rendered more difficult by anatomical conformation, the small relative size of the heart, and the proximity of the ear to the heart itself.

The diagnosis of a mitral regurgitation is not completed until we have recognized the local and general changes consequent upon its existence. It is also upon the gravity of these concomitants that we in great part determine the significance and prognosis of the affection.

In most cases there will be found to be a slight mitral stenosis coexisting, which, in a measure at all events, tends to compensate the insufficiency. During systole the blood finds its way into the left auricle through the insufficient valve, the leak detracting from the amount which the ventricular systole should have expelled into the aorta. We thus see that, on the one hand, the aorta and the general circulation receives too little blood, whereas the left auricle receives too much, as it is now supplied by the left ventricle in addition to its normal supply from the pulmonary veins. This increased supply rapidly sets on foot hypertrophic changes in the auricular wall, which almost as rapidly gives way to dilatation. Synchronous with the hypertrophy is to be noted a rise in tension, starting in the auricle and being propagated into the pulmonary veins, which will give evidence of increased nutrition in the hypertrophic condition of their walls, with here and there foci of fatty degeneration. The increased tension does not, however, stop at the veins, but extends into the capillaries of the pulmonary artery and on into the right ventricle, then the auricle, and eventually into the entire venous system. A moment's reflection will show us that this general reversal of pressure will produce diminished tension in the aorta and increased tension in the venous system. Hence will we find, in cases of mitral insufficiency permitting regurgitation which has been of any duration, that the tension is highest in the pulmonary veins and venæ cave, and at its minimum in the aorta.

The chambers of the heart become speedily deranged, some by dilatation and others by hypertrophy, or by a combination of both. The left ventricle is usually found in a condition of hypertrophy, as it receives the blood under high pressure from the pulmonary veins, and furthermore, it performs all its func

tions under high pressure also. The left auricle will usually, in fact always, be dilated; the right ventricle hypertrophied. The early alteration in the cavities occurs without the individual's knowledge; it is only when the compensation is deranged and the cardiac equilibrium is interfered with that the patient becomes aware of any discomfort. This change in the cardiac action is usually due to alteration in the myocardium, allowing dilatation; should the pericardium be adherent, this dilatation the more speedily arises. Now it is that palpitation arises, owing to the dilated chambers endeavoring to expel their unduly large contents, more noticeable, of course, during active exercise, when the circulatory apparatus receives undue stimulation. Shortness of breath will also become an exacting symptom, as the system at large demands increased oxygen, which even the rapid breathing is unable to supply; local or general dropsy is apt to arise, and, when occurring in the serous cavities, constitutes a grave element in the prognosis. Dry cough, in many cases due to the congestion of the bronchial vessels, will to the patient be the sole symptom that leads him to consult medical aid, and then the condition of the mitral valve is revealed. By this time the alteration in the chambers has so far progressed that the cardiac impulse will be seen and felt lower down than usual, even as low as the sixth or seventh interspace and outwards to the axillary line, or, as we have noted it, in the axilla. Inspection will also reveal marked undulations, even as far to the right as the epigastrium; a purring sensation, the purring tremor of Laennec, will be recognized by placing the hand over the præcordia, synchronous with the systole. Percussion will show a greatly increased area of dulness, which will still, however, maintain the shape of an irregular triangle, to which we called attention earlier in our study.

The degree to which the chambers in cases of mitral disease may undergo dilated hypertrophy and thus alter the percussion outline is well illustrated by the accompanying copy of a photograph of a child under the care of Dr. Hare,* whose history is as follows:

* We are indebted to Dr. Hare for permission to publish this case.

Lizzie D., æt. twelve, presented herself at the Children's Dispensary of the University of Pennsylvania.

Mark shows point of main apex-beat; the broken line indicates approximation of cardiac and hepatic dulness.

Auscultation.-Over the præcordia a loud, rasping, machinery-like sound was heard, which was almost constant, as the heart was acting with great rapidity (150 per minute). By careful auscultation the abnormal sounds were resolved into a predominately presystolic mitral murmur, followed by a soft, purring, systolic bruit at the same valve. No aortic disease could be discovered; both sounds are heard with distinctness at the ensiform cartilage, and at the pulmonary area the second sound is markedly accentuated. The mitral murmur has a wide distribution, is just heard immediately to the left of the sternum in the second and third interspaces, increasing in intensity as the apex is approached and passed and carried on to the angle of the left scapula.

There is no arterial pulsation visible at the wrist.

Cardiac dulness began an inch to the right of the sternum, and extended to the eighth interspace at the posterior axillary line. The distance from the nipple to the extreme left point