933" THE PRESYSTOLIC ZURbiUR, FALSELY SO CALLED."

showed an increase of 76 upon the number returned inthe preceding week, and included 26 which were re-

ferred to whooping-cough, 19 to scarlet fever, 11 to

diarrhaea, 6 to "fever" (typhus, enteric, or simple), 5 tomeasles, 3 to diphtheria, and not one to small-pox; in all, 70deaths resulted from these principal zymotic diseases, against79 and 68 in the preceding two weeks. These 70 deaths were

equal to an annual rate of 2’8 per 1000, which exceeded by’C’3 the mean rate last week from the same diseases in thetwenty-eight English towns. The fatal cases of whooping-cough, which had been 30 and 16 in the previous twoweeks, rose again last week to 26, of which 7 occurred inGlasgow, 6 in Dundee, and 5 in Edinburgh. The deathsfrom scarlet fever, which had been 23 and 22 in the precedingtwo weeks, further fell to 19 last week, and included 9 inGlasgow and 4 in Dundee. The 11 fatal cases of diarrhoeaincluded 4 in Glasgow and 4 in Dundee. The 6 deaths re-ferred to "fever," of which 4 occurred in Glasgow, corre-sponded with the number in the previous week. The fataleases of measles, which had risen from 2 to 5 in the pre-ceding three weeks, were again 5 last week, and included 2in Edinburgh and 2 in Dundee. Of the 3 deaths referred todiphtheria, 2 occurred in Glasgow. The deaths attributedto acute diseases of the respiratory organs in the eighttowns, which had risen from 87 to 120 in the precedingthree weeks, further rose to 124 last week, and exceeded by32 the number returned in the corresponding week of lastyear. The causes of 71, or nearly 13 per cent., of thedeaths registered in the eight towns during the week wereact certified. ———

HEALTH OF DUBLIN.

The rate of mortality in Dublin, which had been 27’3and 24’1 per 1000 in the preceding two weeks, rose againto 321 in the week ending October 29th. During the firstfour weeks of the current quarter the death-rate in thecity averaged 26’9 per 1000, the mean rate during the sameperiod being but 18’3 in London and 19 1 in Edinburgh.The 217 deaths in Dublin last week showed an increase of.54upon the number in the previous week; they included11 which were referred to scarlet fever, 11 to diarrhoea, 9 tomeasles, 7 to "fever" (typhus, enteric, or simple), 4 towhooping-cough, and not one either to small-pox or diph-theria. Thus the deaths resulting from these principalzymotic diseases, which had been 36 and 29 in the precedingtwo weeks, rose again last week to 42; they were equal toan annual rate of 6’2 per 1000, the rate from the samediseases being but 2’5 in London and 2’2 in Edinburgh. Thefatal cases of scarlet fever, which had been 11 and 8 in theprevious two weeks, rose again to 11 last week. The 11deaths from diarrhcea exceeded the number recorded inrecent weeks. The fatal cases of measles, which haddeclined from 13 to 5 in the preceding four weeks, roseagain last week to 9; the deaths referred to " fever and towhooping-cough differed but slightly from recent weeklynumbers. The deaths both of infants and of elderly personsshowed a considerable increase. Seven inquest cases and2 deaths from violence were registered; and 64, or morethan one-fourth, of the deaths occurred in public institutions.The causes of 31, or more than 14 per cent., of the deathsregistered during the week were not certified.

THE SERVICES.

Brigade Surgeon Elkington, Grenadier Guards, ChiefMedical Officer of the Brigade of Guards, will be placedon the retired list on the 5th instant, under the Age Clauseof the Medical Warrant. He will be succeeded as BrigadeSurgeon by Surgeon-Major W. R. Lane, of the Scots Guards.Deputy Surgeon-General A. F. Bradshaw replaces DeputySurgeon-General J. Ferguson in Medical charge at RawalPindi.ADMIRALTY. - The following appointments have been

made:—Surgeons John Frederick Bate, John Andrews, andJohn Eustace Webb, to Plymouth Hospital, for temporaryservice; Surgeons Edward Ashley Spiller and Edward HenryMeaden, to Haslar Hospital, for temporary service (datedNov. Ist, 1887); and Mr. John J. M’Nulty, to be Surgeonand Agent at Derkmore.ARTILLERY VOLUNTEERS.—1st Renfrew and Dumbarton:

