| FIG. 46. |
| Mitral Regurgitation (from a Patient in Bellevue Hospital). |
Coincident mitral or aortic stenosis may render the pulse regular even in extensive mitral regurgitation.
| FIG. 47. |
| Mitral and Aortic Regurgitation (from a Patient in Bellevue Hospital). |
Physical Signs.—Inspection.—The area of visible cardiac impulse extends over an abnormal space, and is more or less distinct according as the right ventricular hypertrophy is moderate or extensive. Sometimes the thoracic wall is seen to rise and fall with each cardiac cycle, and not infrequently the epigastrium exhibits slight pulsation corresponding in rhythm with the heart-beats.
The epigastric pulsation is due to the right ventricular hypertrophy always found with extensive mitral regurgitation.
Skoda, Bamberger, and Leyden record a few instances in which inspection revealed a double impulse accompanying, with more or less regularity, each cardiac systole. This double impulse only occurs in aggravated cases of mitral insufficiency, and arises from non-coincidence of contraction of the two ventricles.
The jugular veins appear swollen, and this is always most conspicuous when the patient is lying down.
Palpation.—The apex-beat is displaced to the left. When hypertrophy predominates over dilatation, the apex-beat is felt lower than normal. When the dilatation exceeds the hypertrophy, the apex-beat is carried outward and often slightly upward. The impulse is diffused and more or less forcible according as the right or left ventricular hypertrophy predominates. This systolic frémissement is most noticeable when the base of the heart lies close to the chest-wall from retraction of the margin of the left lung.
Purring tremor, systolic in rhythm, felt most intensely at the apex and becoming feebler the farther the hand is removed from that part, either to the right or upward, is invariably due to mitral reflux.