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.
Hale wrote Lectures On Diseases Of The Heart, Materia medica and special therapeutics of the new remedies Volume 1, Materia Medica And Special Therapeutics Of The New Remedies Volume 2, Saw Palmetto: (Sabal Serrulata. Serenoa Serrulata), The Medical, Surgical, and Hygienic Treatment of Diseases of Women, New Remedies: Their Pathogenetic Effects and Therapeutic Application, Ilex Cassine : the aboriginal North American tea, Repertory to the New Remedies with Charles Porter Hart, The Characteristics of the New Remedies, Materia Medica and Special Therapeutics of the New Remedies, The Practice of Medicine, Homoeopathic Materia Medica of the New Remedies: Their Botanical Description etc.