marked hypertrophy of the left ventricle. Pulsation occurs in the
epigastrium, which may be due to reflux into the enlarged hepatic veins
or to the fact that the dilated and hypertrophied right ventricle so
presses on the liver that the impulse is conveyed through the diaphragm
with each cardiac pulsation. Guttman thinks epigastric pulsation is due
wholly to reflux into the veins of the liver, and not to right
ventricular pulsation.
{680} Early in the disease the impulse in the jugulars is confined to
the lower part of the vessels, particularly to the sinus. Beyond this
point the vein merely undulates. Later, a systolic pulsation is felt as
high up as the angle of the jaw, and may be accompanied by distinct
though feeble presystolic pulsation.
The liver may first simply undergo systolic depression, chiefly at the
left lobe; secondly, the whole liver may have an impulse coming from an
enormously dilated vena cava; and thirdly, the systolic pulsation of
the veins within the organ may give to it a palpable expanso-pulsatory
movement. The hepatic pulsation is rhythmical with the cardiac impulse.
In rare cases it precedes jugular pulsation. Sometimes pulsation is
felt in the femoral veins.
Sphygmographic tracings of the jugular pulse show it to be dicrotic.
Percussion shows an increase in the area of cardiac dulness to the
right and upward, sometimes as far as the second intercostal space.
Auscultation.--The murmur of tricuspid insufficiency is heard with, or
takes the place of, the first sound of the heart; it is superficial, of
low pitch, blowing, soft, and faint, and is heard with the greatest
intensity over the lower part of the sternum, at its left border,
between the fourth and sixth ribs. It is rarely audible above the third
rib or to the left of the apex-beat. This murmur is transmitted from
the region at the base of the xiphoid cartilage upward and to the right
from one to two inches. Sometimes it is heard only over a very limited
area, and then it may be overlooked.
DIFFERENTIAL DIAGNOSIS.--A tricuspid regurgitant murmur may be
confounded with that due to aortic obstruction, pulmonic obstruction,
and mitral regurgitation. A tricuspid regurgitant murmur is never
audible above the third rib; is not accompanied by an accentuation of
the second sound over the pulmonary artery, but by jugular and
epigastric pulsation; and is heard with maximum intensity near the base
of the ensiform cartilage. These points are sufficient to differentiate
it from an aortic or pulmonary obstructive murmur. The differential
diagnosis between it and a mitral regurgitant murmur has been given.
PROGNOSIS IN VALVULAR DISEASES OF THE HEART.--Any statements as to the
duration of life in valvular diseases of the heart, and their relative
frequency as a cause of death (especially of sudden death), must be
based upon personal observation, and necessarily will differ with
different observers.
In order to establish, if possible, a basis of comparison for the
different valvular lesions, I give a résumé which I have made of 81
cases, in all of which autopsies were made and the diagnosis of
valvular disease verified.[25]
[Footnote 25: _Med. Rec. N.Y._, April 1, 1870, p. 66 _et seq._]
In 14 cases of various valvular lesions, each of which was accompanied
by cardiac hypertrophy and dilatation, 50 per cent. of the deaths were
due directly to the valvular lesion. In 1 of these, where there was
stenosis at both auriculo-ventricular orifices, death was sudden.
In 15 cases of valvular disease, in which there was only cardiac
hypertrophy, there were 11 deaths from the heart lesion. In 5 of these
death occurred suddenly, and these 5 sudden deaths were all directly
due to the heart lesion.
In 6 cases of valvular disease accompanied by dilatation alone, 4
deaths resulted directly from the heart lesion, and 2 of these were
sudden.
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.
{681} 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."
The following are conditions which render the prognosis in each
valvular lesion more or less unfavorable:
In aortic stenosis the prognosis is less grave than in any other
valvular lesion. Life may be prolonged and good health enjoyed for many
years. Yet it must be remembered that extensive aortic stenosis rarely
exists without attendant regurgitation.
So long as the hypertrophy of the left ventricle compensates for the
obstruction, the prognosis is good; but when the hypertrophied walls
fail to overcome the obstruction, dilatation begins, and the
ventricular systole becomes feeble and intermitting, and the arterial
supply to the brain is so much diminished as to lead to cerebral
anæmia.
If after sudden exertion or violent muscular effort there is
interruption or great irregularity in the heart's action, sudden death
may occur from a complete arrest of the ventricular systole.
Evidences of excessive hypertrophy and dilatation, the occurrence of
syncope, signs of cerebral anæmia, attacks of vertigo, great muscular
prostration, continued and marked paleness of the face, and
irregularity of the pulse, render the prognosis exceedingly unfavorable
in aortic stenosis.
