In 15 cases where the aortic valves were involved (either calcified, rigid, or atheromatous) the heart lesion was not the cause of death in any case. Of these 15 cases, sudden death occurred but in 2; in 1 there were firm and long-standing pericardial adhesions, and in the other cerebral apoplexy.
In 12 cases of calcification of the mitral valve, no death occurred as the direct result of the valvular lesion, and there were only 2 sudden deaths, both from cerebral apoplexy.
The aortic and mitral valves were diseased in 14 cases; in 2 of these only did death result from the heart lesion, and the only three sudden deaths in this class were from uræmia, apoplexy, and croupous laryngitis.
The aortic and pulmonic valves were both diseased in 3 cases which died suddenly, and in no instance was death due directly to the heart lesions.
In 2 cases there was disease at the aortic, mitral, and tricuspid orifices, and no sudden death.
Thus it will be seen that of these 81 cases, in 24 only was death due directly to the heart lesion. There were only 8 sudden deaths due directly to the heart lesion.
The results of personal, clinical, and pathological observation lead me to the opinion that the loudness, harshness, and the area of diffusion of any cardiac murmur have little to do with its prognosis.
I deduce from the above-mentioned cases that cardiac murmurs rarely necessitate a bad prognosis unless hypertrophy and dilatation coexist; but so soon as the signs of considerable dilatation and hypertrophy are present a great variety of complications are liable to occur.
In 1870, I had a patient sixty years of age with extensive aortic reflux, who had been under my observation eight years, during which time he had three attacks of pneumonia. There were no appreciable signs of cardiac dilatation in his case.
Walshe says: "The order of relative gravity, as estimated not only by their ultimate lethal tendency, but by the amount of complicated miseries they inflict, is—1, tricuspid regurgitation; 2, mitral obstruction and regurgitation; 3, aortic regurgitation; 4, pulmonic obstruction, 5, aortic obstruction."