In

distinct murmurs occur synchronously at different orifices, the one may mask or overpower the other, so that, for instance, a mitral regurgitant murmur may render a tricuspid regurgitant murmur inaudible. others, again, the coexistence of obstruction and regurgitation may materially modify the character of a murmur, so that, for instance, the occurrence of extensive mitral regurgitation may so far weaken the stream of blood flowing into the aorta, as to diminish or even put a stop to a murmur which would otherwise have resulted from obstruction at the aortic outlet.

But there are still further difficulties in the way of a diagnosis of valvular disease. The heart may be displaced by pleuritic effusion, or by some other form of intra-thoracic disease, or it may be hypertrophied and dilated. Thus, before any inference can be drawn as to the source of a murmur, the position of the heart itself must be determined, and due allowance made for its altered size, and for any displacement it may have undergone.

Again, the seat at which the various murmurs are heard of maximum intensity may undergo material alteration, in consequence of changes in the texture of surrounding parts. Thus, when the anterior margin of the right lung is emphysematous, an aortic murmur may be heard better at the left base than at the right, and this is more particularly the case when the left lung is partially solidified. The reverse holds good in regard to a pulmonary murmur, when the anterior margin of the left lung is emphysematous and the right lung solidified.

Again, if the patient be not seen until after the heart's action has become turbulent and irregular, it is sometimes impossible to determine the rhythm of a murmur, and equally so, therefore, to feel certain as to its nature. But these are difficulties which rarely occur, and, although cases are occasionally surrounded by causes of doubt and perplexity, calculated to baffle even the most experienced observer, yet, in the majority of instances, due attention to the rules already laid down, relative to the diagnosis of the various murmurs-to the character and position of the abnormal sound, to the direction in which, and the period of the heart's action at which it is heard, to the state of the arterial pulse, and to the nature of the accompanying symptoms-will enable a cautious and intelligent practitioner to arrive at a diagnosis which post-mortem investigations will fully verify.

The prognosis of valvular disease is a subject beset with the greatest difficulty. It has been already stated, that, cæteris paribus, it is most

unfavourable in cases of mitral and tricuspid regurgitation, and least so in cases of aortic obstruction. But these bald facts afford no measure of the average rate of progression of the disease, nor any clue to a test by which its duration in any given case can be estimated. The stethoscope informs us of the existence of a murmur, and careful observation will generally enable us to arrive at a correct conclusion as to the fact of that murmur being dependent on functional or organic derangement. But an organic valvular murmur is not inconsistent with a considerable prolongation of the term of life, and the intensity of a murmur does not afford trustworthy evidence as to the amount of the organic disease, or as to the degree to which the circulation is obstructed. Nay, an excessive amount of disease, by producing excessive obstruction, and so diminishing the force of the blood's current, may cause the cessation of valvular murmur, whilst, on the other hand, tricuspid regurgitation, which is the form of disease which proves most rapidly fatal, is precisely that which least constantly gives rise to murmur. The facts appear to

be what careful observation might lead one to infer, viz., that the rapidity with which any form of valvular disease will prove fatal must depend upon

1st. The precise character of the disease; that form of disease which is most rapidly productive of systemic or pulmonic capillary congestion being that which will prove most rapidly fatal.

2ndly. The extent of the disease; the obstruction being greater, and the effects of obstruction more rapidly induced, in proportion as the disease is extensive.

3rdly. The state of the heart as regards dilatation and hypertrophy; valvular disease being more rapidly fatal when it occurs in a heart which is already dilated and hypertrophied than when it is set up in a healthy heart, inasmuch as dilatation and hypertrophy of the heart have a tendency to induce tricuspid and mitral regurgitation, and so, indirectly, to promote systemic and pulmonic capillary congestion.

4thly. The state of the heart as regards its textural integrity; inasmuch as valvular disease runs a less rapid course when the heart is texturally sound, and therefore little prone to dilatation, than when its muscular fibre is weak or in a state of degeneration, so that its cavities readily dilate under the extra strain put upon them, and thus very speedily admit of increased regurgitation. 5thly. The textural integrity of the arteries; inasmuch as when the coats of these vessels are loaded with atheromatous or calcareous

deposits, their elasticity is impaired, and a great extra strain on the heart results.

6thly. The condition of the blood; inasmuch as unhealthy blood by leading to malnutrition of the heart and of the tissues generally, with congestion of the systemic capillaries, not only weakens the heart and renders it irritable, but at the same time subjects it to an extra strain, and so conduces to dilatation of its cavities. 7thly. The state of the lungs and the other viscera; for the reason that disease or irregular action of any of the principal organs of the body is itself productive of, more or less, impediment to the circulation, and becomes a serious hindrance to the action of the heart when that organ is in any way deranged.

8thly. The regularity of the various secretions; the fulness of the vessels and the poisoned condition of the blood which result from defective excretion being provocative of deranged cardiac action. 9thly. The mode of life which the patient pursues; the strain on the heart being infinitely smaller, and the tendency to dilatation and so to increased regurgitation and capillary congestion, far less when the patient leads a quiet life and avoids everything which is likely to excite the action of the heart, than when he adopts an opposite course, and, either by bodily exercise or emotional excitement, makes a large demand on the action of the damaged organ. Accordingly, if the heart be healthy at the date of the occurrence of valvular mischief, if the extent of that mischief be not excessive, if the blood be of a normal character, if the viscera be healthy, and the secretions free, and the patient's mode of life regular, temperate, and sedentary, there is scarcely any limit to the time to which life may be prolonged; whereas, if the heart be hypertrophied and dilated at the time when the valvular lesion occurs, if the blood be spanæmic, if the patient's lungs or other viscera be unsound, or his secretions irregular or defective, or, again, if he leads a laborious life, or habitually takes active, straining exercise, then, even though the valvular lesion be of precisely the same character and extent as in the former instance, the disease would run a rapid course, and prove fatal probably within two or three years. In any and all cases life is apt to be arrested suddenly by syncope.