If the presence of vegetations can be determined, there is danger from
cerebral embolism.
When there are no evidences of alterations in the ventricular walls
after an aortic obstructive murmur has existed for some time, it may be
assumed that no vegetations exist on the valves, and that the murmur is
not due to extensive aortic stenosis, and consequently is not dangerous
to life.
When the mitral valves become involved, the combined lesions render the
prognosis unfavorable.
Death may result from cerebral complications, pulmonary oedema, or
cardiac degeneration.
Aortic insufficiency is a much graver form of valvular disease than
aortic stenosis. It is difficult to estimate the probable duration of
life in aortic {682} insufficiency, for it frequently gives rise to no
symptom that would lead to its diagnosis until it is far advanced.
Twenty-one days and five years are the extreme limits that have been
recorded. It must always be borne in mind in estimating the factors for
and against a good prognosis that in no other valvular lesion is sudden
death so liable to occur. Yet the record of the cases which I have
given (page 680) indicates that mitral stenosis is nearly, if not
quite, as frequently a cause of sudden death.
A diseased valve can never be restored to its normal functions, and the
shorter and more gushing the murmur the more extensive the
regurgitation. The effects of the regurgitation must be carefully
estimated before a prognosis can be given in any case. When one aortic
flap is puckered and shrunken, the other two may elongate and
compensate for the patency. But this occurs only in very young
subjects.
Aortic regurgitation is, however, more serious in the very young than
in adults. In children the valvular changes are less atrophic and more
inflammatory in character.
Where the disease is met with in middle life, in those who daily
undergo severe mental or bodily strain, the prognosis is unfavorable.
And when in such patients there are the evidences of arterial
degeneration or a tendency to it, the dangers are greatly increased,
for the hypertrophied ventricle drives out the blood from its dilated
cavity with greater than the normal force, and the vessels being
weakened there is great danger of their rupture; hence the frequent
occurrence of apoplexy and infarctions. In the very old I have seen
aortic incompetence last a long time and cause little inconvenience.
Again, the prognosis is bad when cyanosis and dropsy result from the
failure of a dilated and hypertrophied left ventricle to empty itself.
This weakness is the result of that interference with the coronary
circulation which brings about impaired nutrition, and therefore
degeneration of the heart-walls.
When mitral insufficiency is secondarily induced, then obstruction to
the systemic circulation leads to induration of the liver and kidneys,
which interferes with the performance of their functions and hastens
the fatal issue.
Sudden rupture of a valve or valvular disease that has developed very
rapidly is more dangerous than when the valvular insufficiency is
slowly developed. The flap or flaps involved can sometimes be
determined during life, and then the prognosis will be more or less
favorable according as the anterior or posterior are incompetent. In
all cases the prognosis depends more upon the condition of the
heart-walls and on the general nutrition than upon any other element.
When aortic regurgitation is complicated by aortic stenosis, mitral
regurgitation, or by the vascular and visceral conditions resulting
from the derangement of the circulation, the prognosis is exceedingly
unfavorable. Death may result from embolism, apoplexy, dropsy,
pulmonary oedema, from sudden cardiac insufficiency, or from visceral
complications. When the radial impulse is felt a little after the
apex-beat, it is always important to determine whether the action of
the heart remains regular under mental excitement or violent physical
exertion: if it does, the prognosis is far better than when it becomes
irregular.
Mitral stenosis admits of but slight compensation; if extensive, it is
always a grave disease. The prognosis in any case can be estimated by
the severity of the thoracic symptoms. When physical exertion greatly
exacerbates the thoracic symptoms, the prognosis is especially bad; for
during violent exercise such patients are not only liable to pulmonary
congestion and oedema, but to pulmonary infarctions and pulmonary
apoplexy with large extravasations.
Where mitral stenosis is extensive it ranks next to aortic
regurgitation in its danger of sudden death. The statistics furnished
by Bellevue Hospital show sudden death to occur as often in mitral
stenosis as in aortic reflux.
{683} Congenital mitral stenosis is not dangerous, and does not cause
much embarrassment, for it is invariably associated with hyperplasia of
the pulmonary arterial system. The later in life mitral stenosis
occurs, the more unfavorable the prognosis.
