Sjmiptoins. 1097 



account the discernible deviations lose more or less in distinct- 

 ness and are often confused into a clinical picture which is diffi- 

 cult to analyze. In insufficiency of the aortic valves and coexist- 

 ing aortic stenosis, for instance, systolic as Avell as diastolic 

 murmurs are discovered, while the pulse is either not bounding 

 or only slightly so, because the variations in pressure in the 

 arteries are not so considerable and less abrupt. 



The clinical picture is even more complicated if two or sev- 

 eral ostia and valves are involved simultaneously. Frequently 

 only portions of one half of the heart are diseased, for instance, 

 the aortic valves and at the same time the bicuspid valve, but 

 sometimes morbid changes are found in the right as well as in 

 the left halves of the heart, as in diseases of the left venous or 

 arterial ostium simultaneously with tricuspid insufficiency. 



As it is possible for two anomalies to occur in each of four 

 places, i. e., insufficiency and stenosis, and as these eight indi- 

 vidual forces may enter the most variable combinations with 

 each other (a total of 247 combinations is possible), the vari- 

 ability of valvular lesions observed in the different cases is not 

 astonishing, and at the same time renders descriptions of the 

 clinical pictures suitable for all possible contingencies an impos- 

 sibility. 



Insufficiency of a valve or stenosis of an ostium disturbs 

 the normal process of the circulation of the blood by producing 

 a permanent rise in the blood pressure in the parts of the heart 

 which lie proximally to the seat of the disease, and, in diseases 

 of the left venous ostium, also in the pulmonary vessels. In 

 order to maintain a normal, or at least approximately normal 

 velocity of the blood current in the body and a normal blood 

 pressure, certain parts of the heart are forced to accomplish 

 continuously an increased amount of w^ork. This causes their 

 walls eventually to hj-pertrophy, and the heart is then enabled 

 to accomplish the plus of work without constantly drawing upon 

 its reserve strength. As long as the increased work of certain 

 parts of the heart maintains the normal velocity of the blood 

 current, and as long as therefore the functions of the various 

 organs rest undisturbed in spite of the existing valvular lesions, 

 with the exception of certain local disturbances which are con- 

 stant accompaniments of some heart lesions: a compensation 

 of the valvular lesion is said to exist. However, in this stage 

 the function of the organs is usually undisturbed only in a con- 

 dition of rest, in greater muscular exertions and still more in 

 over-exertion transitory signs of incompensation may appear. 

 Sometimes, especially in insufficiency of the aortic valves, the 

 heart may be equal even to these excessively increased demands. 

 On the other hand, in certain forms of valvular troubles the func- 

 tion of the organs is impaired to a certain degree, even while 

 at rest, in spite of existing compensation ; for instance, in dis- 

 eases of the left auriculo-ventricular opening, the increased 

 pressure in the lungs causes superficial and hastened respira- 



