teacher at school would produce a remarkable and persistent dark discoloration of his face. This can be accounted for only on the ground of partial cyanosis.

That this anomalous condition of the heart was the indirect cause of death is evident from the moribund phenomena. — There was imperfect circulation of deoxygenated blood.

The blood was obstructed in its exit from the left ventricle by the constriction of the aorta, while there was regurgitation at both the mitral and tricuspid valves, and a “damming up” of the venous system.

Evidently a portion of the venous blood passed through the orifice from the right to the left ventricle, and entered directly into the circulation without being exposed to the aerating process.