Mitral regurgitation uncomplicated by any other valvular lesion gives
rise to very little disturbance of the systemic or capillary
circulation. It is more often fully compensated for than any other
valvular lesion. The changes which lead to it are of slow growth and
their tendency is to remain stationary. Patients with a moderate
regurgitation at the mitral orifice suffer very little except during or
after violent physical exercise, and, were it not for the slight
dizziness which attends it, it would pass unnoticed. As long as the
compensatory hypertrophy of the right ventricle is sufficient to
overcome the obstruction to the pulmonary circulation, patients with
this form of heart disease may not suffer from dyspnoea even after
violent physical exercise. As regards the duration of life, the
prognosis in mitral regurgitation is good. When, however, mitral
stenosis and regurgitation coexist, the liability to sudden pulmonary
complications becomes so great that a very guarded prognosis must be
given; and it must be remembered that combined reflux and stenosis at
the mitral orifice is a frequent combination.
In very many instances it is unnecessary to tell a patient with mitral
reflux that he has an incurable heart disease, for with no other
valvular lesion the individual may live to advanced life. But when it
is combined with mitral stenosis it must be regarded as a very serious
form of valvular lesion. As soon as symptoms occur that show failure of
the right heart, the prognosis becomes unfavorable. Oedema of the
extremities or fluid in any of the serous cavities, cyanosis, dyspnoea,
and hæmoptysis, are indications of such failure.
Death may result from general anasarca, from serous effusions into the
pleuræ, peritoneum, or pericardium, from pulmonary oedema and
congestion, or from heart-insufficiency.
Extensive obstruction or regurgitation at the pulmonic orifice would
necessarily lead to serious results, but there are no reliable data
upon which the prognosis can be based.
The prognosis in tricuspid obstruction and regurgitation, when
associated with mitral disease, is very grave; but it is not as bad as
when it results from chronic bronchitis and pulmonary emphysema.
When in any case jugular and epigastric pulsation are marked, the
changes in the various organs of the body already referred to rapidly
ensue. Walshe says that "tricuspid regurgitation is the worst of all
valvular lesions." Patients with tricuspid reflux are in extreme danger
from intercurrent attacks of acute pulmonary hyperæmia.
Tricuspid disease, of all valvular lesions, leads most rapidly to
cyanosis and dropsy.
TREATMENT.--The treatment of aortic stenosis and of aortic
regurgitation may be summed up under three heads--viz. rest, diet, and
regimen.
Rest is most important; it must be mental as well as physical; the
appetite, emotions, and passions must be kept under perfect control:
these indications are best maintained by a sedentary country life.
Straining, especially when the hands are above the head, should be
carefully avoided.
The stomach also must have all the rest compatible with the most
perfect nutrition; it is frequently a difficult matter to combine both
indications, for it should be remembered that the more perfectly the
nutritive processes are maintained the longer will the cardiac muscle
resist degeneration. Sugar, sweet vegetables, and animal fat must be
sparingly indulged in. The food should consist of nitrogenous,
albuminoid material, and should be taken in quantities that do not
disturb the heart's action.
{684} In aortic incompetence patients in sleeping should assume, as
nearly as possible, a horizontal posture. By lying on their backs they
lower the height of the distending column of blood, and thus relieve
both the cardiac circulation and the tendency to pulmonary congestion.
Sometimes, when defective aortic pressure reacts injuriously on both
the gastric and hepatic secretions and limits both their supply and
their efficiency, moderate alcoholic stimulation may be cautiously
employed to tide over a weakly period. The bowels should be gently
moved once daily. That the cutaneous circulation may be active the body
should be warmly clothed. Any prolonged exposure of the surface to cold
is to be avoided. In winter the warm bath may be occasionally used, and
in summer the patient is frequently benefited by a warm sea-water bath.
Medicinal agents are not to be resorted to until the cardiac
hypertrophy fails to be compensatory. Then relief is demanded for the
failing heart-power. In aortic regurgitation with feeble heart-action
the tincture of digitalis and the tincture of the perchloride of iron
are to be given in ten-minim doses three times a day. The iron is
especially indicated whenever anæmia is evidenced. Digitalis is given
to produce a sedative action, and therefore should be given in very
small doses and regulated according to its effects on each patient. An
infusion of the English leaves is the preparation which is most
reliable, although the tincture, if fresh and well prepared, is equally
good. When rapid and immediate action is demanded, digitalis may be
given hypodermically. There is one guide to its use not unimportant to
remember: that is, as long as it causes an increase in the flow of the
urine it is safe to continue its use. When vertigo and syncope are
prominent symptoms quinine and strychnia may be given with the
digitalis. When the heart in aortic reflux acts with violence and
rapidity, and the arteries are in a state of high tension, aconite will
be found of service in quieting the heart's action. In aortic
incompetence small doses of arsenic seem to have a stimulating effect,
especially when given with digitalis and iron. Iron may disturb the
stomach, arsenic seldom if ever does. It is always a safe rule when
giving iron to administer at the same time a bitter vegetable infusion,
as quassia or columba.
