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.
SYSTOLIC MURMURS.
Mitral Regurgitant.
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.
Aortic Direct.
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.
DIASTOLIC MURMURS.
Mitral Direct.
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.
Aortic Regurgitant.
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.
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.