tuated pulmonic second sound and a small pulse, is not difi&cult. A tricuspid
stenosis, which is a very rare and usually congenital lesion, may be evidenced
by a harsh murmur beginning at the aortic closure and covering the ventric-
ular diastole and auricular systole, but it is heard over the xiphoid cartilage,
not over the apex. A murmur taking place during ventricular diastole and
auricular systole, heard over the apex and at the second right space, the first
half of which is harsh, the second half soft, is due to mitral obstruc-
tion associated with aortic insufficiency. The so-called Flint murmur which
is rough in quality, auriculo-systolic in time and is heard over the apex is due
to aortic insufficiency and is accompanied by the water-hammer pulse and
hypertrophy of the left ventricle and is not associated with the sharp, forcible
apical impact. This last is also absent in the rumbling sound sometimes
heard in adherent pericardium. The fact that the pressure of the hyper-
trophied left aiuricle may cause pressure paralysis of the left recurrent
laryngeal nerve should not be forgotten in connection with the diagnosis of
aortic aneurysm. With the murmur of mitral obstruction the soft ventriculo-
systolic murmur of mitral insufficiency is frequently present.

In obstruction of the mitral valves there are likely to be recurrent attacks
of valvulitis during which emboli may be dislodged and cause various cerebral
disturbances.

Aortic InsuflSciency.

This lesion may be the result of an enlargement of the aortic orifice which
the valve flaps cannot close or of changes in the cusps themselves; it is the
most grave and most resistant to treatment of the valvular defects. Its



AORTIC INSUFFICIENCY. 567

immediate result is a backward flow of blood into the left ventricle during its
diastole; this causes the ventricle to dilate and later to hypertrophy in order
to restore the balance disturbed by the leakage. The over-developed ven-
tricle forces the blood into the aorta with such vigor that it is fuUy distended
but it is rapidly emptied by the back flow of blood through the incompetent
aortic valve and the onward flow into the arterial circulation. This results
in the characteristic pulse of this lesion, a pulse of quick and extreme rise
and sudden fall. The left ventricular hypertrophy is often accompanied by
enlargement of the left auricle and right ventricle. Dilatation and hyper-
trophy are seen in this lesion in their most extreme type and the heart of
aortic insufficiency on account of its great size has been termed the cor hovinum.
It often weighs as much as 35 ounces (1050.0) and has been known to reach
50 ounces (1500.0). The cavities of the organ are enlarged and there may be
co-existent coronary arteriosclerosis with consequent fibrous myocarditis.
During life there may be signs of an aortic arch dilated as a result of the con-
tinued high pressure exerted by the blood current, but the vessel may be
found of normal size after death. As a result of the ventricular enlargement
relative mitral insufficiency occurs and ultimately the compensation estab-
lished by the hypertrophy of the right ventricle fails, relative tricuspid insuffi-
ciency takes place and general venous congestion with its concurrent symp-
toms supervenes.

.etiology. Aortic insufficiency occiirs as a result of congenital defects,
particularly union of two of the cusps; of acute or chronic endocarditis; and of
sclerosis of the valve which is predisposed to by prolonged excessive muscular
exertion, the abuse of alcohol, and syphilis; dilatation of the ascending aorta
or aneurysm causes an enlargement of the valvular ring which results in rela-
tive insufficiency.

Symptoms. During the stage of compensation there may be no manifes-
tations which give rise to suspicion that any cardiac affection is present.
Disturbance of compensation is evidenced by headache, vertigo and a sensa-
tion of faintness, especially marked if the patient rises suddenly, and even
before the failure of compensation, pain may be a distressing symptom; this
may be duU, aching and referred to the precordium or it may be sharp, radiat-
ing up toward the neck or down the arms, more particularly the left. Attacks
of angina pectoris may occur. Dyspnoea with palpitation, at first only upon
exertion but later appearing spontaneously, especially at night and rendering
it necessary for the patient to sleep with his head elevated, is common.
(Edema is frequent but cyanosis is rarely seen. Pulmonary congestion causes
cough, attacks of oedema and perhaps haemoptysis. The patient may com-
plain of a distressing throbbing in the head, unpleasant dreams and troubled
sleep; marked cerebral symptoms such as hallucinations and delirium with
suicidal tendencies may be observed. EmboHsm is not uncommon and



568 DISEASES OF THE HEART AND BLOOD-VESSELS.

sudden death is more likely to take place in this than in any other valvular
lesion; usually it occurs during an unusual exertion and is probably caused
by interference with the coronary circulation either as a result of embolism
or the fact that the valvular incompetence prevents the proper supply of blood
from reaching the heart muscle. An acute ulcerative valvulitis may be
engrafied upon an insufficient aortic valve. Anaemia is frequently observed
in patients suffering from this lesion.