When the hepatic and gastric vessels are engorged, three or four
leeches over the liver or epigastrium, followed by a warm fomentation,
will afford temporary relief.
At no time should a large quantity of fluid be taken into the stomach.
Symptoms of angina pectoris, with local pain and dyspnoea, are
evidences of aortitis. This demands the application of leeches over the
sternum and continued small doses of mercury.
The treatment of dyspnoea, dropsy, pulmonary oedema, and other late and
distressing symptoms will be considered in connection with mitral
disease. Sometimes the pain of aortic disease is so severe as to
require an anodyne for its relief: opium must not be given by the
mouth, but the sulphate or the hydrochlorate of morphine can be safely
given hypodermically. The severe angina-like pain of aortic
regurgitation can often be promptly relieved by the nitrate of amyl.
Barlowe and Fagge both advise senega and ammonia carbonate for the less
severe effects of aortic reflux. They advance no reason for the use of
these drugs, but their cases show that they have a markedly beneficial
effect. All authorities unite in regarding aortic insufficiency as less
amenable to treatment than other valvular lesions.
In all cases the idiosyncrasy of each patient should be carefully
considered.
No treatment can restore a diseased valve to its normal condition, or
prevent, for any considerable time, cardiac dilatation and hypertrophy
when the normal function of the valves is greatly interfered with.
{685} The first step in the treatment of a serious lesion at the mitral
valves is to make the patient clearly understand his exact condition,
that he may see the reasonableness of the advice given, for his
treatment for the most part must be carried on by himself. A patient
must be fully persuaded of its necessity before he will regulate his
habits and mode of life in accordance with the requirements of his
case. The rules as to nutrition are the same as those to be observed in
aortic stenosis and reflux. There should be a gentle and regular daily
evacuation from the bowels. Straining at stool must be avoided, and any
use of alcohol, strong tea, coffee, and tobacco is to be prohibited. If
in either form of mitral valvular disease the patient is anæmic, iron
should be given. This is given as a food to such patients, and is best
administered about half an hour after meal-time. Ten or twenty grains
of Vallette's mass may be given with benefit to anæmic patients two or
three times a day for a long period.
Patients with mitral reflux should avoid a prolonged use of the voice,
especially in speaking or singing. Small doses of quinine and
strychnine, alternating with the administration of iron, are often of
service. If there is anorexia, infusion of quassia or columba may be
given with the iron. The triple phosphates of iron, quinine, and
strychnine, or small doses of dilute sulphuric acid, will be found to
improve the condition of these patients when they show signs of extreme
debility.
In every case of mitral disease there comes a period when the pulmonary
hyperæmia shows that the compensation of the right heart has failed. An
adjustment of the heart to the circulation is now effected by the
judicious administration of digitalis. Digitalis should only be given
at those times when the heart-failure is imminent and there is marked
pulmonary congestion. Half an ounce of the infusion every two hours for
twenty-four or forty-eight hours is often required to overcome the
heart-failure. The time will come when digitalis ceases to have its
sustaining effect upon the heart-muscle; hence it should always be most
sparingly and carefully used, and the patient should never be allowed
to use it continually.
When the pulse is rapid, feeble, and irregular, more time is needed for
the flow of blood into the ventricle, and greater force and regularity
in the ejection of the blood from that ventricle are demanded.
Digitalis fulfils all these conditions: the pulse becomes regular,
beating about sixty per minute, full and forceful. The urine, before
scanty, now becomes abundant and normal. Pulmonary engorgement
diminishes, and commencing dropsy gradually but totally disappears.
Hayden advises ten minims of the spirits of chloroform and fifteen
minims each of the tincture of digitalis and the tincture of the
perchloride of iron in an ounce of water every three hours.
Whenever asystolism is present or suppression of urine is threatened,
digitalis should be given whether the other indications are present or
not. In most cases of mitral stenosis it is best to avoid the use of
digitalis as far as possible.
The dropsy which accompanies advanced mitral regurgitation may be
promptly relieved by compound jalap powder, combined with calomel in
sufficient quantity to produce prompt and free catharsis. In some cases
of cardiac dropsy, squill, juniper, brown cream of tartar, and copaiba
act as diuretics. This latter drug is best exhibited in the form of the
resin.
In mitral reflux a combination of digitalis and nitrous ether will
often be found to act as a diuretic. In all cases when a diuretic is
given in heart disease the loins should be cupped or warm poultices
applied and the bowels freely purged. In copious hæmoptysis in cardiac
disease ergotin may be given in full doses either by the mouth or
hypodermically.