Physical Signs and Diagnosis of Valvular Diseases of the Heart – Endocardial or Valvular Murmurs – Mitral Direct Murmurs – Mitral Regurgitant Murmurs – aortic Direct Murmurs – aortic Regurgitant Murmurs – Recapitulation of Murmurs – Purring Tremor – Diagnostic Characters of Mitral Lesions – Diagnostic Characters of Aortic Lesions – Of Tricuspid Lesions – Of Pulmonic Lesions – Treatment of Disorders Resulting from Valvular Lesions.
GENTLEMEN: We have thus far, in lecturing on Diseases of the Heart, gathered from the latest and standard works, together with our own observations, and have omitted much that might be said, while we have endeavored, by careful study, to give you, in few words, the prominent points which will aid you in the investigation of the diseases of the heart. Our clinics do not yet furnish us with opportunities in this direction, and for this reason have I taken special pains to treat the various affections in a plain and concise way. But you must not stop here, but investigate for yourselves.
We will devote this hour to the consideration of the
PHYSICAL SIGNS AND DIAGNOSIS OF VALVULAR LESIONS
Cardiac murmurs originate either within the heart, or on the peripheral surface of the organ.
In treating of endocardial murmurs, the practical points to be considered relate to the different character which they present, the morbid conditions which they denote, their significance and value as signs of disease, and their application to the diagnosis of valvular affections. These murmurs may be produced within the cavities of the heart, at the auriculo-ventricular or the ventriculo-arterial orifices, and within the aorta or pulmonary artery, near the junction of these vessels with the ventricles. It is practicable often, if not generally, to determine from which of the cavities, orifices, or vessels mentioned, emanate the murmurs heard in individual cases.
The importance of this localization, as pointing to the seat of the lesions which occasion the murmurs, is obvious; to determine the existence or non-existence of valvular disease; to determine the particular situation of structural lesions; to determine the character of lesions, and certain of their effects on the blood- currents through the different orifices.
Endocardial murmurs are not always due to lesions of structure or organic disease. They occur as a result of certain blood- changes and of functional disorder of the heart.
The latter are distinguished as inorganic murmurs, while those dependent on structural changes are called organic murmurs.
Organic murmurs, in the majority of cases, resemble a bellows- sound. Murmurs of this kind are said to be soft murmurs. In some instances they are so feeble as to be just appreciable. In other instances they are so loud as to be heard over the whole chest, and they are sometimes perceived by the patient, especially in the night-time.
Different varieties have been described and named from their resemblance to certain sounds. Enough for practical use is to consider them simply as presenting different modifications and degrees of roughness, the latter being the only distinctive feature worthy of being noted.
Murmurs sometimes have a musical intonation. The sounds have no special pathological or diagnostic significance, except that they denote the existence of organic disease.
The presence of a murmur involves only the fact that there is something abnormal. The presence of a murmur by no means warrants the conclusion, in all cases, that lesions do exist, as will appear more fully after the inorganic murmurs have been considered. The absence of murmur, on the other hand, warrants the conclusion that lesions do not exist, the probability of error being exceedingly small, provided the heart be not, from any cause, greatly enfeebled.
After the systolic contraction of the ventricles, the blood passes through the auriculo-ventricular orifices from the auricles into the ventricles.
The current of blood from the left auricle, through the mitral orifice, into the left ventricle, may be designated the direct mitral current.
The systolic ventricular contractions impel the blood from the cavity of the ventricle into the aorta. The current of blood from the cavity of the left ventricle into the aorta may be distinguished as the direct aortic current. These are the normal blood-currents. If the mitral valves be insufficient, more or less of the blood contained in the cavity of the left ventricle is driven backward by the ventricular systole into the left auricle. Here, then, is a regurgitant current which does not exist when the valves are sufficient. It may be called a mitral regurgitant current. Each of these four currents may give rise to a murmur. A mitral direct murmur begins after the diastolic, or second sound of the heart; or it takes place during the long silence or pause which separates the diastolic and systolic sound, and may be called the mitral diastolic murmur.
A mitral regurgitant murmur being produced by the ventricular systole, commences with the systolic sound; it is, therefore, a systolic murmur, and may be called the mitral systolic murmur.
An aortic direct murmur, also produced by the ventricular systole, is a systolic murmur; it commences with the systolic sound, and may be called the aortic systolic murmur.
An aortic regurgitant murmur, on the other hand, produced by a retrograde current from the aorta into the ventricle after the systolic contraction, commences with the second or the diastolic sound.
