Symptoms and Pathological Effects.-The primary effect of obstructive or regurgitant lesions situated at the pulmonic orifice is enlargement of the right ventricle. The secondary and remote effects, and the symptoms thereon dependent, are essentially those which are occasioned by tricuspid lesions, being due to distension of the right auricle, tricuspid regurgitation, and congestion of the systemic veins.

TREATMENT OF LESIONS AFFECTING THE VALVES AND ORIFICES OF THE HEART.

With reference to the management of patients affected with chronic valvular lesions, several important considerations, which have been already presented, are to be kept in mind.

1. The anatomical changes which the valves and orifices have undergone are irremediable, and therefore do not claim any special medicinal treatment. The existing lesions must remain. The damage which they have occasioned cannot be repaired. Medication employed for that object will be worse than useless. The morbid processes giving rise to the lesions, have occurred long before the symptoms of an organic affection of the heart became developed. In the majority of cases the origin of the affection may be dated at an attack of acute rheumatism several years prior to the period when ailments referable to the heart are first experienced. The changes incidental to these processes have, in the mean time, been slowly progressive. They will, in all probability, continue to progress, involving more and more damage. This we cannot expect to prevent, but something can be done to retard their progress, and, more especially, to control their primary effects.

These facts not being always sufficiently appreciated, practitioners sometimes employ mercury and other remedies called alteratives, with a view to the removal. of morbid material deposited on or about the valves. I have met with cases in which depletion, low diet, counter-irritation, etc., were resorted to, under the idea that the lesions involved persisting chronic inflammation of the endocardial membrane. These measures can hardly fail to aggravate the cardiac symptoms, and to expedite effects which it is a great object of the management to postpone as long as possible.

2. Lesions may exist, giving rise to murmurs more or less intense, without producing any immediate morbid effects, not involv

ing either obstruction or regurgitation. Such lesions may remain for an indefinite time innocuous, but there is a liability of the changes incidental to them leading, at some future period, to serious results. These cases, therefore, claim a certain amount of watchfulness and supervision. The existence of a cardiac murmur dependent on innocuous lesions is often ascertained by accident, there being no symptoms of disease referable to the heart. I have repeatedly met with it in examining persons who considered themselves in perfect health. These persons are in no immediate danger, and it would give rise to needless alarm to inform them that they have an organic affection of the heart, since it is a common notion that any such affection involves liability to sudden death. There is, however a prospective danger not to be overlooked. It has occurred to me in two instances to examine for life insurance persons presenting an organic murmur, without other evidence of cardiac or other disease, who were, of course, not deemed proper subjects for insurance; but they succeeded in obtaining policies in other companies, and both have since died with well-marked disease of the heart.

3. Even when lesions exist which do involve more or less obstruction or regurgitation, it does by no means follow that the immediate danger is great. This statement holds good in some cases in which there is, at the same time, considerable enlargement of the heart. I am acquainted with several persons who do not consider themselves as invalids, some being engaged in active business, in whom the existence of organic murmur, with cardiac enlargement, was ascertained many years ago. In such cases the organic affection does not call for active therapeutical measures, but knowledge of the existence of the cardiac affection is highly important to the practitioner, and should influence his advice as regards habits, regimen, etc., as well as his treatment of intercurrent diseases. The tolerance of lesions in some instances is truly remarkable. A boy, aged eleven years, who recently came under my observation, presenting three organic murmurs, viz., a mitral regurgitant, an aortic direct, and an aortic regurgitant, with much cardiac enlargement, the præcordia projecting and the apex beating half an inch without the nipple, not only made no complaint of symptoms referable to the heart, but was able to take violent exer

1 Vide Essay on Clinical Study of Heart-Sounds, Trans. Am. Med. Association, vol. xi.

cise, and to engage in rough sports with apparently as much ease as any of his companions. In this as in other instances in which lesions involving more or less obstruction or regurgitation are borne without notable inconvenience, the physical signs denoted enlargement by hypertrophy, not by dilatation, and the action of the heart was vigorous.1

4. The enlargement of the heart being, as a rule, proportionate to the amount of obstruction or regurgitation, or both, occasioned by valvular lesions, the abnormal size of the heart may, in general, be taken as a criterion of the importance to be attached to the lesions. So long as the heart is not much enlarged, the patient is exposed to only certain contingent evils incident to the lesionsfor example, arterial obstruction from detached deposits. Exclusive of accidental events and associated affections, the symptoms and remote effects of obstructive and regurgitant lesions correspond to the primary effects of these lesions, as denoted by the increased bulk of the heart. This statement holds good in the majority of cases, but, as already stated, the rule is not without exceptions.

