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  An Anthroposophical Medical Approach to Cardiac Auscultation
  

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By: Kaspar Appenzefler

Translated from Beitraege 39th Edition, Volume 6, November/ December 1986

Auscultation of the heart as a means of obtaining knowledge of developmental and maturity stages, the predispositions and capacities of children, and also knowledge of processes and tendencies of disease in adults.

1. How this came to be

According to classical medical instruction, one hears an iambus at the base of the heart and a trochee at the apex of the heart. Today, only the symbols of these rhythms are still used, the rhythms themselves being scarcely still understood. If one wants to reawaken this knowledge, one must arouse the artist in oneself.

If the 2nd tone is louder than the 1st (at the base of the heart), the heart beat has iambic character (short-long). If the 1st tone is louder than the 2nd (the apex of the heart), the heart beat has trochaic character (long-short). Now, if one additionally takes the transition from iambus to trochee between the heart base and heart apex into account, he will discover a spondee (long-long). As far as I know, this last rhythm has never been described.

For medical science, this unique sounding of the heart is still only the expression of an occurrence within the realm of the physical, as a result of the heart beating within the thorax. However, this fine and differentiated tone to which we listen with a stethoscope is more than just the noise of a machine (which it is not at all!); I became conscious of this for the first time when heart­beats of patients presented during medical lectures were demonstrated through a loudspeaker.

Until then, auscultation had always given some information about the individual who was being examined. The process of health or disease was audible even if not consciously recognized and even if, as customary, the heart was thought of in a mechanical way. In those days, one could still think in a materialistic manner and yet at the same time feel spiritually. However, as these electrical transmissions of heartbeats began and recordings were produced of pathologic auscultatory findings, this was no longer possible.

A decision had to be made: either to be forced into feeling that the heart is a machine, or to witness what was being proclaimed though the loudspeaker. It was not really reproducing heart tones, but announcing that herewith medicine was being won over by an electrified technique with which one was to comply. With this, the hearing quality for auscultation - as well as for many other things - was dulled. Instead, intellect was recognized for its brilliance, but it was also seen that it lacked what it needed for the purpose of healing.

Do not misunderstand me! Never would I have wanted to discredit the development of modern medicine. However, I knew from that point on that it needs a counterweight. I was already well acquainted with Anthroposophy, but only through this shocking experience did I become aware of thus standing on this crossroad. The world needs modern physicians permeated by Anthroposophy. That became clear to me. I did not know then, how difficult this path is.

Ten years later, while preparing my book entitled Genesis in the Light of Human Embryonic Development, I became aware that the first word in the Bible is an archetypal experience of the heartbeat. This word is called 'B'reschit," (in the beginning) in the ancient Hebrew version. The "B" is pronounced as a "B" without the following "e", so that one hears only a fleeting vowel resonance that makes one think of the "e" in the word "men."

Thus, one reads the word in an iambic rhythm. But the spondee can also be heard in it, and even the trochee. The first stressed syllable can sound as though it were split, just as a divided first heart tone. The end-syllable, "it", can also sound as if it were split, just as a second heart tone. However, the beginning of the word, as well as the end, sounds as a unit when spoken, exactly as both heart tones do in their healthy state. This spoken ancient tone is a true two-beat sound; it associated its sound and impetus in me with the heart beat. For years it was as though I heard the murmur of this ancient word during auscultation of the heart.

"Beth," the first letter of the first word in Genesis means "house". This “Beth" has a point inside it; the spirit takes up a house. And then one speaks the letters which follow "B"', .. resch." This series of letters is a word in the Hebrew which means "head." Then "schit" resonates, which is also a word in itself, meaning "the penetration of thorns into the head." The last letter is "Tau," which means "cross" or "sign of the cross." In the middle of the word, however, is "esch" which means "fire."

In this way, the path of this word goes from Beth, the house, to the cross. It is the path from "Beth lechem", Bethlehem (House of the Bread) to the cross on Golgatha. This is the path of the Son of mankind. We hear Him in the heartbeat. Prophetically, this ancient word announces Him, He who introduces creation. In its totality, creation is the development of the ancient word, the heartbeat is its goal.

But there is still another secret. The Hebrew script is composed only of consonants. Man must add the vowels from the breath of his soul. Through this breath lives the word, as Adam lives through "Odem" (breath). And, as the ancient word B'reschit begins to pulse through the breath, the heart beats in the organism as a result of blood pushing against respired air and being penetrated by it. Man fulfills himself in this encounter.

