Disease of the Mitral Valves.
Physical Signs. Obstructive Murmur. First beat of heart natural. Second beat accompanied or replaced by bellows murmur.
Regurgitant Murmurs. The first beat of the heart accompanied by a loud and rough bellows murmur. This sound is like sawing or filing. It is loudest above or below the nipple, between the fourth and seventh ribs. There is occasionally a musical murmur. The second beat of the heart is natural. Sometimes there is a purring tremor.
General Symptoms of Valvular Disease. Cough, in many cases with watery expectoration; difficulty of breathing; frightful dreams and starting from sleep; congestion of the lungs; expectoration stained with dark and grumous blood; swelling of the jugular veins; a livid look of the face; a feeling as if a cord were tied tight around the lower part of the chest; general dropsy, of the legs and feet in particular; passive hemorrhages from the mucous membranes; engorgement of the liver and spleen; congestion of the brain, with feelings of oppression. When the mitral valve is contracted, admitting regurgitation, the pulse is small, weak, irregular and intermittent.
These are the worst symptoms of an advanced stage.
Explanations. The examiner will distinguish the various sounds thus:
The murmurs generated at the origin of the arteries spread their sonorous currents upwards along these arteries.
Those produced in the auricular orifices will be conducted into the auricles, and propagated downwards towards the apex of the heart.
Which Set of Valves. To learn in which set of valves it originates, therefore, find its seat, and trace its direction.
Finding the murmur to be in the aortic orifice, it is then known to be obstructive, if the first sound is morbid, and the second sound natural ; and regurgitant, if the first sound is natural, and the second sound morbid.
But if the murmur be in the mitral orifice, it is obstructive when the first beat of the heart is natural, and the second beat morbid; and regurgitant when the first beat is morbid and the second beat natural.
The Pitch or Key of a murmur depends on the distance of its seat from the ear of the listener, nearness giving a high, and distance a low key. Thus, a murmur seated in the orifice of the pulmonary artery, being nearer the surface, has a higher pitch than any other. It is on about the same key with a whispered s, sometimes a little lower, and depending somewhat on the strength of the current of blood, a strong current elevating, and a weak current depressing the tone.
The mitral orifice is situated opposite the junction of the cartilage of the third rib with the left side of the breastbone. The aortic orifice is about half an inch to the right of this, and the same distance lower. It is known by the key being lower, about like a whispered r, which is the ordinary type of the sawing sound.
Murmurs from pulmonic and aortic regurgitations are about two tones lower, in consequence of the currents of the blood being weaker. They are like whispering awe by inspiration and if the click of the valve be heard, the sound will be changed to paw.
Murmurs in the mitral valve, being more deeply seated, are about four tones lower, and are like a whispered who.
The tricuspid murmurs are higher than the mitral, because nearer the surface.
The musical murmur has been compared to whistling, the cooing of a dove, and the mewing of a kitten. It generally results from regurgitation.
The purring tremor is caused, generally, by regurgitation through the mitral valve
Other Symptoms Explained. The difficulty of breathing, frightful dreams, congestion of the lungs, hemorrhages, engorgements, etc., mentioned above, all proceed from such valvular stiffenings, puckerings, ossifications, enlargements, and contractions, as occasion a decidedly obstructed circulation.
The small, weak, irregular, and interrupted pulse, is caused by contraction of the mitral valve, which occasions an insufficient or irregular supply of blood to the ventricle, and causes the ventricle, by losing the resistance of the valve, to expend its force in a backward as well a forward direction, thus sending but little blood into the arteries.
Treatment. The great object of treatment is to diminish the force and activity of the circulation, to induce the heart to cease striving to do what cannot be done.
To accomplish this, give sedatives (285),(94), (124). The hellebore and cohosh will be found particularly serviceable.
The tincture of the American hellebore is about the best of all. Purgatives may be given according to the strength of the patient.
When there is dropsy, and a scanty secretion of high colored urine, diuretics, or medicines to increase the action of the kidneys, are very important. For this purpose, digitalis and acetate of potash (130) are excellent. Should this not succeed in reducing the dropsy, an active purgative (31) may accompany it.
A remedy which comes in powder form called diuretin, given in 20 grain doses dissolved in water every four hours for one or two days exerts a favorable influence in many cases. If no improvement has been noticed at the end of two days the remedy may be discontinued, but it has worked so satisfactory in a large per cent. of cases that its use is justified.
Diaphoretics, or medicines which promote perspiration, are also useful.
The diet should be unstimulating, and yet should be sufficiently nourishing to prevent the patient from running too low. Animal food of the most digestible kind may be taken once a day; though there are many cases requiring its entire rejection.
The passions should be kept in the most perfect subjection, and the life should be as tranquil as possible. Nothing must be done in a hurry.
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