Physical Signs. Inspection may reveal, especially in young and ema-
ciate^ individuals, a bulging precordium. The apex impulse is displaced
downward and to the left even as far as the seventh space and the anterior axillary
line; if compensation is disturbed the apex beat is diffuse and heaving. Palpa-
tion confirms these manifestations and in rare instances may detect a ventric-
ulo-diastolic thriU at the base or in the episternal notch. There may be a
ventriculo-systolic depression of the intercostal spaces near the sternum due
to atmospheric pressure.

Percussion shows a heart of greater size than is found in any other valvular
defect. The cardiac dulness is increased downward and to the left as a result
of the left ventricular hypertrophy and, in extreme instances, enlargement exists
upward and to the left as well, in which case it is due to upward enlargement
of the left ventricle and increase in the size of the left auricle.

Auscultation detects the characteristic murmur of the lesion, ventriculo-
diastolic in time, and of greatest intensity over the second right space close
to the sternum or at this level over the mid-sternum. It is also in frequent
instances loudly audible along the left border of the sternum even as low as
the ensiform cartilage. It is transmitted over a wider area than any of the
other cardiac murmurs, being usually conducted down the sternum or even
as far toward the left as the axiUa. It is not carried with any great degree
of distinctness upward in the direction of the cervical vessels. In quality it
is loud, prolonged and blowing and while not harsh, possesses more of this
element than does the murmur of aortic obstruction. The so-called "Flint
murmur" (see p. 566) may be co-existent.

Upon placing the stethoscope over the carotid arteries the second arterial
sound is less distinct than under ordinary conditions and may be absent, and
the murmur caused by the leakage of the blood through the incompetent
aortic valve may be audible; a short rough murmur ventriculo-diastolic
in time may be heard as well. Ventriculo-diastolic and ventriculo-systolic
murmurs may also be heard over the large peripheral arteries, especially the
femoral and popliteal.

The pulse of aortic insufficiency is characteristic; its rise is quick and to an
unusual height and it falls even more abruptly, as the blood flows back through
the imperfectly closed valve from the aorta into the left ventricle. Its force
is good and its rhythm regular except in disordered compensation. This



AORTIC OBSTRUCTION. 569

pulse is known as the "Corrigan," "water-hammer" or "shot" pulse and
may be often detected by the eye above the bend of the elbow when the patient's
hand is elevated. The throbbing of the caroad arteries is often visible and
the impulse of the abdominal aorta may cause an epigastric pulsation. Retinal
pulsation may be detected by means of the ophthalmoscope and a capillary
pulse may be observed under the finger nails and by drawing a line across
the forehead or cheek upon either side of which the skin flushes and pales
with cardiac systole and diastole.

Patients with uncomplicated aortic insufficiency may maintain good compen-
sation for long periods and even perform moderately hard labor, but when
there are associated valvular lesions, arterial or myocardial disease, disturbance
of compensation soon occurs.

Aortic Obstruction.

True and uncomplicated stenosis of the aoriic valve is one of the rarest
of valvular defects but roughening of the segments, with or without obstruction
to the flow of the blood current, is less infrequent. With mere roughening
of the aorLic lining beyond the valve there is commonly a miurmur present
which differs only slightly if at all from that of true aortic stenosis. In pure
stenosis of moderate degree the valve cusps are adherent and so stiffened that
during the systole of the ventricle they do not fall back against the wall of the
aor^a but obstruct the emerging blood current to a greater or less extent; in
advanced grades of the lesion the segments are thickened and hardened and
may be converted into calcareous masses. The obstruction prevents the flow
of blood into the aorta and in consequence left ventricular hypertrophy ensues
which compensates for the stoppage. Until compensation becomes disturbed
the rest of the heart remains in its normal condiiion but when failure takes
place, dilatation ensues with consequent pulmonary congestion and hyper-
trophy of the right heart.

