his cases who suffered from the acquired variety of the disease, but found it well marked in those cases who presented cyanosis, depending upon congenital defects in the valve and orifice.

Insufficiency of the valves of the pulmonary orifice extrauterine in origin is beyond all question the rarest form of valvular disease. Its etiology is similar to all other valvular

affections.

A consideration of the disorders of the pulmonary orifice and valves would indeed be incomplete without extended reference to the case reported by Bruen* of a young girl who at the age of twenty years presented well-marked signs of cardiac derangements. The patient was a syphilitic, and was under observation from November, 1878, until July, 1882.

Post-mortem.-Heart, left side: Slight ventricular hypertrophy; mitral valves somewhat thickened at the margins, with roughening of their auricular aspect; valves competent; the left auricle is normal, as are also the aorta and the aortic valves.

Right side: Two of the semilunar leaflets at the mouth of the pulmonary artery are nearly destroyed by atheromatous changes, while the third segment is much thickened and projects as a leaf-like fold, roughening the mouth of the pulmonary artery. This vessel is dilated to twice its normal size, forming nearly an aneurismal dilatation; the vessel-walls are covered with a fringe of vegetation, of inflammatory origin, or due to atheromatous changes. The right auricle is very small and imperfectly developed, the bulk of its cavity being formed by the auricular appendix.

The tricuspid valve was much thickened, but appeared to be competent.

An intra-ventricular communication large enough to admit the forefinger was noted directly beneath one of the two tricuspid leaflets; it was lined with endocardium, and must have allowed free interchange of blood between the two ventricles. Walls of right ventricle were thickened and its cavity dilated.

* Dilatation and Atheroma of the Pulmonary Artery, etc., Dr. E. T. Bruen, Trans. Path. Soc. Phila., 1883, p. 78.

Dr. Bruen's conclusions are as follows: The case well illustrates the fact that an admixture of venous and arterial blood may occur without cyanosis occurring. Pulmonary artery disease is consistent with a fair amount of general health, and compensation by the right heart may occur, just as in cases of aortic disease. In descriptions of pulmonary artery disease attention is called to bronchitis, pneumonia, and hydrothorax as sequential states. In Bruen's case no such complications were present until just before death, when the patient finally succumbed to congestion of the lungs added to the cardiac state.

The aneurism of the pulmonary artery formed a pulsating tumor on the left side of the sternum, between the second and fourth ribs, extending outward from the border of the sternum and including an area covered by a silver dollar. Over the tumor a post-diastolic and a presystolic, bruit-like murmur could be heard at a point between the second and fourth ribs, while close to their junction with the sternum a hoarse systolic murmur could be heard. The bruit was localized; the heart systolic murmur was carried out into the entire arterial system.

Dr. E. O. Shakespeare, remarking upon the specimen, said that he had been struck with one point of great interest in connection with inflammation of the lining coats of the pulmonary artery as evinced by the vegetations. These growths are very rarely found in the venous current; arterial blood seemed a requisite for such diseased action. Evidently the site of the perforation being just below the aortic and pulmonary valves brought about just this necessary prerequisite,viz., abundance of arterial blood within a vessel which normally carries venous blood.

CHAPTER VII.

GENERAL DIAGNOSIS, PROGNOSIS, AND TREATMENT OF VALVULAR DISEASE.

DIAGNOSIS.—In making up our diagnosis of valvular heartdisease it is necessary to proceed in a systematic manner, bearing certain well-established rules in mind. First, we should determine whether there is any actual organic disease present, or if it is not simply a functional disturbance; then we should

consider the alterations, if any, in the size or capacity of the cardiac chambers, together with the changes in its walls.

Most important is it to determine the etiology of the lesion. In order to accomplish this desirable object we should carefully inquire into the antecedent history of our patient, noting well the presence or absence of any family predisposition to heart-disease, also the previous history in regard to certain diseases which have a known cardiac tendency, as rheumatism, scarlatina, and morbilli.

The symptoms present, more particularly those indicating interference in the circulation, are to be carefully chronicled. All-important in this respect are the physical signs. Indeed, it is a good rule to examine the heart in all cases that consult us. In the physical examination we note,

1. The position of the apex-beat and the character of the impulse.

2. The contour of the præcordia.

3. The presence or absence of a tactile fremitus or thrill. 4. The percussion outline of cardiac dulness.

5. Auscultation of the heart-sounds over all the different parts of the præcordia, together with the lines of known transmission.

