374 DISEASES OF THE HEART. 



CHAPTER IX. 



INSUFFICIENCE OF THE TRICTJSPID, AND STRICTURE OF THE RIGHT 

 OSTTUM ATRIO VENTRICT7LARE. 



A SO-CALLED relative insufficience of the tricuspid used formerly, 

 upon theoretical grounds, to be regarded as a very common form of 

 valvular disease. The ostium was seen to be enormously widened, 

 and it was assumed that the valve was incapable of closure. This 

 relative insufficience, if it ever occurs, is rare. When the ostium 

 dilates, the valve grows in breadth and length, almost always remain- 

 ing competent to close the widened orifice. Primary and independent 

 disease thickening, shrinking, etc. of this valve is also quite rare. 

 It is more common for it to accompany similar disorder of the mitral. 

 JSamberger, indeed, regards the combination of mitral and tricuspid 

 deficience as the most frequent of all combinations of valvular defect, 

 and I, too, have repeatedly observed contraction of the tricuspid, with 

 rupture of the chordae tendineae, as an accompaniment of severe stric- 

 ture of the mitral. 



In insufficience of the tricuspid, which is in general pure (stenosis 

 being extraordinarily rare), the blood regurgitates into the vena cava 

 during systole of the ventricle ; but, as the right ventricle is generally 

 hypertrophied in consequence of mitral disease, this regurgitation takes 

 place with great violence. The vena cava and the jugulars become 

 enormously dilated. The valves of the jugular, which, if its calibre 

 were normal, would set a limit to the regurgitation, become insuffi- 

 cient from dilatation, and it is transmitted as far as the vessels of the 

 neck. Real pulsation of the dilated jugulars, perceptible both to 

 touch and sight, is a pathognostic symptom of insufficience of the 

 tricuspid. Besides this, we hear a distinct systolic murmur at the 

 lower part of the sternum, which, in conjunction with the venous pul- 

 sation, makes the diagnosis certain ; but here also we must make sure 

 that the murmur is really strongest at this point, and is not conducted 

 thither from the aorta. 



As insufficience of the tricuspid causes the most intense engorge- 

 ment of the veins of the aortic circulation, so, of all valvular disorders, 

 this leads most rapidly to cyanosis and dropsy.* 



* When one valvular defect complicates another, the symptoms of the former one 

 are modified. The modifications vary according as the complication has a similar or 

 an opposite effect upon the circulation ; and according as one or other defect predom- 

 inates. The signs of complex va/vular disease may easily be deduced from the analv 

 gis of the foregoing chapters. 



