lesions. Auscultation furnishes important information, first, nega. tively, by showing the absence of adventitious sounds indicative of valvular lesions, and, second, positively, by showing that the natural sounds preserve their essential characters and normal relations to each other.

As regards adventitious sounds, the question arises, may not an endocardial murmur be produced by functional disorder alone? It is supposed that a mitral systolic murmur sometimes occurs in paroxysms of palpitation, in consequence of spasmodic action of the papillary muscles connected with the mitral valve, interfering with the action of the latter sufficiently to permit a certain amount of regurgitation irrespective of any valvular lesions. Without denying the possibility of this occurrence, it must be extremely rare, and a murmur thus produced is necessarily either intermittent or of a transient duration. A murmur referable to the mitral orifice, in the vast majority of instances, proceeds from physical changes, although these may be trivial as regards any immediate effects; and if the murmur be persistent, it certainly denotes lesions, either innocuous or otherwise. At the arterial orifices, viz., the pulmonic and aortic, a murmur is often present in connection with functional disorder of the heart, when there are no valvular lesions in these situations. This murmur is therefore inorganic, and in the great majority of cases it is dependent on the condition of the blood. The very frequent association of functional disorder with anæmia, accounts for the frequency of the murmur. May not the murmur in some instances be dynamic, i. e., due to the excited action of the heart, without involving an abnormal condition of the blood? The affirmative is not improbable, but it is difficult to answer this inquiry positively, and practically it is not very important to do so. The question to be settled, clinically, in individual cases is, whether a murmur referable to the aortic or pulmonic orifice, coexisting with disturbed action of the heart, be organic or inorganic. The points involved in the discrimination of organic and inorganic murmurs have been considered in a preceding chapter.' These points may be here briefly recapitulated. An inorganic murmur is always systolic, and very rarely, if ever, rough in quality. As suming that it is produced at the arterial orifices, and therefore seated at the base of the heart, it may be referred to the aorta or pulmonic artery, either or both; if the latter, this fact renders its inorganic character almost certain, provided congenital valvular

1 Chapter IV. p. 202.

lesions are excluded. An arterial murmur is heard over the carotids, and perhaps over other large arteries which are accessible.' Venous hum in the veins of the neck, especially on the right side, coexists in the great majority of instances. The murmur is usually feeble, and variable in intensity; it is often intermittent. The palpable evidences of anæmia are usually present, and it occurs much oftener in females than in males. An organic murmur, on the other hand, may be diastolic, or systolic and diastolic murmurs may be combined. It is often rough or musical. It is referable to the aortic orifice, if not to the mitral, unless it be dependent on congenital valvular lesions. If not propagated into the carotids, murmur in this, as well as in other arterial trunks, may be wanting. Venous hum may not coexist. The murmur is persistent and less fluctuating as regards intensity. Anemia is often not apparent.

Attention to these differential points will generally enable the practitioner to discriminate correctly between an organic and inorganic murmur; but this discrimination, practically, with reference to the question, whether disturbed action of the heart be due purely to functional disorder, or not, is of less importance than might at first be supposed. The disturbance is probably dependent on functional disorder, whether an existing murmur be organic or inorganic, if the heart be not enlarged. It may be stated, as a rule, that valvular lesions do not give rise to notable disturbance of the heart's action prior to more or less enlargement. Hence, cardiac disorder in a marked degree, when valvular lesions exist, is attributable to abnormal conditions which are independent of the latter. The fact already repeated more than once is not to be lost sight of, that the causes of functional disorder may be superadded to organic disease; in other words, that structural lesions do not render the heart exempt from the liability to become functionally disordered in consequence of the same causes which occasion disturbance of its action when it is structurally sound.

The heart-sounds in cases of functional disorder, preserve essentially their normal characters. They are, however, intensified in proportion to the increased force of the heart's action. Their intensity is often such that they are perceived by the patient with great distinctness, especially at night. The beating of the heart is sometimes distinguished by others at some distance from the

It is to be borne in mind that an arterial murmur may be produced simply by pressure over the artery with the stethoscope.

chest. The valvular element of the first sound is in some cases unusually developed, owing to the abnormal force and quickness of the systolic contractions, and it may predominate over the element of impulsion, rendering this sound short and valvular in quality like the second sound. The predominance of the valvular element of the first sound may thus occur in opposite conditions as respects the muscular action of the heart, viz., when it is enfeebled, and when it is excited. The first sound, more than the second, is affected in its intensity, by the vital condition of the heart. It is relatively weakened, and may be suppressed when the muscular power of the organ is greatly reduced. On the other hand, it becomes the accentuated sound at the base, and at points removed from the præcordial regions, when the muscular action is increased by morbid excitement. The integrity of the heart-sounds; the normal relative intensity of the aortic and pulmonic second sound, and of the mitral and tricuspid elements of the first sound, constitute important evidence, in cases of disturbed action of the heart, that the latter is due to simply functional disorder.

