Diagnosis. — The systolic murmur of mitral regurgitation is heard upon the left side of the sternum; as a rule, loud est at the apex; and transmitted toward the left axilla. if both the mitral and the tricuspid valves are incompetent, usually upon careful use of the stetho scope an area can be found, going from, left to right, where the mitral systolic murmur ceases, and on further advance toward the right an area where the tri cuspid murmur begins. Moreover, the latter murmur may be different in pitch and quality from the mitral murmur.
Etiology.—Tricuspid incompetency is usually secondary to dilatation of the right ventricle because of obstruction in the pulmonary circuit. This may be due to chronic bronchitis, pulmonary em physema, fibroid induration of the lungs, or to mitral disease. Of these two classes of causes, the pulmonary are said to be of more unfavorable prognosis. Also, tricuspid regurgitation may be directly due to endocarditis. This may excep tionally affect primarily and alone the tricuspid valve, but it is mostly secondary to trouble upon the left side of the heart. If the endocarditis is ulcerative, there may be secondary pulmonary abscesses.
Tricuspid Stenosis.
Tricuspid stenosis is an extremely rare condition, causing obstruction of the right auriculo-vcntricular valve. It may be congenital, in which ease it is asso ciated with other lesions, so that the patient seldom lives long. If acquired, it is almost invariably associated with oilier valvular lesions, particularly mitral stenosis.
Its symptoms are cyanosis, sensitive ness to cold, dyspncea, and palpitation. A presystolic thrill has been observed, and a presystolic murmur, heard best at the base of the xiphoid cartilage or toward the right from that point.
The etiology and pathology are not different from those of the more com mon valvular lesions.
The prognosis is extremely unfavor able.
Pulmonary Steuosis. Definition.—Obstruction of the pulmo nary valve.
Symptoms.—This condition is almost invariably congenital, and it is usually associated with other structural anom alies, such as persistence of the foramen ovate and of the ductus Botalli, and defects in the septum ventriculorum. Most eases come to an early termination. Life is seldom prolonged beyond fifteen years. The marked symptoms are cya nosis, dyspnon, clubbing of the ends of the fingers, and deficient bodily develop ment.
auscultation we hear a loud, systolic murmur over a rather extensive area, but loudest in the second left inter space, and sometimes accompanied with a systolic thrill. The pulmonary second sound is weak or absent, or it may be replaced by a diastolic murmur. The systolic murmur is not transmitted into the arteries of the neck, but in some cases seems to extend toward the left shoulder.
Diagnosis. — It should be borne in mind that functional systolic murmurs may he heard in the second left inter space. They can be distinguished by the other physical signs and the age and gimeral appearance of the patient. And it should also be remembered that some I hues the murnm• of mitral regurpita may be heard along the left edge of the sternum; but the latter murmur may also be heard in its usual position near the apex or in the back near the angle of the scapula. Moreover, the general symptom-complex would doubt less aid in distinguishing the true lesion.
Prognosis. — The prognosis is always unfavorable. Beside the impending car diac failure, such patients are notably predisposed to pulmonary tuberculosis.
Pulmonary Regurgitation.
Pulmonary regurgitation is an ex cessively rare valvular lesion which is said to be accompanied by a diastolic murmur heard best over the pulmonary area, and transmitted downward and toward the xiphoid cartilage. It is usu ally associated with pulmonary stenosis or with some lesion on the left side of the heart. As distinguished from aortic regurgitation, it does not present the arterial and capillary symptoms of that disease, nor the striking hypertrophy of the left ventricle.
lIigh pressure in the pulmonary artery may give rise to a functional leak in the pulmonary valves (Graham Steel, Barr, Gibson, and others). For instance, this may be heard in some examples of mitral stenosis. In this case we have the picture of the principal organic lesion to show us the proper diagnosis.
General Remarks Upon the Treatment of Valvular Diseases.
Our first effort must be to promote and maintain perfect compensation of the valvular lesions. Our most impor tant means to this end is control of the diet and of the bodily and mental activi ties. The diet should be simple, nutri tious, easily digested, and the amount taken at any one time should be mod erate. A considerable proportion of nitrogenous elements is desirable; sugar and starchy foods should be used spar ingly. Thirst should mainly be quenched with pure water; this, again, is better taken frequently in moderate amounts than in excessive draughts. Tea is to be forbidden. Coffee may be enjoyed in moderate quantity if its effects do not prove unfavorable. Cocoa, milk, soups, and broths are suitable elements of the diet. In elderly and feeble persons, and in those previously habituated to its use, a moderate amount of alcohol may be advantageous; but, in general, its daily employment is harmful. Mental strain, overwork, worry, and excitement, even if pleasurable, shorten the prognosis of comfortable existence. Physical exer cise should not be summarily interdicted; its kind and amount should be most care fully determined in each individual case, and—above all—its effects alertly ob served for future guidance. The mod erate employment of many muscles is, of course, much better than the undertak ing of special feats of strength. Walking and horseback-riding are suitable. Golf can be recommended for many patients with moderate lesions. The bicycle, if used, should be of low gear, and the pa tient should be warned against long jour neys and against mounting hills. Facing a high wind has proved harmful, and even fatal, to cardiac patients. When ordinary exercise is no longer wise, mass age and passive movements may be of great benefit; also stimulating baths, as those of Nauheim. Many patients are amemie, and are benefited by iron, and others by arsenic; but this latter drug should not be used where there is any suspicion of tendency to fatty degenera tion. Cases which evince a liability to pulmonary disturbance (especially mitral diseases) should be guarded against ex posure to cold and wet.