Then we have the systolic murmurs, commencing with the systolic or first sound of the heart: 1st. A mitral regurgitant, or a mitral systolic murmur.
2nd. An aortic direct, or an aortic systolic murmur.
Also the diastolic murmurs, commencing with or following the diastolic or second sound of the heart: 1st, A mitral direct, or a mitral diastolic murmur; and, 2nd, An aortic regurgitant, or an aortic diastolic murmur.
The mitral direct, or the mitral diastolic murmur, generally denotes a particular kind of lesion, namely, union of the mitral curtains, leaving a slit-like and more or less contracted aperture between the auricle and ventricle. It may be distinguished as a blubbering sound when this quality is strongly marked. The mitral direct murmur always ends with the ventricular systole. This murmur may be produced – and it may be quite intense – when the mitral valves are not the seat of any lesion. The fact that the mitral curtains are floated out and brought into apposition to each other, by simply distending the ventricular cavity with liquid, is sufficiently established and easily verified.
Now, in cases of considerable aortic insufficiency, the left ventricle is rapidly filled with blood flowing back from the aorta, as well as from the auricle, before the auricular contraction takes place. The mitral curtains, under these circumstances, are brought into co-arctation, and when the auricular contraction takes place, the mitral direct current passing between the curtains, throws them into vibration, and gives rise to the characteristic blubbering murmur.
Mitral regurgitant, or systolic murmur, is most frequently met with in cases of organic disease of the heart. Whenever the mitral valve is insufficient, a portion of the blood contained in the left ventricle is driven backward by the ventricular systole into the left auricle.
The gravity of valvular lesions, as has been seen, depends on the amount of obstruction and regurgitation resulting from them; hence the importance of bearing in mind, that a mitral systolic murmur is not always, strictly speaking, a regurgitant murmur, that is, the murmur may be produced without regurgitation.
Aortic direct or systolic murmur. In proportion as obstruction to the aortic blood-current is involved, evils ensue, namely, accumulation of blood in the ventricular cavity, enlargement of the left auricle, followed by pulmonary congestion, and the more remote consequences which are essentially those resulting from obstruction and regurgitant lesions at the mitral orifice. There are no constant characters pertaining to the murmur itself which enable the auscultator to determine whether the lesions do, or do not, involve obstruction. In a large proportion of the cases of obstructive lesions at the aortic orifice, the valves are involved sufficiently to compromise, to a greater or less extent, their function, and impair the intensity of the aortic second sound. Aside from attention to the aortic sound, the evidence of obstruction, and also of its degree and duration, must be derived from the amount of enlargement of the left ventricle, and the remote effect of the heart affection.
Aortic regurgitant or diastolic murmur. This ranks next to a mitral direct murmur as regards infrequency. The gravity of the lesions represented by this murmur depends on the extent of insufficiency or the amount of regurgitation. Absence of an aortic regurgitant murmur, therefore, is not positive proof that there is no regurgitation. Roughness of the inner surface of the aorta above the aortic valves may occasion a murmur with the retrograde movement of the column of blood within the vessel, although the aortic valves are sufficient. An aortic non- regurgitant diastolic murmur is then characterized by its ending abruptly with the second sound of the heart; whereas an aortic regurgitant murmur continues, more or less, after the second sound.
Localization of the systolic murmurs. The first point is to ascertain whether it be a systolic or a diastolic murmur. If the heart-sounds recur with great frequency, the difference in duration between the two pauses or intervals is scarcely apparent. Whenever there is doubt or difficulty in determining whether a murmur be systolic or diastolic, it is to be remembered that the first or systolic or diastolic, it is to be remembered that first or systolic sound of the heart is synchronous with the apex-beat and the carotid pulse. If the beginning of a murmur be coincident with the carotid pulse, it is either an aortic or a mitral systolic murmur. A murmur may be inappreciable, owing to feebleness of the action of the heart. Before deciding, therefore, on the absence of murmur, it is sometimes advisable to excite the heart’s action by muscular exertion. If the murmur be a mitral systolic, its maximum of intensity is at or near the apex of the heart. This is to be depended upon as a rule.
If a systolic murmur be an aortic direct murmur, its maximum of intensity is at or above the base of the heart. The particular situation where it is most intense is usually in the intercostal space near to the sternum. From the base of the heart it is propogated upward for a greater or less distance, usually more so on the right than on the left side. It is often pretty loud at the sternal notch.