This is the site of interweaving of two rhythms, those of pulse and respiration, which is the innermost, and at the same time, most sublime receptacle of the spirit of mankind. Here occurs what Rudolf Steiner speaks of as the "beat of heart and lung." And here lays the starting point for the auscultation which is being discussed here. Yes, here lays the ultimate starting point for the diagnostic process which announces the therapy at the same time.

In his first course for physicians in 1920, Rudolf Steiner emphasized that the heart is not a pump, but a fine sensory organ for perception of the body processes carried by the blood. He said that the pump theory of the heart should be revised and cited the work of Dr. Karl Schmidt. He was a physician from northern Steiermark who had compared the heart to the hydraulic ram because to him certain observations could only be explained in that way; for example, the phenomenon of the beat at the apex. Rudolf Steiner called Dr. Schmidt's work of 1892 a beginning with much potential for a renewed investigation of the mechanical principles of heart activity.

Many years ago Dr. Gisbert Husemann had a number of hydraulic ram apparati built by a contractor according to the relations in the heart, in order to study them. After having spoken about the heartbeat and its association with the first word of Genesis at a medical conference in Stuttgart, we demonstrated the first model of this hydraulic ram, upon which I laid my stethoscope; then, a colleague said 'B'reschit - B'reschit." I had to answer him "I do not hear it." Even though one could hear a wonderful double-beat, it was only an apparatus and not a heart.

Then I obtained one of these models myself and began to experiment The results were amazing — tachycardiac, bradycardias, extra systoles and even bigeminies and trigeminies could be produced and the pulse curve had a dicrotic descent. All of these "pulse changes" occurred by playing with the "aorta" of the apparatus, partially through the bringing about of atypical air flows. This is interesting because the nerves of the carotid sinus, whose pathology leads to such pulse changes, originate from the aortic arch.

Thus it became more and more clear to me that the heart from a mechanical point of view could be compared with no apparatus more readily than with the hydraulic ram. Just as the ram is brought into motion through the water, so it is the blood which must activate the heart. Through experiments of this kind, through many clinical observations and extensive studies on chicken hearts (wherein I showed in a film how blood moves without activation by the heart), I came to the conclusion that, although the layout of the heart is also similar to a mechanical apparatus, it does not play a mechanical role in life.

The mechanical tendency of the heart is impeded at its origin with every systole. Through the living blood, it is continuously overcome in status nascendi. The blood flows on its own accord. However, the heart is the reference point for this movement, as hinges are for doors (Compare with Aristotle, De Anima, III,10). Without the principle of rest, there is no movement, without any center there is no goal; without a middle, there is no striving towards it.

At one specific movement, I discovered Rudolf Steiner's indication of a connection of the iambic rhythm with feeling, the trochee with thinking and the spondee with willing. In addition to my private practice, I had been filling the position of the school physician in St. Moritz for over 20 years, having to examine hundreds of children yearly, and naturally also auscultating; several things had attracted my attention. For a long time I had sought for expression of the soul in the heart rhythms. With this, everything became dear. And thus it came to an extended heart auscultation, the beginnings of which shall be briefly described.

2. Child development, interpreted by the auscultatory picture of the heart.

When one examines the heart of a small child, one hears only iambi at the base of the heart, at Erb's point, and at its apex. This rhythm entirely corresponds to the child and is said to be a rising rhythm, as one feels uplifted by it. One has the impression of the ringing of bells if the child is healthy and has been allowed to grow up in a harmonious manner. However, certain children never attain a cheerful, springing iambus; their iambi are dull or scarcely clear.

A new-born child still has a non-intonated rhythm, a double-beat which is very similar to the fetal heart beat. It is really a spondee (long-long), although the longs are very short. The fetal heartbeat becomes audible approximately in the seventh week of pregnancy to the directly applied ear or the gynecological stethoscope. It emerges out of silence. At first, it is only suspected, but then it becomes stronger and stronger, finally clearly announcing the fetus which is living and maturing.

This double-beat is characterized by its uniformity. Often, it is acoustically muffled and still makes a clear impression. If one would like to paint it, I would think it should be tinged whitish-yellow. It reminds me of the vocal cords of young children or women which are short and somewhat rounded and budding. I designate this tone as "E", or the embryonic tone. The newborn also has this tone, only with more strength and dynamic. This is because of the respiration through the lungs. The dynamic that is the inner enlivening of the tones becomes stronger during the first year of life, until the iambus bursts through at one site, "J." It is usually heard first over the base, but it can also be heard first in the middle or at the apex of the heart.

