Practical utility of 1 & II grade remedies in the rubric “Murmurs” of Kent’s Repertory

Dr G Supriya Pai 

The differential diagnosis of a heart murmur begins with a careful assessment of its major attributes and response to bedside manoeuvres. The history, clinical context, and associated physical examination findings provide additional clues by which the significance of a heart murmur can be established. 

In Kent’s Repertory we find direct rubric for Murmur in the CHEST CHAPTER. It is important to closely analyse and differentiate the remedies with respect to the clinical conditions causing the murmur. 

DEFINITION OF MURMUR:
Heart murmurs are caused by audible vibrations that are due to increased turbulence from accelerated blood flow through normal or abnormal orifices, flow through a narrowed or irregular orifice into a dilated vessel or chamber, or backward flow through an incompetent valve.

POINTS TO NOTE WHILE DESCRIBING A MURMUR:

  • Area over precordium where murmur is best heard.
  • Whether murmur is Systolic or Diastolic.
  • Timing and character of the murmur (Early Systolic Murmur-ESM, Pan-systolic Murmur-PSM, Mid-Diastolic Murmur-MDM, End-Diastolic Murmur-EDM)
  • Intensity of the murmur (grading) -The intensity of a heart murmur is graded on a scale of 1–6 (or I–VI). 
  • Pitch of the murmur (low or high pitched)
  • Whether the murmur is best heard with the bell or the diaphragm of the stethoscope (MDM is best heard with the bell of the stethoscope, whereas ESM, EDM and PSM are best heard with the diaphragm of the stethoscope)
  • Conduction of the murmur
  • Variation of the murmur with respiration (left sided murmurs are best heard in expiration, whereas right sided murmurs are best heard in inspiration)
  • Posture in which murmur is best heard (MDM of MS is best heard in the left lateral position and EDM of AR is best heard with the patients sitting and leaning forward and holding his breath in expiration)
  • Variation of the murmur with dynamic auscultation (manoeuvres, postures, pharmacological agents like amyl nitrite). 

The intensity of a heart murmur is graded on a scale of 1–6 (or I–VI).

Grade 1 Murmur is very soft and is heard only with great effort.
Grade 2 Murmur is easily heard but not particularly loud.
Grade 3 Murmur is loud but is not accompanied by a palpable thrill over the site of maximal intensity.
Grade 4 Murmur is very loud and is accompanied by a thrill.
Grade 5 Murmur is loud enough to be heard with only the edge of the stethoscope touching the chest.
Grade 6 Murmur is loud enough to be heard with the stethoscope slightly off the chest.

FIRST & SECOND GRADE REMEDIES FOR MURMURS IN KENT’S REPERTORY- CLINICAL INDICATIONS.

