MITRAL INSUFFICIENCY. 
41 
JOGETHER WITH A FEW ON THE 
Examination of the eart. 
A Clinical lecture by Chas. W. Hickman, M. D., Lecturer on Diseases of 
The Eye, Ear and Throat, it the Medical department of 
The University of Georgia, Augusta, Ga. 
Delivered at the Clinic of the Medical College. 
W. T. Richards, Son & Co., Printers, 
Augusta, Ga., 1881. MITRAL INSUFFICIENCY, 
TOGETHER WITH A FEW POINTS ON THE PHYSICAL EXAMIN- 
ATION OF THE HEART. 
A Clinical lecture by ,Chas. W. Hickman, M. D., Lecturer on Eye, Eear and 
Throat Diseaaes, SfThe Medical Department of the University of Georgia-, 
Augusta, Georgia. 
Delivered at the Clinic of the Medical College. 
Gentlemen—We have before us to-day, a case of great inter- 
est, and one demanding our closest study and attention; 
namely that of a valvular lesion, an insufficient action of one 
of the heart valves, upon which our life is so dependent. 
In order to appreciate fully what is before us, it is necessa- 
ry first of all, to hold constantly in view, the construction and 
workings of the important organ with which ,we wish to deal. 
The heart is a muscular aparatus, or more properly speak- 
ing, a series of muscular chambers combined in one, while its 
action may be compared to that of a force-pump, its object be- 
ing to distribute blood throughout the entire body. It con- 
sists of two smaller receptacles on either side, the right and 
left auricles, and joined to them two larger ones, the right and 
left ventricles, into which, the blood xmurs and the forcible 
contraction of which, gives to the organ its well known force 
pump, or driving engine properties. 
The superior and inferior Vena Cava pour the dark Venous 
blood into the right auricle, from thence it passes through an 
auriculo-ventriculo, opening into the right ventricle, by the con- 
traction of this it is thrown through the pulmonary artery at 
its top to the lungs, there to be vitalized t)y receiving oxygen 
from the air. Teeming now with life-giving properties, it re- 
turns by means ofthe pulmonary veins to the heart, emptying 
into the left receptacle or auricle, and from thence passing in- 
to the left ventricle, the contraction of which latter, sending 4 
Mitral In sufficiency. 
it through the aorta at its top, the first great artery of our sys- 
tem, and into all its ramifications and subdivisions. 
Having now accomplished its work, having given up its life 
and health to all portions of the body, the blood is to all in- 
tents and purposes, dead without its oxygen renewed. 
The venules then collect it from all parts, pour it into the 
smaller veins, and from thence into the larger, and so on until 
it again returns into the ascending and descending Vena ('ora. 
again to pass into the right auricle and to go its round as Indore. 
For the completion of the mechanism of such an organ, i" is 
necessary during the play of the ventricles, that some arrange- 
ment should be made to prevent a return flow of blood from 
whence it came, Just such, do we find in the valves placed 
at the auriculo-ventriculo openings, on the right side the tricus- 
pid, on the left, the mitral. As the Ventricles contract the 
closure of theft orifices by theft valves, completely a 
return flow of blood. At the pulmonary artery and aorta, we 
find three valves semilunar in shape and so arranged, that :is 
the Ventricles dilate, their falling together effectually shuts 
off' a backward flow of blood. 
The perfect action which the heart exhibits, is indeed w on- 
derful, Although in reality a double organ, its action is that of 
one. The two Ventricles contract together, and dilate togeth- 
er, then comes a short period of rest; this process occurs about 
sixty-five or seventy times in the course of a minute. 
In the examination of a heart, a thorough systematic meth- 
od must be observed throughout, or else we will constantly 
encounter innumerable difficulties. As various methods are 
given for this purpose, some rather confusing to a student, 1 
wish to describe the most perfect with which I have ever met, 
one formed rather from a combination of the most perfect, and 
calculated in the main, always to yield up the wished for 
results.. In so doing, I mainly follow the precepts of my 
honored Master, and that prince of teachers “Sch rotter”,* 
First, by inspection of the heart region a few' points may l>e 
gleaned in regard to the position and character of the impulse 
as well as anything of an unnatural appearance in that neigh- 
borhood. 
More important still are the results obtained from palpation 
* Professor Extraordinary and Successor to the Clinic of Oppolzer, in the University of 
Vienna, Mitral Insufficiency. 
5 
or placing the hand over the seat of the organ. In this way 
may not only the position of the impulse be more accurately 
determined, as well as its character more readily appreciated, 
but alsh a peculiar trembling movement ( the purring tremor 
of Laennee,) or a rougher feeling reach the hand at times, and 
almost always indicative of mischief. 