To determine the presence of both these murmurs: If a murmur heard at the apex be transmitted over the left lateral aspect of the chest, and if it be heard at the lower angle of the scapula behind, a mitral regurgitant murmur is present. If, now, a murmur heard at the base be heard over the carotids, there is also present an aortic direct murmur.
Localization of the diastolic murmur. A mitral direct murmur is pre-systolic. It occurs just before the first or systolic sound, and is almost always continued up to that sound. None of the other murmurs occur in the same relation to the first sound of the heart, and hence, this alone is distinctive. Its maximum of intensity is within a circumscribed space around the apex of the heart. If the diastolic murmur be an aortic regurgitant murmur, it commences with, and follows, the second sound of the heart. As no other of the four murmurs under consideration commences with the second sound of the heart, it suffices for its recognition to make out this point; and if it be difficult to determine which of the heart-sounds is the first, and which the second sound, the relation of the murmur to the second sound is shown by the interval between the murmur and the carotid pulse.
RECAPITULATION of Points involved in the Localization of the Systolic and Diastolic Murmurs referable to the Mitral and the Aortic Orifices.*
*From Flint on Diseases of the Heart.
Maximum of intensity at or near the apex of the heart.
Comparatively feeble or wanting at the base.
Not propogated above the base of the heart. Not heard over carotids.
Often heard over left lateral surface of chest.
If heard in the interscapular space, most intense near the lower angle of scapula.
Aortic second sound weakened in proportion to the amount of regurgitation, but distinct.
Pulmonic second sound often intensified.
Mitral valvular element of the first sound more or less impaired.
Maximum of intensity at the base of the heart in the second intercostal space, near the sternum. Intensity diminished over body of heart and at the apex.
Propogated above the base of the heart and generally heard over carotids.
Rarely heard over left lateral surface of chest.
If heard in the interscapular space, most intense as high as the spinous ridge of scapula.
Aortic second sound often weakened, and more or less indistinct.
Pulmonic second sound less frequently intensified.
Mitral valvular element of the first sound not impaired.
Occurs just before the systolic or first sound, and ends with the occurrence of this sound. Usually vibratory or blubbering in quality.
Maximum of intensity over apex of heart.
Generally not appreciable at the base of the heart.
Mitral valvular element of first sound impaired.
Pulmonic second sound often intensified.
Commences with and follows the diastolic or second sound. the quality usually soft.
Maximum of intensity over body of heart, near the sternum.
Generally appreciable at the base of the heart.
Mitral valvular element of first sound not impaired.
Pulmonic second sound less frequently intensified.
In connection with murmurs, it may be safe to say, that they show organic lesions are accompanied by an organic murmur in the great majority of cases.
Lesions which occasion neither obstruction nor regurgitation may give rise to murmurs.
Purring tremor. This term is applied to a sense of vibration, or thrill, felt on placing the fingers or the hand on the praecordia. It resembles the sensation given to the hand by the purring of a cat. It is doubtless due to tremulous movements of the heart. A well-marked purring tremor may be considered as a sign denoting valvular lesions associated with hypertrophic enlargement of the left ventricle. It occurs when the mitral orifice permits free regurgitation, and may also occur in aortic lesions.
DIAGNOSTIC CHARACTERS OF MITRAL LESIONS.
Physical signs: – An endocardial systolic murmur is present in the majority of cases, with the traits which distinguish a mitral regurgitant murmur, viz.; its maximum of intensity at or near the apex of the heart, the intensity diminishing as the stethoscope is carried upwards over the body of the heart; generally feeble or lost above the base of the organ; not propagated into the carotids; often diffused over the left lateral surface of the chest; and not infrequently heard on the posterior surface, at the lower angle of the scapula, and in the interscapular space below the level of the spinous ridge of the scapula; the murmur more or less intense; generally soft, but sometimes rough, and occasionally musical. The aortic second sound is weakened; the pulmonic second sound is often intensified. Enlargement of the heart exists in the majority of the cases which come under observation.
Pain is rarely present. Abnormal force of the heart’s action and palpitation denote consecutive enlargement, but the symptoms are often not prominent.
The pulse is small and weak, and, in an advanced stage, it becomes irregular and intermitting; inequality of the pulse is, in some measure, characteristic of obstructive lesions. Turgescence of the jugular and other veins, lividity, or cyanosis, and dropsy occur at an advanced period, when dilatation of the right cavities of the heart has been induced. Dyspnoea is more or less marked. Cough and muco-serous expectoration occur frequently. Haemoptysis is of frequent occurrence, and extravasation of blood in the lungs, or pulmonary apoplexy, takes place occasionally. OEdema of the lungs is not infrequent.