Surgeon J. W. Taylor is granted the honorary rank of Sur-geon-Major (dated Oct. 29th, 1887).RIFLE VOLUNTEERS.-1st Durham: Surgeon and Ilono-

rary Surgeon-Major S. W. Broadbent resigns his commission;also is permitted to retain his rank and to wear the uniformof his Corps on his retirement (dated Oct. 29th, 1887).THE VOLUNTEER MEDICAL STAFF CORPS.-The London

Division : Surgeon and Honorary Surgeon-Major JohnIIornsey Casson resigns his commission; also is permittedto retain his rank, and to continue to wear the uniform ofthe Corps on his retirement (dated Oct. 29th, 1887).-TheManchester Division : Shepherd McCormick Boyd, Gent., tobe Surgeon (Supernumerary, dated Oct. 29th, 1887).

Correspondence."Audi alteram partem."

"THE PRESYSTOLIC MURMUR, FALSELY SOCALLED,"

To the Editor8 of THE LANCET.

SIRS,-Having endeavoured to prove the correctness ofthe late Dr. Barclay’s explanation of the causation of the

"presystolic"1 bruit, in a paper in vol. vii. (1876) of theSt. Thomas’ Hospital Reports, and in a communication toths Clinical Society last year (vol. xx., p. 1), I was interestedin reading Dr. Dickinson’s views upon the subject latelypublished in your journal. I venture to offer this contribu-tion to the discussion of the subject because I think thatsomething more may be said in support of Dr. Barclay’sviews, and because I am unable to agree with Dr. Dickinsonin one point of his argument. I think the matter can bemost succinctly put from this point of view (1) by showingthat the physical conditions of the valvular mechanism aresuch that there must be in cases of mitral stenosis a ven-tricular systolic bruit, distinguishable or indistinguishableby auscultation, having all the characters of the 11 pre-systolic " bruit and the same relations to associated diastolicand systolic bruits, and (2) by pointing out that Dr.Barclay’s view is confirmed by clinical observations whichshow that the " presystolic " period of the ventricular systoleis sufficient for the production of an audible bruit, and toogreat to allow the supposition that a bruit running up tothe first sound could be produced by auricular contraction.

1. However perfectly the healthy valvular curtains, withtheir thin membranous edges, may perform their function,rigid and resistant mitral flaps cannot be brought into con-tact by the ventricular contraction without some reflux ofblood, more or less, according to circumstances. The soundproduced by this unavoidable reflux, if audible, would be ofprogressive intensity until abruptly arrested by contactof the curtains, the sound of valvular tension at themoment of closure being accentuated from delay ofthe contact of the curtains to a later and more active periodof the systole. With rigidity of the mitral valves, the firstsound must be preceded by a regurgitant bruit, audible orinaudible to an auscultation, having these characters of the" presystolic bruit, which are those of arrested reflux. Theconsideration of another feature of the physical con-ditions shows that this "presystolic" regurgitant bruitwould have the other clinical characters of the well-recognised murmur-i.e., its rough, harsh sound andattendant tremor, its distinction by this character froma succeeding systolic bruit, and its fusion with a precursorydiastolic murmur when occurring in association with them.The loudness and harshness of the bruit produced at themitral valve by the comparatively weak force of the bloodstream entering the ventricle or running back through theopen valve before contact of the curtains is due to theflaps themselves being held away from the ventricular wallsby shortening of the chordas tendineæ, or by cohesion at thecusps, and being thrown into vibration by the fluid streampassing between them. The ie valvular vibrations are trans-mitted by the chordae tendineas to the apex of the ventricle,and thence to the part of the chest wall in contact with it,where they may be perceptible as audible and sensiblevibration limited to that region. Sonorous vibrations ofthe valvular curtains set up by the iyaflowing blood streammay be continued by "presystolic" reflux through the stillpatent valve, and the bruits of influx and reflux will then

1 The term " presystolic " is here used as equivalent to " pre-systolic-sound."