Far more important though, are the results obtained from 
percussion of this organ. You will bear in mind that the 
heart lies obliquely in the chest, behind the lower two thirds 
of the sternum, and projecting over towards the left side. The 
right lung extends to the middle of the sternum. The left does 
the same, as far as the fourth costal cartilege, when its bound- 
ary line ceases to extend so far, leavihg a portion of the heart 
uncovered, which mainly consists of the lower portion of the 
right ventricle, with the apex of the left. In percussing a 
heart then, the first thing to do, is to find its apex. This is 
done by placing the hand over the chest wall, when, at a point 
corresponding to an inch and a half to two inches below the 
left nipple, and somewhat to the inner side, its beat against 
the chest wall is felt. In order to insure ourselves against er- 
ror, let us commence percussing from the outer side towards 
the point taken for the apex, and upon reaching it if we have 
been correct in our surmise, the clear note of the lung tissue is 
immediately changed for the dull sound of a solid organ. Let 
us now errry our percussion obliquely upwards towards the 
sternum, upon reaching the edge of which, or a little over, 
the clear lung note again strikes our ear. This brings us to 
the right boundary. To find the upper boundary, we com- 
mence below tne middle of the clavicle, and proceed down- 
ward over the lung until at the lower border of the fourth 
costal cartilege, a dull sound tells us that we have reached the 
point sought. Although as we can see, this does not give us 
the actual size of the heart, but only that portion left uncover- 
ed by the lungs, bat yet we find that it answers for all practi- 
cal purposes. 
Equally as great, if not more important, results do we obtain 
from a close study of the heart sounds. The ear placed over 
this region receives two sounds, the first occurring during the' 
contraction of the Ventricles, or as we commonly express it, 6 
Mitral Insufficiency. 
the systole of the heart, ami produced mainly by the dosing of the 
auricido-ventriculo valves, although the contraction of the ven- 
tricles and hound of the heart against the chest wall, aid in its 
formation ; thesecond occurring during the dilation of the Ven- 
tricles or diastole of the heart, and produced by tin; sudden 
falling together of the semilunar valves of the pulmonary arte- 
ry and aorta. 
If we wish to separate the sounds of the individual valves, 
we listen for the tricuspid at the lower portion of the sternum, 
for the mitral at the apex. The semilunar valves of the pul- 
monary artery, are best heard in the second intercostal space 
near the left edge of the sternum, while the ear is carried to 
the second intercostal space of the l ight side to catch the play 
of the aortic valves. 
In disease, the heart-sounds vary greatly from what they are 
in health, and this condition makes itself known to us by more 
or less blowing sounds commonly classed under the term of 
murmurs. These vary greatly both in intensity and character, 
and may be so low that the ear can scarcely detect them, or 
so loud as to be distinctly heard at some distance from 
the patient. They may be soft and musical, or harsh and gra- 
ting. In order to appreciate any deviation from the normal 
sounds and the meaning conveyed thereby, it is important to 
have constantly at our fingers ends (so to speak I, the events 
taking place during the systole and diastole of the heart. At 
the moment of the systole, the two ventricles contract, produc- 
ing the impulse against the t-hest wall, the auricv\o-ventriculo 
valves close and the blood rushes along the pulmonary artery 
and aorta. At the moment of the diastole the ventricles dilate 
the blood passes from the auricles into the ventricles and the 
semilunar valves guarding the orifices of the pulmonary artery 
and aorta, suddenly close together producing the short abrupt 
second sound of the heart. 
The first question always to be answered then is, does the mur- 
mur we hear occur during the systole or diastole of the heart, 
and this point undetermined, the mere fact of hearing a mur- 
mur gives us very little, if any, aid in the examination of our 
case; Xor is this by any meads so easy as it may seem at first 
sight. If the heart would only beat as in its natural condition, Mitral Insufficiency. 
7 
giving us a murmur in one or the other of its sounds, we could 
then easily tell to which the murmur belonged, but unfortu- 
nately in its diseased state its action is often so stormy and 
rapid that it becomes a matter of considerable difficulty to tell 
where it belongs. We sometimes hear of a pre or peri sys- 
tolic or diastolic murmur, and that such and such is the case, 
because a pre systolic or a peri systolic (or diastolic) murmur 
is at hand. I wish to inroress upon you that if we are only 
sure that the murmur belongs to either the systole or diastole 
it is a matter of no importance whatever whether it be pre, peri 
or anything else. As before stated however, this is at times a 
matter of considerable difficulty and as the prolonged sounds 
seem to run into each other to a degree indeed perplexing to 
an auscultator, Ave do find that by separating a pre systolic 
from a peri diastolic or a peri systolic, from a pre diastolic 
murmur, a certain amount of aid may be given us in isolating 
the abnormal sounds.§ 
The next question which naturally strikes us is, Avhence 
comes this murmur, and to what is it due, which valve is at 
fault, or is any valve at fault; and as this brings us at once to 
the examination of our patient, let us se if the symptoms as 
they present tliemselve, together Avith the physical signs we 
obtain, will not give us all Ave require to fully understand the 
case as it really exists. 