The treatment of valvular disease of the heart is necessarily palliative, not curative. Its aim or object is to regulate the action of the heart, by moderating undue action, or, by supplying the stimulus essential to more forcible action in a weakened organ, to control the tendency to local congestion, and to mitigate or remove the symptoms resulting

from cardiac derangement. More than this it cannot effect; for nothing will avail to remove organic valvular lesion. Practically, therefore, the points to be decided are-1st, whether the action of the heart is too forcible, or too feeble; 2ndly, whether any pulmonary or other local congestion calls for immediate relief; 3rdly, whether dropsy is producing urgent distress; and 4thly, whether any, and if so, which, of the excretory organs are defective in action. If the patient be plethoric, the heart's action turbulent, and its impulse forcible, moderate venesection, or the abstraction of blood by cupping between the shoulders, followed by dry cupping in the same situation, will often afford immediate relief to the palpitation and oppression at the chest. But though the moderate abstraction of blood is serviceable in these cases, repeated or profuse venesection is dangerous, as calculated to excite irritability of the heart, impoverish the blood, and induce dropsy. And, if the patient be pallid and of lax fibre, and the heart's impulse be feeble, then general venesection is not admissible, notwithstanding the existence of oppression at the chest, and of uneasiness in the region of the heart. The utmost which can be safely done by bloodletting in such cases, will be effected by the application of a few leeches to the præcordial region; and very generally relief will be obtained even more readily by purgatives, aided by dry cupping, mustard poultices, or turpentine fomentations.

When active congestion of the lungs exists, venesection, or cupping, dry cupping, blisters, and sinapisms, are imperatively called for, and expectorants may be administered in aid of other remedies. But it must ever be borne in mind in the treatment of this form of pulmonary congestion, that the mischief we have to combat is essentially cardiac, not pulmonary, and that remedies which will relieve the cardiac distress will at once mitigate or remove the oppression on the lungs. Hence, although in some few instances ipecacuanha, or tartarized antimony, may be useful, and, in others, squills, senega, and the more stimulating expectorants, our chief reliance must be placed on bloodletting, dry cupping, counter-irritation, and the use of internal remedies calculated to stimulate increased excretion, and to regulate the action of the heart. If the bowels be costive, a brisk purgative must be given; if the liver be engorged, and the conjunctivæ yellow, the administration of a few doses of calomel or blue pill, in combination with or followed by a purgative, will be essential to the action of other remedies; if the kidneys be congested, and the urine scanty and albuminous, dry cupping across the loins, or a warm bath, will often prove extremely serviceable, removing all trace of

albumen, and promoting free diuresis; but if they fail, saline and other diuretics must be administered. Dyspnoea and paroxysmal shortness of breath may be relieved by a cough drop containing æther and lobelia, stramonium, hydrocyanic acid, belladonna, or hyoscyamus, whilst, if the stomach be much deranged, as it usually is in cases of heart disease, owing to the obstruction in the portal circulation, occasional doses of blue pill with antacids, light vegetable bitters, and warm carminative medicines must be had recourse to. Sometimes in these cases hæmatemesis occurs, or hæmorrhage takes place from the bowels, and gives considerable relief.

The action of the heart must be carefully regulated. A belladonna plaister should be applied to the cardiac region, whilst recourse is had to the internal administration of the veratrum viride, aconite, hyoscyamus, and other remedies which exert a sedative influence over the heart. Opium, which allays the nervous irritability, on which palpitation in some measure depends, may also be given, if the patient be excited and unable to obtain refreshing sleep. But, inasmuch as opiates are prone to derange the stomach, and interfere with or arrest secretion, their administration should be avoided if possible. If the heart be weak, and its impulse feeble and irregular, no treatment can be satisfactory which does not involve the administration of digitalis. It stimulates the heart, and regulates its action, augments the tone and contractility of the vessels, increases the flow of urine, and exerts a restorative and calming influence on the system which is not to be attained by any other means.

*

Seldom, however, are these measures of more than temporary service in patients who are pallid, and whose heart's impulse is feeble. Under these circumstances, iron is needed to give effect to the other treatment. In no form of disease are the effects of the judicious exhibition of this medicine more strikingly displayed. If taken for some months in combination with diuretics and light bitter infusions, whilst, at the same time, the condition of the liver and alvine evacuations is carefully attended to, and the force and regularity of the heart's action sustained by the administration of digitalis, the results are often most satisfactory. The palpitation subsides, the dyspnoea and breathlessness pass off, the pulse becomes more regular, and of better strength, the appetite improves, and the aspect and sensations of the patient betoken returning health. An essential element in the treatment of cardiac disease is the careful *This is contrary to received doctrines, but it is true, nevertheless, in proof of which I would refer the reader to pp. 144-5 of this treatise.