A relative aortic obstruction may resiflt, when the valves remain normal
but there is dilatation of the first part of the aorta.

.Etiology. Aortic obs:ruction is most frequently met in patients of advanced
years and is usually associated with calcareous degeneration of the arteries.

Symptoms. While compensation persists the symptoms are insignificant
but there may be vertigo and syncopal attacks due to insufficient cerebral
and cardiac blood supply. Pain and symptoms of angina may be induced
by exertion but are less common than in aortic insufficiency. Failure of
compensation is followed by the usual symptoms of venous congestion, dysp-
noea, cough, palpitation and oedema.

Physical Signs. Inspection reveals an apex beat displaced to the left,
the degree of the displacement depending upon the amount of ventricular



570 DISEASES OF THE HEART AND BLOOD-VESSELS.

hypertrophy; the apical impulse may be of good force if compensation is
present; when the latter is disturbed and even before this event, it may be
weak and indistinct.

Palpation confirms the signs detected by inspection; a thriU may be present
at the base and apex, rarely at the apex only, and in certain instances of extreme
hypertrophy there may be a prominence of the precordium. Percussion
shows an increase of precordial dulness, especially downward and to the left.

Upon auscultation a ventriculo-systolic murmur is detected, loudest over the
second right interspace close to the sternum and sometimes accompanied by a
thriU. The hndt is harsh when there is roughening of the aortic lining;
after disturbance of compensation it may become soft and more musical.
The murmur is transmitted upward along the course of the blood current
and may be audible in the popliteal and dorsal arteries of the feet. There
may be a co-existent ventriculo-diastolic murmur due to associated aortic
insufl&ciency; the double murmur of these lesions when occurring together
may be mistaken for the hruit of aortic aneurysm (see p. 6oi).

The pulse is usually small, its upward stroke is tardy, and its rate may be
slow but is more often frequent; it is regular while compensation persists.

The diagnosis of aortic obstruction is often difl&cult on account of the
great similarity between its murmur and that of simple aortic roughening;
with the latter condition the pulse is less small and no thrill is present. Func-
tional murmurs which are so often heard at the base are more common in
young persons, are associated with anaemia, are not accompanied by a thrill
nor by any cardiac hypertrophy and are frequently intermittent.

Tricuspid Insufficiency.

Primary insufi&ciency of the tricuspid valve is very rare but may occur
as a congenital defect; in certain instances it is observed as a result of acute
or chronic endocarditis; secondarily the lesion takes place as a result of valvu-
lar affections in the left heart and is of the relative type. It is also met as a
complication of conditions which cause pulmonar}' congestion, such as chronic
bronchitis, pulmonary emphysema and fibroid phthisis.

Symptoms. These have been discussed at length in the section devoted
to mitral insufficiency and are those of obstruction to the pulmonary circula-
tion with congestion of the stomach, kidneys and liver, with enlargement and
tenderness of the last organ, and anasarca. Late manifestations are cyanosis,
dyspnoea and pulmonary oedema.

Physical Signs. Inspection reveals a diffuse pulsation in the region of the
xiphoid cartilage and a pulsation of the liver and of the jugular veins. The
latter is ventriculo-systolic in time and more forcible in the vessel of the right
side. Upon coughing the vein may form a tumor-like protrusion; in some



TRICUSPID OBSTRUCTION. 57 1

subjects the pulsation may be observed in the subclavian, axillary and even
in the cutaneous veins over the shoulder and breast. The hepatic pulsa'^ion
is also ventriculo-systolic, the impulse resulting from the tricuspid incom-
petence being transmitted through the inferior cava to the veins of the liver.

Palpation confirms the signs detected by inspection. Percussion deter-
mines an area of cardiac dulness enlarged to the right margin of the sternum,
the result of right ventricular hypertrophy.

Auscultation reveals a ventriculo-systolic murmiu:, the maximum intensity
of which is over the sternum just above the ensiform cartilage. In quality
it is soft and usually faint; it may be transmitted to the right as far as the
anterior axillary line. It is often quite definitely localized to the tricuspid
area. The pulmonic second sound may be accentuated. The relative
tricuspid insufficiency occurring with mitral insufficiency may not be evidenced
by a murmur; here the valve may be in perfectly normal condition, and the
incompetency is the result of a dilatation of the valvular ring.