The patient comes to us complaining of shortness of breath, 
asthmatic attacks, these attacks brought on by the slightest 
exertion, pain at the same time being frequently felt over the 
heart region accompanied by palpitations greater or less in 
degree. Adopting the method shown, avc find that inpsection 
does not gives us as much aid as is usual in these cases, but 
palpation reveals the heart’s impulse instead of being in the 
fifth intercostal space somewhat to the inner side of the line 
from the nipple, to be in reality nearly an inch and a half to 
the outer side. Percussion not only confirms this, but tells us 
also that its line of dullness extends almost to the middle of 
the sternum, showing tlie heart enlarged in its transverse di- 
ameter. On placing our ear over the chest, instead of the two 
clear ond distinct tones, we ahvays get from a healthy heart, 
we receive a prolonged first sound, in other Avords a systolic 
§ Note; The manner in which this is more clearly shown to students, cannot at present, 
well be represented without an especial diagram for the purpose. 8 
Mitral Insufficiency. 
murmur, but with the second sound remaining unchanged. 
Closely listening to the different valves, we soon recognize 
tli is murmur as loudest at tlic apex, telling us of trouble at t lie- 
mitral valve. 
Still attentively listening, we notice that the second sound, 
although everywhere clear anil distinct, has nevertheless a de- 
cided accentuation over the pulmonary artery. What then do 
these facts tell us, and what conclusion may we draw from 
them! If we are sure that the heart is enlarged in its tr ans- 
verse diameter, that we have present a systolic murmur, heard 
loudest at the apex, accompanied by a decided accentuation of 
the second sound over the pulmonary artery we may with all 
certainty know that we have to deal with an imperfect action 
of the mitral valve, an action insufficient during the contract, 
ion of the left ventricle, to prevent the blood fron pouring 
back into the left auricle. Let us look a little further into this. 
The increased amount of blood which reaches the left auri- 
cle distends and enlarges it. This reversed pressure, so to speak, 
continuing through the pulmonary veins reaches the lungs 
and from thence extends through the pulmonary artery to tin? 
right ventricle, and unless here arrested by the compensating 
action of this latter, reaches the right auricle and finally the 
entire venous system producing numberless troubles into 
which, we have not time at present to go. We can easily see 
then that the compensating action of the right ventricle neces- 
sarily tends to its hypertrophy. In addition to this the left 
ventricle being over-filled with blood during its dilation from 
the engorged left auricle, naturally works under a high pres- 
sure and becomes enlarged. Hence tin; increased area of per- 
cussion dullness. The increased column of blood, also, thrown 
upon the semilunar valves of the pulmonary artery gives riso 
to the accented second sound heard over this region. 
Some time back, at our clinic, we had a case of insufficiency 
of the aortic valves, as well as what is quite rare, one of 
stenosis of the pulmonary artery, and did time permit, the 
differential diagnosis would be interesting in the extreme, but 
this unfortunately we must defer for another lecture. 
A few words in regard to the treatment of this affection. Un- 
fortunately the heart cannot be taken out and its valves repair Mitral Insujftciency. 
9 
ed. or anew one put in as a pump sent to a plumber, yet, for 
nil that, much may be done towards comfortably prolonging 
the life of our patient, and greatly relieving the unpleasant 
■symptoms to which the insufficiency gives rise. The tendency 
of the affection as the rule, is not bad, and the patient carefully 
warned to observe a few hygeinic rules, may live a lifetime of 
comparative comfort. So long asthe compensating action of the 
right ventricle is well kept up, so long have we nothing par- 
ticularly to fear. All our attention therefore, should be direc- 
ted to this end, and every thing strictly guarded against which 
tends to interfere with it. A quiet life, regular hours, a free- 
dom from all excitement, should be rigidly enforced. 
Violent exercise, such as running, walking rapidly, climb- 
ing heights and the like, as wel 1 as intemperance in eating and 
drinking must be carefully avoided. As the rule, spirituous 
liquors, tobacco, strong tea and coffee, should be forbidden. 
When the right ventricle fails in its action, or even the left 
becomes uncertain and weak, our main reliance consists in the 
administration of digitalis and iron, but as digitalis in heart 
affections, constitutes quite a subject in itself, a discussion of it 
we must put of! for another time. 
And now gentlemen, in conclusion let me say, that although 
in reality there is scarcely a department of medicine, where 
in the large majority of cases we can tell with such mathemat- 
ical accuracy with what we have to deal, yet equally true is it 
that scarcely a department demands on our part more pains- 
taking and patience. A thorough appreciation of the normal 
heart, is not acquired by the examination of one but of many 
normal hearts, much more so is this the case when we come to 
deal with the numberless affections to which this organ is lia- 
ble. Not by the examination^olie, but of hundreds of abnor- 
mal hearts can we ever hope to obtain anything like proficien- 
cy or be able like the leader of some grand orchestra to isolate 
among the confused Babel of sounds, anythin g that tends to 
produce discord or lessen the harmonious workings upon 
which the great effect depends.