RECORD OF MEDICAL SCIENCE.
ANATOMY AND PHYSIOLOGY.
Experimental Inquiry into the Causes of the Sounds of the Hearty
Confirmatory of the Views of Dr. Billing.
By Harris C. Brakyn, Esq., Trinity College, Dublin.
Dublin, Mercer’s Hospital, William street, July 20, 1849.
To Archibald Billing, M. D.
Sir,—The following communication is addressed to you by a very
unpretending student in medicine, trusting the liberty of so doing will
be excused, in consideration of its being offered in a spirit of perfectly
respectful well meaning, even should the task prove superfluous.
I enclose you a very rude diagram of an experiment upon a heart,
designed as an illustrative proof of your doctrine of the sounds of that
organ, the history of which is as follows :—Having had the good for-
tune, last year, to become possessed of a copy of your work on “ The
Principles of Medicine,” I became, through it, first acquainted with an
intelligible theory of the heart-sounds, with which acquisition I was
intensely pleased, both on account of its beautiful simplicity, and the
pleasure of surmounting an obstacle which had hitherto been to me a
pons asinorum. As to the very great pleasure and profit I derived
from the study of the rest of the book, it will be at present unne-
cessary to speak further.
To my surprise, Sir, however, I found that the doctrines which you
had so courageously, and, in my opinibii, success fully ekplodecL, were
still believed and taught, with but oha or two exceptions, ijy the most
distinguished practitioners and professors in Dublin. ’The knowledge
of this fact made me, of course, but,the mpr.e £ypous’t(J soq<td doc-
trine promulgated: and accordingly, on eyery available opportunity, I
took occasion to produce your book, and discuss your opinions, but I
am sorry to say, by no means with the success I could desire. I found
that the amount of self-satisfied ignorance, indifference, or stupidity,
which was such a very ordinary accompaniment to laborious study and
reputed acquirement, was so great, that notwithstanding the weight
your name carried, I could seldom obtain more than the liberty of hold-
ing my own opinions, under the protection of so eminent an authority.
This being an exceedingly unsatisfactory state of things, it occurred
to me as very desirable, and not impossible, to prove the truth of your
doctrines by the irrefragable authority of a legitimate ex perimentum
crucis. With this hope, during March and April last, I commenced a
series of experiments on ox-hearts, which I had finally the extreme
gratification of finding succeed to my utmost wishes. After several
trials in private to the entire conviction of some intelligent friends, I
was invited by Professor Fergusson, whose clinique I was attending, to
exhibit the experiment to the class in Sir Patrick Dunn’s Hospital.
The result was triumphant : the double sound of the valves, when
thrown by alternating currents of air into tympanic tension, could be
heard all over the room. Dr. Fergusson, who had long held a doctrine
coinciding with yours, was much pleased, and kind enough to honor
the experiment with very liberal commendation.
Some time after, my private teacher, Mr. T. Led wick, of York-
street, requested me to lay the matter before Dr. Lees, of the Meath
Hospital, who did not agree with your views. lie seemed much sur-
prised, and very unwilling to admit the evidence before him, until after
I had satisfied him by repeated examinations, alterations, and modifi-
cations of the experiment ; when, with much candor, he admitted that
he was unable to offer any further opposition to the opinion advocated
by the experiment. Dr. Lees further very kindly introduced the sub-
ject to the notice of his distinguished colleague, Dr. Stokes (author of
“ Diseases of the Chest,”) who, after a private examination, appointed
a morning for me to attend him at lecture, when he delivered a well
digested resume of the various doctrines of the cardiac sounds—during
the course of which I had the very gratifying honor of being pre-
sented by the Doctor to his class, with the request to exhibit and
explain the experiment, which I did, to the best of my ability, as an
illustration suggested by Dr. Billing’s writings, in support of his theory.
The success was perfect, and seemed to give Dr. Stokes very great
satisfaction, who finally pronounced the experiment conclusive. This
public recognition of a much cherished opinion by so distinguished an
authority, gave me extreme satisfaction, in which, I trust I do not pre-
sume too much in hoping that Dr. Billing may somewhat participate.