The diagnosis is simple when pulsation is present in the cervical veins
and in the liver, these being pathognomonic signs. In many instances of
relative tricuspid insufficiency where the lesion is secondary to mitral disorder,
no murmur is present and the complicating affection may remain undiagnos-
ticated until after death. In the differentiation of the tricuspid ventriculo-
systolic souffle from that of mitral insufficiency the difference in location,
quality and transmission are points to be remembered.

Tricuspid Obstruction.

Isolated tricuspid obstruction is a very rare condition but as a secondary
lesion to disease of the left heart, especially mitral obstruction, it is not infre-
quently observed; it also occurs as a congenital defect together with other
valvular affections. It seems to be more common in women than in men.
The changes in the valve are analogous to those taking place as a result of
like causes in other valves and the symptoms also resemble those due to
similar lesions occurring in other parts of the heart. In advanced instances
the more typical manifestations are cyanosis of the face and intense and per-
sistent oedema.

Physical Signs. Enlargement of the right side of the heart is evident upon
percussion, dtdness being perceptible as far as the right margin of the sternum.
A murmur beginning at the closure of the aortic valves, covering ventricular
diastole and auricular systole, harsh in quality, accompanied by a thrill and
ceasing abruptly with the impact of the apex against the thoracic wall, is an
evidence of extreme tricuspid obstruction. This is a hruit practically identical
with that of mitral obstruction, but the latter is heard over the apex. The
two lesions are often co-existent and the signs of the latter may so obscvu^e



572 DISEASES OF THE HEART AND BLOOD-VESSELS.

those of the former as to render very difficult the diagnosis of the secondary
condition. In many subjects a tricuspid obstruction may exist without
giving definite signs.

Pulmonic Insufficiency.

This is a rare condition but may occur as a congenital lesion and it has been
observed in malignant endocarditis.

The symptoms are those of venous congestion.

Physical Signs. There is increase to the right in the area of cardiac dulness
due to hypertrophy of the right ventricle and in the later stages there may be
pulsation in the veins of the neck. The characteristic murmur is ventriculo-
diastolic in time, heard with maximum intensity over the pulmonic area —
the second left space close to the sternum. It is to be differentiated from
the hruit of aortic insufficiency by the absence of the characteristic pulse of
this lesion and the lack of left ventricular hypertrophy. Very high pressure
in the pulmonary artery may cause slight regurgitation through the valve
and a consequent soft ventriculo-diastolic murmur.

Pulmonic Obstruction.

This is a very rare lesion; when it does occur it usually exists as a result
of congenital cardiac disease and may be associated with anomaly of the
tricuspid valve and of the interventricular septum and patency of the ductus
arteriosus or foramen ovale. Malignant valvulitis has been known to involve'
the pulmonary valve. When the defect is congenital the insufficiency is due
to a union of the margins of the cusps.

The chief symptoms of pulmonic obstruction are those due to venous
obstruction, particularly cyanosis and dyspnoea. It is one of the lesions which
may cause the blueness of the so-called "blue baby."

Physical Signs. These are often indefinite; there is right ventricular hyper-
trophy with consequent increase in the area of cardiac dulness toward the
right border of the sternum. The typical murmur occiurs with ventricular
systole and is heard loudest over the second left space close to the sternum;
a thrill may be present. The pulmonic second sound may be faint or inaudible.
At times the murmur is heard posteriorly between the shoulders.

The frequency with which murmurs are audible at the pulmonic area is
remarkable but the clinician should be very chary of attributing these, in the
majority of instances, to defects of the pulmonic valve which are extremely
rare. Anaemic murmurs are often heard in this region as also are the func-
tional bruits which occur when the heart is beating with undue force as during
febrile disease or after unusual muscular exercise. In healthy individuals a



COMBINED VALVULAR LESIONS. 573

murmur may be heard, particularly if the thoracic wall is thin, over the base
of the heart and the cardio-respiratory souffle may be noted in this vicinity.
None of the above conditions is accompanied by other evidences of cardiac
disease and the associated murmur should never be mistaken for that which
evidences a defect of the pulmonic valve.