The apex-beat, or systolic sound of the heart, is sometimes accompanied by a ringing intonation called by Laennec cliquement metallique, or metallic tinnitus. This is occasionally observed to some extent, in health, especially in young persons, even when the heart is tranquil. It is, however, in general, a sign of excited action of the organ. It may be imitated by making light percussion on the back of the hand, the palmar surface being applied over the ear. Hope explains the production of this metallic ringing sound by supposing that "the heart in gliding forwards and upwards during its systole strikes with its apex against the inferior margin of the fifth rib, and thus creates an accidental sound, attended by cliquetis when the blow is smart." He adds: "It may be prevented at pleasure by pressing the edge of the stethoscope or anything else into the intercostal space by which that space is put, internally, on the same plane or the rib over which the heart then glides without catching." If this be the correct explanation, inasmuch as the heart does not move upwards and forwards during its systole, the sound must be due to the apex impinging against the upper margin of the sixth, rather than the lower margin of the fifth rib, that is, assuming the point of apex-beat to be in the fifth intercostal space, as it is in the majority of persons. Whatever may be the explanation, clinical observation shows that the sign occurs when the action of the heart is abnormally quick and forcible, and that it is produced by the

movements of the apex against the thoracic walls, can hardly be doubted. It may occur in cases of hypertrophy, but it is more apt to be developed in connection with merely functional disorder, and it is, therefore, to some extent, significant of the latter. It was stated by Hope, that he never found it to occur in any but the meagre. It occurs certainly very seldom in persons whose chests are thickly covered with muscle or fat. Tympanitic distension of the stomach contributes to the intensity and clearness of the sound, and it may occur only under this condition. In a case observed by Dr. Walshe the sound was so loud as to be a source of alarm to the patient. Dr. Stokes remarks, and justly, that it is more common in cases in which the heart acts with great force combined with regularity of action, than in the irregularly acting hearts. As a physical sign, tinnitus is not of much practical value, since it may occur when the heart is excited, and, under circumstances, when it is tranquil, in health, and since it occurs in cases of enlargement as well as of merely functional disorder, although more frequently in the latter. It is perhaps important to warn the inexperienced auscultator not to attach to it a degree of significance as a morbid sound to which it is not entitled.

DIAGNOSIS OF FUNCTIONAL DISORDER OF THE HEART.

The diagnosis of functional disorder of the heart involves in all cases the question whether organic disease be or be not present. The symptomatic phenomena referable to the heart are sufficiently explicit as to their source. The patient, as well as the physician, is able at once to determine their cardiac origin. But whether these phenomena proceed merely from disturbed action, or are due to a structural affection, is not so easily determined. The question is one of great practical importance. If there be only functional disorder, the physician is warranted in giving positive assurances of the absence of danger, and in holding out confident expectations of recovery. If organic disease be present, such assurances and expectations are not admissible. An intelligent patient is sufficiently aware of the difference between organic disease and functional disorder to appreciate its great importance; and he anxiously appeals to the physician for positive information with respect to this point. The ability to say positively that organic disease does not exist, often enables the physician to exert a moral influence of

no mean value upon the continuance of the malady, as well as in rendering it more supportable. Errors in diagnosis are quite common. Instances have repeatedly come under my observation in which patients suffering only from disturbed action of the heart, having been told that they were affected with organic disease, have lived for months or years under a sense of danger of sudden death, a condition of mind highly conducive to the perpetuation of the disorder. On the other hand, it is not uncommon for the symptoms connected with structural lesions to be imputed to merely functional disorder. The latter error, although less unfortunate as regards its consequences than the former, sometimes leads to evil results. If the physician be not confident in his ability to decide as to the existence or non-existence of organic disease, but is sufficiently prudent not to commit himself to any conclusion, he loses the advantage which he might avail himself of, assuming the affection to be merely functional, and the patient naturally construes his reserve or indecision into an unfavorable opinion. In short, there are few problems in clinical medicine more important than that which calls for a decision as to the existence of a purely functional disorder of the heart, or an organic affection; and this problem cannot fail to present itself very frequently in medical practice. Cases of organic disease of the heart are not infrequent, and cases of merely functional disorder are exceedingly common. The importance of the diagnosis must be felt almost daily by the reflecting and conscientious practitioner.

But the diagnosis involves more than the question whether disease be or be not present. Functional disorder may be superadded to organic disease. The latter may exist, but not to an extent to occasion immediate inconvenience or danger, the symptomatic phenomena being due to disturbed action arising from morbid conditions, independently of the structural lesions which happen to coexist. The fact that functional disorder and organic disease may be associated, and the former not dependent on the latter, is not to be lost sight of. Hence, it is not enough to decide that organic disease is present; the question then arises, Is this organic disease the source of all the symptomatic phenomena referable to the heart, or are they not due, in a greater or less degree, to functional disorder dependent on morbid conditions which have no connection with the cardiac lesions? This is a question of great importance, which is to be considered in the cases of disturbed