DIAGNOSTIC CHARACTERS OF AORTIC LESIONS.
Physical signs. – An endocardial systolic murmur is present in the majority of cases, with the traits which distinguish an aortic direct murmur, viz.: its maximum of intensity at the base of the heart; comparatively feeble and often lost at the apex; propagated upward in the direction of the aorta, and into the carotids; not diffused over the left lateral surface of the chest; and if heard on the posterior surface, either limited to, or most intense in, the interscapular space on and above the level of the spinous ridge of the scapula. Murmur more or less intense; generally soft, but sometimes rough. The aortic second sound of the heart is often weakened and indistinct; the pulmonic second sound is much less frequently intensified than in cases of mitral lesions. Enlargement of the heart exists in the majority of cases. An aortic regurgitant murmur is present in a certain proportion of cases.
Pain is oftener present than in cases of mitral lesions, but is often absent. Abnormal force of the heart’s action and palpitation, as a rule, are more prominent symptoms than in cases of mitral lesions.
The pulse in cases of aortic regurgitation is quick, jerking, collapsing, and a longer interval than natural is sometimes observed between the apex-beat or systolic sound and the pulsation in remote arteries.
Visible pulsation of superficial arteries is frequently marked. Turgescence of the jugular and other veins, and dropsy, occur at a later period than in cases of mitral lesions, and oftener wanting.
Dyspnoea is less marked. Cough and muco-serous expectoration and haemoptysis are comparatively infrequent. Pulmonary apoplexy rare. OEdema of the lungs less frequent.
DIAGNOSTIC CHARACTERS OF TRICUSPID LESIONS.
Physical signs. – The rule, that a murmur is present in the vast majority of cases, cannot be applied to tricuspid lesions: and hence, absence of murmur is not proof that the latter do not exist. A tricuspid regurgitant murmur, however, is sometimes observed. It is rarely intense or rough, and is usually low in pitch. Its maximum of intensity is at or above the xiphoid cartilage.
Tricuspid lesions, not congenital, are in most instances associated with lesions of one or more of the valves of the left side of the heart. One case is reported of the diagnosis being based on the fact that the presystolic murmur was heard, not only around the apex, but at, and to the right of, the ensiform cartilage.
Regurgitant and obstructive lesions, situated at the tricuspid orifice, do not produce those immediate effects on the respiratory system and the pulse which pertain to analogous lesions seated at the mitral orifice. Their immediate effects are manifested in the systemic venous system. Congestion of the systemic veins is a direct result, tending to general dropsy. Cerebral apoplexy is more liable than in mitral or aortic lesions.
DIAGNOSTIC CHARACTERS OF PULMONIC LESIONS.
Physical signs. – Lesions situated at the pulmonic orifice may give rise to a murmur with the first sound of the heart, which may be called a pulmonic direct murmur. This murmur has its maximum of intensity in the second intercostal space on the left side of the sternum, the situation where the pulmonic second sound of the heart may be isolated from the aortic second sound.
Pulmonic lesions, however, exclusive of congenital malformations, are so rare, that the opportunities of any clinical observer, however large his experience, for studying the physical signs, are extremely limited.
Hypertrophy of the right ventricle, which is produced by obstructive or regurgitant lesions of the pulmonic orifice, involves augmented intensity of the tricuspid valvular element of the first sound, and an impulse in the epigastrium.
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 DISEASES RESULTING FROM VALVULAR DISEASES OF THE HEART.
It is evident that the anatomical changes which the valves and orifices of the heart have undergone, are not amenable to any medical treatment. The lesions existing must remain. The most that can be done is to retard their progress and control their primary effects.
Cases may, however, occur where suitable remedies may set up such an action in the system, as may result in the partial or complete removal of certain morbid products deposited on or about the valves. A thorough trial of those remedies known to us as antipsorics may give you excellent results.
You need not feel discouraged in the treatment of valvular diseases, nor should you discourage your patients, for in general no immediate danger is present, even when those lesions exist which involve more or less obstruction or regurgitation.
For the treatment of the primary effects of valvular diseases, I refer you to the treatment of enlargement of the heart.