5. The secondary and remote effects of valvular lesions, as a rule, are not developed so long as the enlargement of the heart is by hypertrophy, unless, from some cause, weakness of the organ has been induced. Obstructive and regurgitant lesions tend first to produce hypertrophy. The muscular walls increase in thickness up to a certain limit. When this limit is reached, dilatation of the cavities ensues, and, finally, predominates over the hypertrophy. The increased power of the organ, incident to the hypertrophy, compensates for the immediate consequences of obstruction and regurgitation. The hypertrophy is, in fact, a conservative provision to obviate the evils of obstructive and regurgitant lesions. The patient is comparatively safe while hypertrophy predominates. The secondary and remote effects are incident to the dilatation which takes place after the hypertrophy has reached its limit. The immediate danger, other things being equal, is proportionate to the amount of predominance of the dilatation. This is because the heart is weakened in proportion to the predominance of dilatation. Weakness of the organ, due to other causes than dilatation, will also favor the development of the secondary and remote effects of valvular lesions. These facts are of great importance in their bearing on the treatment of patients affected with these lesions.

1 Case of Horan, New Orleans Charity Hospital. H. Reports, vol. xiii. p. 84.

In view of the foregoing considerations, the main objects of treatment which relate directly to the condition of the heart, in the early stage of valvular lesions, are, 1st. To prevent, or, as far as possible, to retard the progressive anatomical changes incident to the existing lesions; and, 2d. To obviate the tendency to weakness and dilatation of the heart.

The anatomical changes seated in the valves and orifices, give rise to the varied morbid appearances which have been mentioned' in Chapter third. These changes cannot be reached by any special remedies. Their progress can only be indirectly affected by preventing overstraining of the valves, which must occur whenever the organ is unduly excited or overtasked, and by avoiding the causes which favor renewal of inflammation of the endocardium. Excessive muscular exercise, great mental excitement, the intemperate use of alcoholic stimulants, etc., promote the progress of valvular lesions, by exciting unduly and overtasking the heart. Patients with valvular lesions devoid of immediate danger, should pursue a course of life which, as far as practicable, will be exempt from causes inducing great disturbance of the circulation. In pointing out the regimen, habits, etc., however, the importance of fostering the muscular power of the heart, to which reference will be presently made, is not to be lost sight of. The causes favoring the development of endocarditis, are, in general, those which tend to give rise to rheu matism, since in the vast majority of cases endocardial inflammation is of rheumatic origin. Unusual exposure to the vicissitudes of the weather are regarded, perhaps justly, as often determining an attack of rheumatism when the diathesis exists. The existence of the diathesis is shown by the previous occurrence of one or more rheumatic attacks in the majority of the persons affected with val vular lesions, the origin of the latter being referable, in such cases, to a former attack of rheumatism. A fresh attack exposing the patient to a renewal of the endocarditis, is a calamity to be averted, if possible, by avoiding the exciting causes so far as these are appreciable. In fulfilling this object of treatment, hygienic regulations are chiefly involved. Judicious management will undoubtedly do something toward rendering the progress of the lesions more slow than would otherwise be the case; but we can hardly expect to arrest their progress. If, however, they are very slowly progressive, life and comfortable health may be prolonged for an indefinite period, perhaps even to an advanced stage.

1 Vide page 120.

The same hygienic regulations are equally important with reference to the second object, viz., to obviate the tendency to weakness and dilatation of the heart. The judicious management of patients affected with valvular lesions prior to the development of the secondary and remote effects of these lesions, depends in a great measure, on a proper appreciation of this object. It is commonly said by writers on diseases of the heart, that the treatment of valvular lesions virtually resolves itself into that designed to prevent and diminish enlargement of the heart. This involves an important error as well as an important truth. It is highly desirable to prevent dilatation but not to arrest hypertrophy. On the contrary, if enlargement must occur as a result of obstructive or regurgitant lesions, hypertrophy is to be encouraged, if by so doing, dilatation may be prevented. The serious evils of valvular lesions, as we have seen, occur when the limit of hypertrophy has been reached and dilatation predominates. In the predominance of hypertrophy may be said to consist, in a great measure, the security of the patient. This remark is also applicable to the muscular power of the heart. So long as the organ acts with vigor, the secondary and remote evils are deferred. Weakness of the heart leads to these evils. Weakness predisposes to dilatation, and, conversely, dilatation involves weakness. To prevent weakness and dilatation, then, in the early stage of valvular lesions, is the great object of treatment so far as it relates directly to the condition of the heart.

Undue excitement and overtasking of the heart induce weakness and favor dilatation. The muscular power here, as in other situations, is exhausted by too great exertion, and the walls yield more readily to distension, under these circumstances, from the accumulation of blood within the cavities. The causes, already referred to, which excite unduly and overtask the heart, viz., excessive muscular exercise, mental excitement, the intemperate use of alcoholic stimulants, etc., are, therefore, to be avoided with respect to the second, not less than the first object of treatment. Exercise, however, within certain limits, is highly important with a view to the preservation of the power of the heart's action. Patients affected with obstructive or regurgitant lesions will retain a compensatory vigor of the heart, and the epoch when dilatation succeeds hypertrophy will be postponed for a longer period by habits which involve a judicious amount of exercise than by a life of complete repose. Active occupations, whether pursued as a calling or for amusement, or with reference merely to exercise,