Aortic lesions giving rise to obstruction are not characterized by a pulse weakened in proportion to the diminishing quantity of blood propelled from the left ventricle. In cases of aortic obstruction, when great enlargement of the heart has ensued, and especially when the muscular power of the organ is much diminished by either dilatation or fatty degeneration, the pulse may become irregular, intermitting, and unequal. Irregularity and inequality are thus, in some measure, diagnostic of lesions affecting the mitral orifice, as contrasted with those affecting the aortic orifice; but it is to be borne in mind that they occur in cases of dilatation, fatty degeneration, etc., uncomplicated with any affection of the valves or orifices.
Slowness of the pulse, that is, the gradual expansion of the artery, as distinguished from quickness (not frequency), denotes the prolonged systole of the left ventricle, and is distinctive of aortic obstruction. In cases of aortic lesions, with considerable insufficiency, the jerking or collapsing feature of the pulse is usually strongly marked. It is not, however, a symptom of aortic obstruction.
Prolongation of the interval between the pulsation of the radial artery and the heart’s impulse, is significant of aortic regurgitation.
TURGESCENCE OF THE VEINS AND VENOUS PULSATION.
Abnormal fullness of the veins occurs whenever there is an obstacle to the free entrance of blood into the right auricle. an obstacle exists when the right auricle is already full, or distended with blood. The most direct and efficient causative condition is contraction of the tricuspid orifice. Obstruction to the pulmonary circulation from emphysema of the lungs occasions an undue accumulation of blood within the right ventricle and auricle, leading after a time to enlargement, and a consequent obstacle to the free transmission of blood to the systemic veins. Pressure on the vena cava by an intra-thoracic tumor produces obstruction and venous turgescence. Thus, marked fullness of the veins of the head and neck is observed in some cases of aneurism of the arch of the aorta. As a symptom, then, this is not distinctive in itself of cardiac disease, nor, when it proceeds from the latter, does it point to the seat, or even denote the existence of lesions of the valves or orifices, but rather that the right auricle is either dilated or over-distended.
Venous turgescence is usually most conspicuous on the neck, in the jugulars and the venous branches communicating with them. In extreme cases the vessels present a varicose appearance.
If the obstruction at the right auricle be considerable, when pressure is made on a vein high on the neck, the vessel remains distended below the point of pressure, and may be refilled after the contents of the vessel have been pressed backward by the finger, showing not only a resistance to the gravitation of the blood, but a reflex current.
This symptom, taken in connection with the physical signs which establish the nature and seat of organic lesions of the heart, possesses considerable value.
Venous pulsation is a diastolic movement of the veins, which is visible, and sometimes even appreciable by the touch. The movement is due to a retrograde current or impulse communicated to the blood contained in the veins. It is to be distinguished from the movements occasioned by respiration, with which every one is familiar, and also from those communicated by subjacent arteries. With the latter it is liable to be confounded, unless care be taken to avoid this error. The error may be avoided by making moderate pressure over the veins at the lower part of the neck. Pressure here, not sufficient to stop the circulation in the arteries, will arrest pulsation of the veins. The movements due to respiration may be arrested by causing the patient to suspend breathing for a few seconds. Pulsation is rarely observed elsewhere than in the veins of the neck. It is often limited to the veins just above the clavicles. It is now admitted that venous pulsation, if marked or extensive, is, in a certain proportion of cases, evidence of tricuspid degeneration. (Flint.)
The conditions most favorable for the production of the venous pulse, are free tricuspid regurgitation and hypertrophy of the right ventricle.
The systolic contraction of the right auricle may cause a movement of the blood in a retrograde direction sufficiently to give rise to this symptom. Experimental observations show that the auricular systole precedes the ventricular. A venous pulse due to auricular contraction should therefore precede slightly the arterial pulse, or apex-beat of the heart.