  1. CACTUS GRANDIFLORUS:
  • Cactus is a special irritant of heart and controls its action by acting upon first cervical ganglion that controls the circulation of brain.
  • Clinical indication: Endocarditis with mitral insufficiency.
  • Type of Murmur: Pan-systolic Murmur.
  1. COLLINSONIA CANADENSIS:
  • This remedy acts on heart in two ways i) Removing obstructions or irritations in liver, portal septum, kidneys by acting on the venous side of the heart.
  • ii) By increasing its muscular tonicity.
  • There are periodical attacks of faintness and oppression; with palpitation. After heart symptoms are relieved, piles or menses return.
  • Clinical indication: Mitral Stenosis
  • Type of Murmur: Diastolic Murmur.
  1. DIGITALIS PURPUREA:
  • There is irregular beat especially in mitral valve disease, also in diseases of aortic valves.
  • Clinical indication: Mitral stenosis/ Mitral insufficiency
  • Type of Murmur: Mid diastolic murmur of MS, Pan-systolic Murmur of MR/AS
  1. FERRUM METALLICUM:
  • Heart suddenly bleeds into blood vessels and suddenly draws a reflux, leaving pallor of surface. Palpitations worse from least motion, better by walking slowly.
  • Clinical indication: heart complaints from anaemia.
  • Type of Murmur: Haemic murmur (Systolic Murmur) 
  1. KALMIA LATIFOLIA:
  • Rheumatic endocarditis with consequent hypertrophy and valvular disease especially aortic.
  • Quick but slow pulse. Wandering rheumatic pains in the heart extending to left arm.
  • Clinical indication: Aortic insufficiency; audible S3 & S4
  • Type of Murmur: Diastolic Murmur.
  1. NAJA TRIPUDIANS:
  • Damaged heart after infectious diseases. Hypertrophy, weakness, valvular disorders.
  • Fluttering and palpitation of heart that is visible and audible.
  • Action recognized by pushing hand up behind sternum felt as cardiac thrill.
  • Clinical indication: Acute and septic Endocarditis.
  • Type of Murmur: cardiac thrill (Grade IV Murmur)
  1. RHUS TOXICODENDRON:
  • Hypertrophy of heart from over-exertion.
  • Clinical Indication: Athlete’s Heart
  • Type of Murmur: Functional Murmur (Ejection Systolic Murmur)
  1. SPIGELIA ANTHELMIA:
  • Violent palpitations, audible attending other symptoms. Throbbing in carotids, Subclavian arteries. 
  • Purring of heart as of cat. Tumultuous action of the heart in acute rheumatism and other acute disorders.
  • Clinical Indication: Rheumatic carditis, Aortic Regurgitation with positive Corrigan’s sign, pericardial rub.
  • Type of Murmur: Diastolic Murmur. Pericardial friction rubs which can be mistaken for Systolic Murmur.
  1. SPONGIA TOASTA:
  • Dry chronic sympathetic cough. Awakened suddenly in the midnight with pain and suffocation. Hypertrophy of heart with asthmatic symptoms.
  • Clinical Indication: paroxysmal nocturnal dyspnoea, cor- pulmonale, right ventricular hypertrophy, valvular insufficiency, Rheumatic Carditis, Aneurysm of Aorta.
  • Type of Murmur: systolic or diastolic depending on the valves involved.
  1. AMYLENUM NITROSUM:
  • Tumultuous action of the heart. Fluttering of heart on least excitement. Violent beating of heart and carotids (is felt up into the ears). 
  • Clinical Indication: atrial flutter
  1. APIS MELLIFICA: 
  • Beats shakes the body. Palpitation of heart from scanty secretion of urine. Insufficiency of mitral valve. Organic heart disease.
  • Clinical Indication: Mitral Regurgitation.
  • Type of Murmur: Pan-systolic Murmur
  1. ARSENICUM ALBUM:
  • Pain in the heart radiating to neck, occiput with anxiety. Fainting spells. Pulse more rapid in the morning. Palpitation < lying on back, ascending stairs. Irritable heart in smokers, tobacco chewers. Cyanosis. 
  • Clinical Indication: Angina Pectoris, cor-pulmonale, tobacco heart.
  • Type of Murmur: Non-specific.
  1. ARSENICUM IODUM:
  • Weak heart, pulse rapid, chest pain either with or without valvular disease especially accompanied with induration of lung disease.
  • Clinical Indication: Angina- Pectoris, Pulmonary Tuberculosis.
  • Type of Murmur: Non-specific.
  1. AURUM METALLICUM:
  • Sensation as if heart stopped breathing for two to three seconds immediately followed by tumultuous rebound with sinking in epigastrium.
  • High blood pressure, valvular lesions of arteriosclerosis. Carotids, temporal arteries throb visibly. 
  • Clinical Indication: Arrhythmias, Aortic Regurgitation, HTN, calcification of valves.
  • Type of Murmur: Diastolic Murmur.
  1. AURUM MURIATICUM:
  • Sharp lancinating pain in the heart.
  • Clinical Indication: Angina Pectoris
  • Type of Murmur: Non-specific
  1. CALCAREA CARBONICUM:
  • Weakness, palpitation at night and after eating. Palpitations with feeling of coldness with restless oppression of chest after suppressed eruption.
  • Clinical Indication: Anaemia
  • Type of Murmur: Haemic Murmur (systolic)
  1. CHELIDONIUM MAJUS:
  • Deep seated pain in whole right side of chest. Stiches and soreness of lower ribs right side.
  • Clinical Indication: Intercostal Rheumatism
  • Type of Murmur: Non-specific.
  1. COCCOLUS INDICUS:
  • Palpitation of the heart, nervous with anxiety. Hysterical spasm in the chest. Fatigue of the chest from reading aloud.
  • Clinical Indication: Angina Pectoris, somatoform disorder.
  1. COLCHICUM AUTUMNALE:
  • Violent palpitations in the heart.
  • Pressure and apprehension in the region of heart as if attack of apoplexy threatened.
  • Clinical Indication: Ischemic heart disease.
  • Type of Murmur: Non-specific
  1. CROTALUS HORRIDUS:
  • Much pain in the heart through left shoulder blade and down the left arm.
  • Feeling as if heart tumbled over.
  • Heart tender when lying on left side.
  • Pulse hardly perceptible.
  • Clinical Indication: Ischemic heart disease.
  • Type of Murmur: Non-specific.
  1. GLONOINE:
  • Fluttering, palpitation with dyspnoea
  • Throbbing carotids.
  • Purring noise in the region of heart.
  • Boiling sensation in the region of heart.
  • Any exertion brings on rush of blood to heart and fainting spells.
  • Clinical Indication: Atrial flutter, pericardial effusion
  • Type of Murmur: non-specific; pericardial rub.
  1. HYDRASTIS CANADENSIS:
  • Rawness in throat, chest.
  • Asthma and oedema of lungs.
  • Cancer of right lung.
  • Feeling of immediate suffocation on attempting to lie on left side.
  • Clinical Indication: orthopnoea, pulmonary oedema due to congestive cardiac failure.
  • Type of Murmur: Non-specific.
  1. IODUM:
  • Violent heart action feels as if squeezed by iron band, followed by great weakness and faintness
  • Feeling of vibration, purring over heart, pulsation in large arterial trunks.
  • Clinical Indication: Ischemic heart disease, myocarditis, pericardial effusion.
  • Type of Murmur: non-specific, pericardial rub.
  1. KALI CARBONICUM:
  • Violent palpitation shakes the whole body, throbbing extending to tips of fingers, toes.
  • Sensation as if heart is suspended, seems to hang by thread.
  • Clinical Indication: Arrhythmias, threatened heart failure.
  • Type of Murmur: Non-specific.
  1. LACHESIS:
  • Palpitations, fainting spell during menopause.
  • Anxiety about the heart.
  • Constricted feeling causing palpitation, cyanosis
  • Pulse weak intermittent slow, irregular.
  • Clinical Indication: Senile arteriosclerosis.
  • Type of Murmur: systolic or diastolic depending on the valve involved.
  1. LITHIUM CARBONICUM:
  • Trembling and fluttering of heart, extending to back. Worse after vexation
  • Sudden shock in the heart throbbing dull stitch in heart.
  • Rheumatic soreness in cardiac region.
  • Pains in heart before menses and associated with pain in bladder > after urination.
  • Clinical Indication: Rheumatic heart disease, Arrhythmias.
  1. LYCOPODIUM:
  • Palpitation < night, lying on left side.
  • Pulse fast < eating, evening.
  • Clinical Indication: Aneurysm, Aortic disease, cardiomyopathy.
  1. LYCOPUS VIRGINICUS:
  • Rapid heart action of smokers.
  • Heart with many side symptoms, haemorrhages due to valvular heart diseases, or passive from nose, piles, lungs etc.
  • Shifting pains from heart to eyes, head to heart, heart to wrist.
  • Clinical Indication: cardiac asthma, toxic goitre, valvular Heart disease.
  1. MERCURIUS SOLUBILIS: 
  • Palpitation on slight exertion.
  • Awakes with cardiac tremor.
  • Pulse irregular; quick strong and intermittent or soft and trembling.
  • Clinical Indication: Arrhythmias
  1.   NATRUM MURIATICUM:
  • Anxious and violent palpitation of heart at every movement of body, but principally when lying on left side.
  • Irregular and intermittent palpitation of heart
  • Enlarged heart
  • Clinical Indication: Arrhythmias, cardiomyopathy.
  1. NITRICUM ACIDUM:
  • Nervous palpitation caused by slightest mental excitement.
  • Pulse very irregular, one normal beat is often followed by two small rapid beats, the fourth entirely intermits.
  • Congestion in chest with anguish, heat and palpitation while going upstairs.
  • Clinical Indication: Arrhythmias, congestive cardiac failure.
  1. PHOSPHOROUS:
  • Violent palpitation with anxiety, while lying on left side.
  • Pulse rapid, small, and soft.
  • Heart dilated, especially right.
  • Feeling of warmth in heart.
  • Clinical Indication: Right ventricular Hypertrophy
  1. PSORINUM: 
  • Pain in heart better by lying down.
  • Gurgling in the region of heart noticeable while lying down.
  • Pulse weak, irritable, indicating a return of abscess on neck.
  • Clinical Indication: Pericarditis.
  1. SUMBULUS MOSCHATUS:
  • Nervous palpitation.
  • Neuralgia around left breast and left hypochondriac region.
  • Cardiac asthma.

References: 

  1. Harrison’s Principles of Internal Medicine-19th Edition
  2. Manual of Practical Medicine, 4th edition- R Alagappan.
  3. A Dictionary of Practical Materia Medica- JH Clarke
  4. Homoeopathic Materia Medica- William Boericke.
  5. Physiological Materia Medica- William Burt.
  6. Homoeopathic Remedy Guide- Murphy R.

Dr G Supriya Pai
PG Scholar, Department of Practice of Medicine,
Government Homoeopathic Medical College & Hospital,  Bangalore.

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