6. The presence or absence of a murmur, together with the characters of such murmur.

7. The condition of the general circulation, the pulse, and the venous system.

We have already indicated the conditions which cause the præcordia to become either retracted or unduly prominent, and those that displace the apex-beat.* We must always bear in mind that in children organic disease, sometimes of a very serious nature, may exist with but few or any signs, and that even the physical signs in the early stages of the process may be ill-defined and difficult to interpret. On the other hand, patients may complain bitterly of cardiac disorder, and present some objective symptoms, but we will be unable to take a more serious view of the case than by considering it one of mere functional disorder.

* See chapter on "Methods of Study" and Addenda, No. VI.

Prognosis. With increasing knowledge in diagnosis our prognosis is becoming much more favorable. Indeed, it seems patent to us that the prognosis in the young is extremely favorable, and even in adults "heart-disease" is not the awe-inspiring death-knell in the public ear that a few short years ago placed it in the popular mind in the same category that "cancer" occupies to-day.

The first question asked by friends and relatives is, What is the danger of sudden death, and is a cure possible?

The probable duration of the case should, if possible, be determined. This, of course, depends greatly upon the seat and extent of the lesions and their concomitants.

Simple roughening of the endocardium is per se of little consequence, although it will produce a murmur, if it does not extend and involve the valves, which renders the case more serious, but not of equal gravity in all the valves. For example, sudden death is perhaps most likely to ensue in cases of aortic regurgitation, the least likely in mitral regurgitation, although it is said to have occurred in rare instances. Cases of aortic obstruction may last for a long time, their main effect being damming back of the blood-current, thus affecting the heart and lungs. Mitral stenosis becomes serious on account of the inability of the auricle to undergo simple hypertrophy, unaccompanied by early dilatation; the lungs are more speedily affected in cases of mitral disease than in any other valvular lesion.

Tricuspid regurgitation is at the same time one of the most distressing and most serious of the valvular disorders; the venous system speedily becomes overloaded and the symptoms. exacting. Furthermore, the patient is apt to have multiple cardiac lesions, the tricuspid leak being one of the last of the series. The last hours in the life of a patient with this lesion are among the most trying scenes of a practitioner's experience. All extensive or double lesions-i.e., obstruction and regurgitation-of course increase the gravity of the prognosis.

A cardinal question in the prognosis, Is valvular disease ever curable? From our own experience we would certainly answer this in the affirmative, as we have met cases in the young in which distinct mitral murmurs due to organic dis

ease have disappeared under our observation, although we do not think that the valve is ever restored to its normal condition. Still, it seems probable that the inflammatory deposits may be partly absorbed or removed after the lapse of several

years.

Hypertrophy in the majority of cases is to be considered nature's method of protecting herself, and is not to be interfered with. It alone becomes dangerous when excessive, as it may cause the blood to tear through diseased arteries, or, on the other hand, if the right heart is hypertrophied, the lungs are supplied with an over-abundance of blood, and, per consequence, are constantly in a state of active congestion.

Dilatation of the chambers is always dangerous, and is never to be considered in any light but as one of evil import. Its gravity is in proportion to its degree and its relation to the hypertrophy; if in excess, the prognosis is serious indeed. It appears to us that the degree of dilatation is the keynote of the prognosis. Many cases of sudden death in valvular disease are due to a weak, flabby, dilated heart, which will be found to be in a condition of asystole.

Dilatation adds much to the patient's distress, throwing increased labor upon the circulatory apparatus, and predisposing to local or general dropsy.

Should fatty degeneration of the heart-wall arise, sudden death may occur at any time; pericardial adhesions tend to set this change on foot, and hence should be considered in making up our prognosis.

A summing up of all symptoms present will throw considerable light upon the case; for instance, great irregularity or intermittency in the heart's action, serious interference in the venous circulation, dropsies, apoplectiform or epileptiform seizures, render the outlook somewhat alarming, remembering, however, that patients often survive a long time after being "water-logged;" the intervention of pulmonary disorders will cause serious symptoms to arise, also increasing the existing dropsy or causing a general anasarca, all of which may subside. with the subsidence of the lung-symptoms. In all cases we must carefully investigate the condition of the kidneys, iungs, and arteries, as upon their integrity to a great extent depends