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At the heart of general practice since 1960

A hundred years ago: Tricuspid regurgitation

By Raymond Crawfurd, M.A Oxon., M.D., F.R.C.P

Physician to King's College and the Royal Free Hospital

By Raymond Crawfurd, M.A Oxon., M.D., F.R.C.P

Physician to King's College and the Royal Free Hospital

Extracted from the June 1907 issue of The Practitioner

The diagnosis of tricuspid regurgitation depends, for the most part, on the presence of a systolic murmur in the tricuspid area, together with such venous pulsation as I have described in the liver or jugular veins. The venous pulse is a more valuable criterion than the murmur, for, even when present, it is often very difficult to decide its site of production. Again, when regurgitation occurs simultaneously at each auriculo-ventricular orifice, it may be quite impossible to assert the existence of an independent tricuspid murmur, as the mitral murmur may be propagated throughout the tricuspid area, and will tend to overpower the short and soft tricuspid systolic murmur. The appearance of dropsy in the systemic venous territory does not necessarily indicate tricuspid regurgitation, and does indeed occur in a low degree, while the valve is still competent. High degrees of back pressure, in the absence of tricuspid stenosis, almost necessarily do. Similarly one may find considerable enlargement of the liver while the tricuspid valve is competent, but hardly ascites, or other signs of grave portal stasis of cardiac origin, without incompetence, or obstruction of the tricuspid orifice.

The outlook in tricuspid regurgitation is of very varying moment according to the nature of its cause. If of accidental, of febrile, or of gastro-hepatic origin, it is essentially temporary, and will disappear with rest and attention to the digestive functions, and, at the same time, the signs and symptoms of loss of circulatory equilibrium will be of the slightest. If due to disease or essential weakness of the heart muscle, to adherent pericardium, or to chronic lung disease, the incompetence may disappear for the time, with rest and appropriate medicinal treatment, but will inevitably recur, while the balance is never so completely restored as to abolish all sense of cardiac impairment. At each recurrence, relief is less complete and less lasting, so that the progress is constantly downhill. It matters but little whether the incompetence is purely functional, or whether the valve is the seat of organic change as well. Death, in the absence of intercurrent trouble, comes by gradual cardiac asthenia, often with widespread dropsy.

In the direct treatment of tricuspid regurgitation, we have, as in mitral regurgitation, two main lines of action, viz., to diminish the resistance and to increase the power. Rest is the first and most essential agent, and, alone, will often suffice to restore equilibrium; rest should at first be complete and in bed, and should be relaxed only as improvement becomes marked. The most valuable auxiliary of rest is digitalis, which, beyond all question, acts as powerfully on the right ventricle as on the left. In grave cases, it should be given with the usual precautions, viz., after a free initial purge to unload the veins, and, combined with more rapidly-acting stimulants, such as strychnine, ammonia, or ether, to tide over the delay of its effective doses. It is remarkable, as a rule, how, with rest and digitalis, in a few days the circulation is steadied, free diuresis set up, and dropsy begins to disappear. At the same time the murmur and systolic venous pulse may vanish. At times diuresis fails, or is inadequate; then theobromine or caffeine may be given with salicylate of soda. When the whole body surface, and perhaps the serous sacs as well, is dropsical, these measures are all apt to be quite ineffectual, until such effusion has been relieved or removed; then paracentesis of the abdomen or thorax, or puncture or incision of the feet and legs may be a necessary prelude to the success of digitalis. Such relief is usually followed by a rapid increase in the output of the urine, and by a return of restful and comfortable sleep. There are yet other cases, and these are commonly those, in which dropsy is not a prominent feature, in which the strain on the right heart is so great as to render the patient livid, and on the verge of suffocation. Early venesection, followed by diffusible stimulants, such as ammonia and ether, offers the best chance. Acute distress of this kind in tricuspid regurgitation is nearly always attended by two dangerous auxiliaries, sleeplessness and vomiting, directly due, in each case, to venous stagnation. Sleep must be obtained, and, at times, at any price. I have seen the end accelerated by morphia but far more often by the fear of morphia. I am sure that in conditions of urgent cardiac distress, with restlessness and insomnia, we are far too fearful of morphia, and patients are allowed to die of sheer exhaustion for want of sleep. I fancy it may be given most safely in the form of suppository, but, if given subcutaneously, it may be advantageously combined with strychnine. It is useless to give morphia, if we have not the courage to give an efficient dose. It is idle, in advanced cardiac disease, to put one's trust in hypnotics other than morphia; the habitual sequel is a night of disturbed delirium, followed by a day of tantalising drowsiness. Trional, sulphonal, and paraldehyde are most commonly employed, because, forsooth! they do not depress the heart. Paraldehyde has the added horror of a clinging and nauseous after taste, and may excite persistent vomiting.

Vomiting is another grave danger. At times, even the smallest amount of fluid food is at once rejected. In such a state, it is worse than useless to attempt feeding by the stomach. The obvious indication is, without delay, to unload the portal circulation. Any bulky saline draught will be immediately rejected by the stomach, and a full dose of calomel, with an equal quantity of bicarbonate of soda, mixed in a dessert-spoonful of milk, is most likely to be retained; this will often prepare the stomach to tolerate small amounts of peptonised milk. Rectal feeding is probably useless, as the condition calls for urgent and immediate relief.

It is in this same class of cases, in which general anasarca is not a prominent feature, that the enlarged liver is apt to cause a great deal of discomfort and even pain. Free leeching over the liver, with a brisk purge, may afford some measure of relief.

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