[Reprint from the Buffalo Mkdical and Surgical Journal, December, 1898.] 
TRICUSPID INSUFFICIENCY. 
Hy FRANK J. THORNHURY, >f. 1).. 
Demonstrator of Raeteriolojry, University of ltul^lo. 
“Regurgitation at the tricuspid orifice is generally secondary to 
mitral stenosis or regurgitation; primary disease of the tricuspid 
valves, however, is not infrequent.” 
The above statement is made by Dr. Wm. Pepper, in his 
admirable System of Medicine, where he devotes no less than 
three pages to the discussion of this disease. The valvular lesions 
which lead to tricuspid insufficiency are similar to those which 
produce mitral insufficiency. The valves are thickened, shrunken, 
and opaque; the papillary muscles are shortened and thickened. 
The valves of the cordae tendineae and columnae carneae may rup- 
ture ; in either case, acute and extensive insufficiency results. 
Acute endocarditis of the right heart is rare in adult life, but when 
it occurs the tricuspid orifices are its primary and principal seat. 
The first effect of tricuspid regurgitation is dilatation of the right 
auricle ; following this there will be more or less hypertrophy of 
its walls. As soon as the valves in the subclavian and jugular 
veins are no longer able to resist the regurgitant current, jugular 
pulsation follows. The tributaries of the inferior vena cava, and 
the organs to which they are distributed, become greatly engorged. 
The liver may present pulsation and, later, assume a nutmeg charac- 
ter in consequence of the continued, chronic congestion. The 
skin takes on a dingy yellow hue, which, combined with the cyano- 
sis, gives a peculiar greenish tinge that is only met with in heart 
disease. The condition which I designate cyanotic induration, 
occurring more often under other circumstances, may also be 
present in this disease. This gives rise to a gastro-intestinal 
catarrh, or, perhaps, hemorrhoids, which, with ascites, speak for con- 
gestion within the abdominal cavity. The spleen becomes enlarged, 
1. Read Iwfore (he RufTulo Academy of Medicine, October 31, 1893. 2 
TRICUSPID INSUFFICIENCY. 
ordinarily. The kidneys often show cirrhotic changes. Edema of 
the lower extremities and general anasarca may develop. The 
obstruction to the systemic circulation may cause hypertrophy of 
the left ventricle, by an extra amount of work being thrown 
upon it. Then we have disease of the left ventricle consecutive 
to that of the right heart. 
The symptoms in tricuspid insufficiency, whether the disease be 
primary or secondary, are for the most part those which pertain 
to derangements of the abdominal viscera. There may also be 
present palpitation, cardiac dyspnea, and irregularities in the force 
and rythm of the heart’s action. 
Gastro-intestinal disturbances are very common. The latter 
comprise dyspepsia, nausea, vomiting, or hematemesis. There may 
be constipation or hemorrhoids. The urine is often high-colored 
and scant, sometimes containing albumin or casts. Cephalalgia, 
dizziness, and vertigo may be present as indications of cerebral 
congestion (passive), and there is a peculiar mental disturbance, 
which Pepper regards as characteristic of tricuspid insufficiency. 
Of especial importance in this disease is the possible disastrous 
consequence of the assumption of the horizontal posture, as illus- 
trated by the following case. The patient taking the recumbent pos- 
ture may become cyanosed, and, remaining long recumbent, stupor, 
coma, and even death may supervene. This fact may be called 
upon to explain why people are sometimes found dead in bed 
with heart disease, the case being, perhaps, one of this peculiar 
type. 
According to Dr. Pepper, in no other form of valvular disease is 
the area of cardiac impulse so markedly increased as in extensive 
tricuspid insufficiency. This area sometimes extends from the nip- 
ple to the xyphoid cartilage, and it may reach as high as the second 
right intercostal space. Not only the jugular veins pulsate, but 
also those of the face, arms, hands, and even of the thyroid gland 
and mamma. The apex beat of the heart is indistinct, and there is 
commonly epigastric pulsation. Sphygmographic tracings of the 
pulse show it to be dicrotic. 
The area of cardiac dulness, as revealed by percussion, some- 
times reaches to the second intercostal space. Auscultation elicits 
a murmur which is synchronous with, or takes the place, of the 
first sound of the heart. It is superficial, of low pitch, blowing, 
soft, and heard best directly over the valves between the fourth 
and sixth ribs. TRICUSPID INSUFFICIENCY. 
3 
The distinctive features of this murmur, as compared with that 
due to aortic or pulmonary stenosis, or to mitral regurgitation, are, 
first, its location; second, its character; third, its point of 
maximum intensity near the base of the ensiform cartilage, and, 
fourth, the absence of any associated accentuation of the second 
sound. The presence of jugular and epigastric pulsation are what 
give weight to the diagnosis in this disease. 
Tricuspid Regurgitation (after Galabin) a, a, anadicrotic wave synchronous with the 
auricular systole, and caused by reflux into the large veins. 
In connection with this presentation of the subject, I desire to 
report the following case of tricuspid insufficiency, with autopsy : 
S. G., male, cet. 35 years; single ; an American; a farmer by occupa- 
tion. He gave the following history : had rheumatism four years ago, and 
was now suffering from “ heart and liver disease.” There had been 
progressive weakness for the past six weeks, which, together with 
shortness of breath and irregular heart’s action, necessitated dis- 
continuance of work. There had been edema of the feet and general 
anasarca, which subsided under treatment. Present condition : patient 
fairly well developed, of medium height and weight ; physique, poor; 
expression of countenance, haggard ; pulse, very feeble and irregular; 
area of cardiac impulse enormously enlarged, and its outlines imper- 
fectly defined. Patient was intensely dyspneic, and suffering from great 
mental anxiety. He had walked a long distance prior to coming under 
observation. He now laid down, and, upon doing so, immediately 
died. 
Autopsy, fourteen hours after death, revealed the following con- 
ditions : body that of an adult male, about thirty-five years of age, 
well developed ; poorly nourished. Rigor mortis is present. Some 
post-mortem staining. Thoracic organs: heart enormously hyper- 
trophied, especially upon its left side. Right auricle and ventricle very 
much dilated. The tricuspid (right auriculo-ventricular orifice) 
extremely enlarged, admitting the tips of four fingers, the valves being 
incompetent. Ante-mortem clots were found in the ventricles of the 
left side. Liver, intensely congested ; lungs, hyperemic and edematous 
Other organs normal. 
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