The murmur of mitral insufficiency may be heard as far up the left border
of the sternum as the second cartilage but the differentiation of this lesion
from those of the pulmonic valve should be made with ease (see p. 564).

Combined Valvular Lesions.

It is not at all infrequent to find associated lesions of two or more valves;
the mitral and aortic valves are very often jointly affected as are the mitral
and tricuspid. Aortic defects more commonly exist independently than
those of the mitral valve but disease of the aortic valve is less likely to be
accompanied by mitral stenosis than by insufficiency. In children a frequent
combination is insufficiency of both the aortic and the mitral valve. A
stenosis occurring with an aortic or mitral insufficiency may be beneficial
in that it prevents too free regurgitation of the blood current.

Congenital Cardiac Defects.

These most frequently affect the right side of the heart and may be the
result of inflammations occurring during intrauterine life or of anomalies
of development. In most instances they are incompatible with the continu-
ance of life or if not, little can be accomplished by curative or palliative measures.
Pulmonic obstruction is the most frequent lesion and other lesions which may
be observed are persistence of the foramen ovale, of the ductus Botali, a
patulous interventricular septum and a persistent communication between
the aorta and the vena cava or between the aorta and the right auricle. The
exact diagnosis of the lesion in a given case is difficult since the murmurs
present are not characteristic but the symptoms of congenital heart disease
are typical. The most salient of these are insufficient physical develop-
ment, persistent cyanosis (the "blue baby"), dyspnoea and clubbing of the
fingers. The murmur is usually basic.

Various malformations of the heart have been described, such as entire
absence of the organ — acardia; double heart; dextrocardia, in which the heart
is in the right side of the thorax and with which transposition of the other
viscera may or may not co-exist; and ectopia cordis where the organ may be
located in the neck, thorax or abdomen. Fission of the thoracic wall and
of the abdomen is associated with the last named condition. The semi-
lunar valves may be two in number instead of three owing to a union of two



574 DISEASES OF THE HEART AND BLOOD-VESSELS.

of the cusps (the bicuspid condition), and the semilunar cusps may be
fenestrated.

The Prognosis in Chronic Valvular Lesions.

The outcome of any case of chronic valvular endocarditis is difl&cult of
prophecy since the factors which may influence it are numerous and uncer-
tain. The problem depends whoUy upon how long compensation can be
maintained. Women seem to withstand the effects of valvular defects better
than men, possibly because their habits and mode of life are more quiet and
because the aortic valve is less frequently affected. Child-bearing is fre-
quently fraught with no ill-effects. In children the prognosis is bad, the
subjects of congenital heart disease seldom surviving more than a few years,
while in those below the age of ten or twelve valvular lesions are serious even
though the coronary circulation and the myocardium are likely to be in good
condition. Much depends upon the maintenance of proper nutrition and
the abstinence from violent exercise. Children affected with chronic endo-
carditis seldom die suddenly.

With regard to the prognosis of the lesions of the different valves it may be
said that mitral defects are, other things being equal, less serious than those
of the aortic valve, especially insufficiency, in which sudden death often takes
place. The co-existence of a certain amount of obstruction with a valvular
insufficiency is conservative, the stenosis preventing the regurgitation in some
degree. In giving the prognosis in any valvular lesion we must take into
consideration the condition of the heart muscle and of the arterial system
and the general health and mode of life of the patient, as well as the amount of
compensation present and the predisposition to rheumatism.

Intercurrent disease of even mild type is a serious matter to the patient
whose cardiac valves are affected; especially is any pulmonary trouble
likely to result unfavorably.

The Treatment of Valvular Lesions.

Prevention consists in the proper treatment of all diseases which are likely
to be followed by cardiac defects especially rheumatism and chorea. All
rheumatic patients should receive prolonged salicylate treatment, for whether
or not this class of drug influences the incidence of heart lesions, it certainly
shortens the attack of rheumatism and in connection with prolonged rest
renders relapse more unlikely. Subjects predisposed to rheumatism should be
advised to avoid all exposure and every influence which may induce an attack.

I. Treatment during the stage of compensation. At this time the object
should be to maintain the strength of the heart and to preserve the compen-



THE TREATMENT OF VALVULAR LESIONS. 575

satory condition as long as possible. This is to be accomplished by properly