I have still preserved in my possession the apparatus used on the last
mentioned occasion, which consists of an ox-heart carefully dissected
from the animal, so as to avoid injury to any of the appendages. To
this (as displayed in diagram) I attached an apparatus consisting of a
flanged tube, a, attached to the middle of left ventricle, and piercing its
wall, introduced through the auriculo-ventricular opening, to which was
screwed externally another tube, b, with a flange also, so as to grasp
the wall of ventricle all round the tube, and render the junction air-
tight; to the outer tube a bladder is tied. A free communication is
thus established between the bladder externally and the cavity of the ven-
tricle within. To the left auricle, a similar apparatus, but without
flanges, was then attached by one trunk of the pulmonary veins, the
rest being tied. Then having tied all the offsets of the aorta, I tied a
tube and bladder to its abdominal extremity ; to the distal end of this
a small stop-cock was then tied, into which a brass pipe fastened to the
end of an india-rubber one, can be wedged ; the other extremity of
the caoutchouc pipe is finally attached to the distal extremity of
the auricular bladder. There is thus completed an apparatus permit-
ting a mimic circulation through the left heart, (it being sufficient for
illustration,) which may be conducted with great ease in the following
mode. Let the system be inflated with air through the orifice of the
elastic tube next to the stop cock (marked by an arrow in diagram); when,
having wedged back the stop-cock into the pipe and opened the cock, a
rhythmical circulation may be carried on by alternating manual pressure
applied to each of the three bladders in succession (without removing
any of the three hands applied)—thus representing the successive con-
tractions of auricle, ventricle, and aorta, with the natural attempts at
regurgitation, which close both sets of valves in succession. Hereby a
complete imitation of the normal sounds may be produced on either a
very magnified or diminished scale, according to the force used in pro-
pelling the air. These sounds being produced without any muscular
contraction, or rush of blood, &c., must evidently be valvular, which can
be further demonstrated by removing part of the apparatus, (the auricu-
lar,) so as to show the mitral valves in action synchronously with the
first sound ; or by introducing a wire cage, prevent them closing on
regurgitation, when no sound follows : above all, the first sound is as
perfect as the second, the valvular origin of which is, I believe, undis-
puted. In fine, the illustration, though conducted with air, ought to be
conclusive, inasmuch as a suddenly strained membrane, which gives a
tympanitic sound in air, will do the same in water also, as I have tried,
but not so loudly.
Dr. Stokes, also, in subsequent conversations with me, mentioned a
fact which he had noticed several times in typhus fever, and which he
seemed to think likely to favor your doctrine—viz., that patients, after
the fever had progressed some time, and great debility had supervened,
ceased to have any sound of the heart, though circulation continued.
Sometimes, however, the second continued, the first being absent ; but
it was to be remarked in these cases, that the impulse of the heart was
quite absent. This, no doubt, Sir, the muscular theorists would
endeavor to appropriate, as well as the supporters of your opinions. I
imagine, however, that this additional fact would not be so easy of
digestion to the former gentlemen, which is, that as the patients
improved, impulse was found to return, often with considerable energy,
but unaccompanied for some days by any sounds, or, in some instances,
by the second only. This state of things can be also imitated most
accurately by the bladder apparatus.
I also endeavored to try the experiment with water, but did not
succeed, for want of a proper hydraulic apparatus of adequate power,
which would have been too expensive and laborious an undertaking for
me to have ventured on. I should have mentioned before, a fact of
some interest in connexion with the character of sound produced by
the valves—namely, that when the mitrals were made to act whilst ex-
posed to view, the sound could be produced by the sudden straining of
the valves, when the ventricular bladder wa3 pressed, even though the
valves had been previously in contact, or with a very minute orifice
existing by their partial patency, such as in the accompanying diagram.
This fact would seem to me to disprove the state-
ments made in several works of eminence, that
the second sound is produced by a click of the
sigmoid valves ; the first being regarded by such
authors as muscular, whilst the above fact must, I
think, prove your assertion of both being “tym-
panitic.”
In apologizing for the great length of the present communication, I
would beg to state that I had intended reserving it for a personal inter-
view with Dr. Billing, in London, with which I hoped to have been
favored during the ensuing month; but as certain circumstances have
lately occurred, which I fear may possibly compel me to defer that
visit indefinitely, I have thought it, Sir, more judicious to acquaint you
with the foregoing facts, as, should they happen to afford you any satis-
faction, or not to have been anticipated, the sooner you were possessed
of them the better; for I considered it would have been both imprudent
and indecorous in me to have brought the matter any further into notice
than I have mentioned, which was, indeed, all but unavoidable.
In conclusion, I have, Sir, but to apologize for the liberty I have
taken with your name and opinions; and venturing to hope that my
humble efforts may not be altogether unacceptable, beg to place them,
with much respect and esteem, entirely at your service.
1 am, Sir, your very obedient servant,
Harris Carr Brakyn, T. C. D.