Percussion may show some enlarge ment of the left ventricle. Change in the right side of the heart does not ensue until the later stages of the disease.
Palpation very often detects at the base of the heart on the right side a dis tinct rough, systolic thrill.
Auscultation discloses a rough, long drawn, systolic murmur, heard best in the second right interspace, of a sawing character, and transmitted into the ca rotids. It is followed by the second aortic sound, unless there is also a dias tolic murmur, when the latter may sup plant the normal valvular sound. Often there is accentuation of the second aortic sound, particularly if there be chronic degenerative changes in the kidney.
The murmur is not invariably harsh. It may exceptionally be soft and blow ing, or even musical.
Diagnosis.—A systolic murmur at the base of the heart may be heard in anamia, but this is usually in young subjects, and loud upon the left well as upon the right side of the sternum; and it is not accompanied by the char acteristic thrill nor by hypertrophy of the left ventricle. A systolic aortic mur mur is heard very frequently in connec tion with the murmur of aortic regurgi tation independent of any stenosis. This murmur is comparatively soft in char acter and unaccompanied by thrill. A systolic murmur may be heard in the aortic region caused by roughening of a calcified aorta without the existence of stenosis. Here we would fail to find enlargement of the left ventricle, or the peculiarly slow, infrequent pulse of stenosis. The systolic bruit of a tho racic aneurism, heard in the same region, would be accompanied by pain, dilating tumor, x-ray shadow, and other signs of the true condition, and not associated with the peculiar pulse or with any hypertrophy of the left ventricle unless there were co-existent aortic regurgita tion. A mediastinal new growth may press upon the aorta in such a way as to cause a harsh systolic murmur, but with out any necessary sclerosis of the arteries, as seen in aortic stenosis, and with a tumor to be detected by percussion and by the x-ray. Moreover, the blood-count might aid here in diagnosis.
The systolic murmur of pulmonic ob struction and that of patent ductus arteriosus are not transmitted into the systemic arteries.
Etiology. — In some cases the valves appear as if the lesion might have been congenital, but almost always the dis ease develops late in life, and is a slow, fibrous, and calcareous change in the valves associated with degenerative changes in the whole arterial system.
The left ventricle is slightly dilated, but mainly hypertrophied.
Pathology. — Sometimes there is a subvalvular stenosis because of foetal endocarditis. There may be vegetations on the valves due to endocarditis. Usu ally the lesion is sclerotic or calcareous_ The coronary arteries may be involved, resulting in myocardial degeneration.
Prognosis.—The prognosis is compara tively favorable. Good health may be enjoyed for many years. When com pensation begins to fail, sudden death, with cerebral symptoms, may occur.
Treatment.—lodide of potash in small doses, long continued, may be of great value.
For further suggestions the reader is referred to the article in the previous volume on DILATATION OF THE HEART and to general remarks in regard to the treatment of valvular diseases, in fol lowing pages.
Tricuspid Regurgitation. Definition.—Insufficiency of the right auriculo-ventricular valve.
Symptoms. — The symptoms of tri cuspid regurgitation are those seen in most cases of ruptured compensation, in valvular lesions of the left side of the heart, provided the patient lives long enough. They are headache, dizziness, indigestion, scanty urine, uneasiness in the right hypochondrium, wakefulness, cyanosis, anasarca, and orth optima . Sometimes there is a peculiar greenish coloration of the skin, due to a slight icteric hue mingling with the cyanosis.
On physical examination we find by inspection a marked epigastric impulse, and by percussion a very extensive dull ness to the right of the sternum. The characteristic murmur of tricuspid re gurgitation is a soft, low, systolic mur mur, heard best at the left edge of the sternum between the fourth and sixth ribs, and transmitted toward the right. It is seldom audible above the third rib. The incompetency of the tricuspid valves causes dilatation of the subclavian and cervical veins, and when this has become so great that their valves are no longer competent, the veins pulsate with every systole of the heart. This pulsation may be seen sometimes even in the axillary, thyroid, and mammary veins. The same systolic centrifugal impulse is also trans mitted downward into the liver, and this organ may exhibit an expansile pulsation with every cardiac systole.