Placing the finger over the apex of the heart, the apex-beat, if it be felt, will be found to follow the venous pulse in the neck, provided the latter be produced by the contraction of the auricle; whereas if the venous pulse be due to tricuspid regurgitation, it will be either synchronous with, or lagging a little behind the apex-beat. By placing the finger over the carotid, and the eye fixed upon a pulsating vein, it is easy to determine whether the venous pulse precedes or occurs simultaneously with the beating of the artery.
CARDIAC DROPSY IN RELATION TO VALVULAR LESIONS.
General dropsy, when dependent on disease of the heart, is called cardiac dropsy. It may be due to other pathological conditions, and especially to disease of the kidney, when it is distinguished as renal dropsy. It appears first, as a rule, in the form of oedema of the feet and ankles, which gradually extends over the lower extremities. OEdema of the face follows, or may occur simultaneously with, or precede, the oedema of the feet. So enormous is the swelling sometimes, that erythema and gangrene may occur. The surface cracks or ulcerates, and allows the liquid to flow away. The surface assumes a dusky hue, due to venous congestion, which distinguishes this variety of dropsy from renal dropsy, but both may be combined. Effusion into all the serous cavities may occur. The occurrence of dropsy has reference to the situation, nature, and degree of valvular lesions. Tricuspid contraction is the lesion which most directly and efficiently tends to give rise to this effect; but this lesion is exceedingly infrequent.
The occurrence of dropsy, other things being equal, in cases of mitral or aortic lesions, will depend, not immediately on the nature and extent of these lesions, but on conditions induced thereby which relate to the right side of the heart. Dilatation of the right ventricle, or weakness from fatty degeneration and other causes, precedes, in the great majority of cases, the occurrence of dropsy.
Dropsy, therefore, is an event which usually belongs to an advanced period of organic disease, and it is frequently a precursor of fatal termination. Enlargement of the right side of the heart, especially if accompanied by degeneration of structure or great muscular weakness, may induce dropsy when valvular lesions are not present. The occurrence thus, when aortic or mitral lesions are present, is evidence that the effects of these lesions on the right side of the heart, which have been considered under another head, have taken place.
Embolism. Arterial obstructions by vegetations or fibrinous masses detached from the valves or orifices of the heart. The obstruction is carried onward with the current in the course of the circulation, until it reaches an arterial trunk smaller than its own dimensions. Here it is arrested, obstructing the passage of blood in the artery and its branches beyond the point at which they are lodged.
Emboli from within the heart, in cases of chronic valvular lesions, are derived, in the vast majority of cases, from the left ventricle, since lesions affecting the valves of the right side of the heart are exceedingly infrequent.
Emboli derived from within the heart are sometimes calcareous. They may cause apoplexy, coma, paralysis and softening of the brain, by obstructing the cerebral circulation. They may even cause typhoid symptoms and petechial eruptions.
SYMPTOMS AND PATHOLOGICAL EFFECTS REFERABLE TO THE RESPIRATORY SYSTEM.
The phenomena referable to the lungs, irrespective of associated or intercurrent pulmonary affections, depend, for the most part, on vascular engorgement of these organs. Congestion of the lungs is an immediate result of an impediment to the free admission into the left auricle, of blood from the pulmonary veins. An impediment exists whenever the left auricle is over-distended with blood; and over-distension of this auricle occurs as a consequence of any interruption of the blood-currents through the orifices of the left side of the heart. Obstructive lesions at the mitral orifice especially give rise to pulmonary congestion. Aortic lesions, obstructive and regurgitant, also, sooner or later, are followed by over-distension and dilatation of the left auricle and consequent congestion of the lungs. The engorgement of the lungs arising from valvular lesions gives rise to important pulmonary symptoms without any other superinduced affection of these organs. The most prominent of these symptoms are dyspnoea, cough, muco-serous expectoration, and haemoptysis. Certain pulmonary affections appear in some cases to be dependent, directly and exclusively, on over-distension of the vessels, namely, extravasation of blood, or apoplexy of the lungs, and oedema. The existence of valvular lesions thus involves a liability to bronchitis, pnuemonitis, pleurisy, and emphysema.
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.