The secondary effects of valvular lesions do not generally appear so long as the enlargement of the heart is by hypertrophy, unless, from fatty degeneration or some other cause, weakness of the organ has been induced. Flint says that obstruction and regurgitant lesions tend first, as a rule, to produce hypertrophy, the muscular walls increase in thickness upto a certain limit. when this limit is reached, dilation of the cavities ensue, and, finally, predominates over the hypertrophy. So long as the hypertrophy lasts the increased power of the heart compensates for the immediate consequences of the obstruction and regurgitation.
But when dilatation takes place, the real danger appears. It is then that other organs become affected, and a train of evils follow which will require your watchful care to relieve and arrest.
The main objects of treatment, before these resulting affections have appeared are mainly preventive. (1) You must seek to prevent or retard the progressive anatomical changes. (2) You must strive to prevent weakness and consequent dilatation of the heart.
As I have just now stated, you will find this treatment fully set forth in your notes on hypertrophy and dilatation.
You must ever bear in mind, that in the treatment of the secondary and remote effects of these lesions, the condition of the heart should not be forgotten. You cannot successfully treat the local congestions in such cases by specific remedies directed solely to the organ affected. For example, leptandra will not as often remove a jaundice caused by cardiac disease as will digitalis, because the latter has a specific influence over the heart.
These secondary affections are mostly dependent on passive congestion, and as they arise from a weakened circulation, those cardiac remedies which strengthen the force of the circulation will give the most relief. I have enumerated these in Classes I., II., and III. in “Dilatation.”
Dyspnoea, otherwise known as cardiac asthma, or breathlessness, will often claim your special attention. In advanced cases you can only palliate, but you can do much with such medicines as digitalis, hydrocyanic acid, arsenic, lobelia, cuprum aceticum, phosphorus, and tartar emetic.
Cough can be alleviated by the same remedies, aided by hyoscyamus, conium, lycopus, etc.
Expectoration in valvular disease should be encouraged rather than checked, for it often relieves the congestion. When it becomes too profuse, it may be lessened by squilla, tartar emetic, cubebs, copaiva, ammonia, ipecac, and similar remedies.
Intercurrent pulmonary affections, such as bronchitis. Pleurisy, pneumonia, are to be treated in the ordinary manner.
The disorders of digestion and hepatic affections are sometimes quite obstinate. If you will study the provings of digitalis, you will observe the peculiar and prominent derangement of the gastric and hepatic functions which causes. It causes these disorders by deranging the action and impulse of the heart. Digitalis is our most reliable remedy in similar cases; and next in value come nux vomica, ignatia, china, cornus, aesculus, hydrastis, podophyllum, leptandra, lycopodium, sulphur, and benzoic acid.
Cerebral congestions are to be met with digitalis, nux vomica, opium, glonoine, agaricus, arnica, solanum, aided by hot mustard foot and hand baths. The extremities must be kept warm and full of blood.
General dropsy is one of the most troublesome of the secondary effects, and will tax your skill greatly. Remember that the kidneys are not primarily in fault. The co-existence of Bright’s disease gives the disease a double character.
Any remedy which will aid the heart by giving it increased power will benefit the dropsy. It is not necessary that the remedy should be a kidney remedy. The best remedies for cardiac dropsy may be arranged in two classes, namely:
I. Those which act primarily on the heart: digitalis and its analogues; nux vomica and china and their analogues.
II. Those which act specifically on the kidneys: apocynum cann., asparagus, eupatorium purp., benzoate of ammonia, colchicum, asclepias syriaca, squilla, potass nitras and acet., etc.
In cases of co-existing Bright’s disease, I have found sulphuric acid to act in a wonderfully efficient manner.
It is a significant fact that allopathic authorities are quite unanimous in asserting, that from experience they find that by combining a remedy of my Class I. with one of Class II., they are enabled to remove cardiac dropsy more rapidly than in any other way. A favorite combination with them is digitalis and squills. Now, we need not combine medicines to get these good effects. Better results can be gained by alternation. You will, according to my experience, get prompt action from an alternation of digitalis and apocynum cann., or china and asclepias, or nux and benzoate of ammonia.
Obstinate cases have been reported where the internal administration of remedies failed to remove this form of dropsy, but in which their external application over the abdomen and kidneys was successful.
If your dropsical patient is anaemic, give him ferrum (the iodide is the best,) and advise a strong nitrogenous diet.
Finally, gentlemen; do not always inform your patients of the presence of organic disease of the heart. Such an announcement will militate against your best chosen remedies, by depressing your patient’s spirits, and thus lowering the vital energies. Better is it to encourage; and only allude to the heart in a vague or indirect manner.