I have accustomed myself to auscultating primarily 11 points: aortic region, pulmonary region, at the left sternal border approximately in the center of the sternum, almost vertically under this point approximately at the level of the 5th rib, apex, 2 points to the left near the apex just slightly toward the upper/inferior region, 3 points to the right of the sternum at the level of the 5th rib and laterally superior, and at the central point (point of Erb). Of course, this has developed in the course of time. At first there were only 3 points — base, middle and apex. With time, I began to differentiate between the aortic and pulmonary region in the base; later, points below greatly supported the development of the subject.

It appeared that a developmental stage which had once been attained does not leave its mark in all regions. Thus, the embryonic tone "E", for example, remains for an entire lifetime. It is to be found completely to the left exteriorly over the spleen and is thus to be heard over the 7th auscultation point named. A reminder remains of the embryonic form of life and, through this, of the cosmic past. There are children in whom this E-point is strong. In others, it becomes less clear or lies sometimes higher or lower. The E-point is characteristic of the manner in which a child is connected to his past through memory. If it is missing, it is the expression of unstable soul life without anchor in the soul ground. It is outshone and inaudible by iambi only in the small child.

Two points lie to the right inferiorly. They can be described as nuclei of the future and are also windows as are all regions of auscultation; these windows are, however, still closed. What they tell us arises from the body, but has a pre-earthly cosmic aspect and, therefore, can only have value in conjunction with the other tone spaces.

The iambus of a child is weighted down at 5-6 years of age. This process usually begins in the inferior region of the heart. The first heart tone becomes stronger and a new spondee occurs, "S". If one hears a spondee at the heart apex and at the inferior sternal point to the left, the child is ready for school. This occurs usually by the age of seven. One would naturally also look at the teeth and other characteristics, but the heart is a very strong indicator.

The spondee can also begin in the middle of the heart or it can quickly migrate upwards. This can show itself in children who are extensively burdened at an early age, for any of many reasons. The iambus is essentially the expression of a happy and unburdened childhood, expression of trust and security. Every early burdening of this cheerful rhythm is a sign of fear in the largest sense.

The entire soul-body picture really becomes obvious to the physician who is listening to the sounds of the heart. He hears the development of the child in its intimate steps and can read its unconscious needs. Just as the parents and teachers can sense the development and soul-body needs from the voice of a child, the voice of the heart is audible through auscultation; this allows us, the physicians, to understand children very exactly and quickly, even those whom we know little or not at all. For this reason, I envision that this method can primarily serve children and school physicians, especially since a diagnosis obtained in such a manner also carries in itself the starting point towards a therapy.

The next large step in the development of a child follows between the 9th and 10th year. The iambus at the heart apex, which in the 6th - 7th year weighted into becoming a spondee, now turns into a trochee, "T".

I next discovered that the more mature children have a trochee; I later associated this rhythm with the independent thinking of these children, from data given by Rudolf Steiner. A small child, I told myself, can also already think out loud, but these thoughts are, at the very most, adult thoughts mirrored by the child in his own manner, when they do not involve ancient truths which the child speaks. I had observed that individual thoughts come to germination only after this new developmental step in the child's soul. Thus, I expected the trochee to arise for the first time then, using the knowledge of child development made possible by Anthroposophy. However, this had to be proven first. As I had achieved a certain amount of practice in auscultation as a school physician, the annual obligatory examinations became a field of research. So, for the first time, I let systematic auscultation accompany this question. Many years have gone by since then and today that which was just discovered has become evident and its examination has become routine.

Some children can thus be taken out of special classes for those who are intellectually weak and led into regular classes. When finding a trochee, for instance, one may be sure that the child has reached a certain stage of developmental maturity; that child might, however, have initial difficulties with languages (for example, a child of immigrant workers), or have other obstacles to development. If the trochee does not come about, the child is retarded in his development. One could then determine from the "number" of spondees or, better said, from the width of the spondaic field whether the child could still readily overcome the difficulty or whether there is a pathologic interference.

Dynamic-sounding and high-pitched iambi, especially in the pulmonary region or in the middle of the heart, indicate an artistic capacity and could delay the coming forth of the trochee. In such children, it is very important that the trochaic element come forth at the age of 11-12 years. Otherwise, for example, a developing musician will have no real foothold. Also, an artist must develop a strong capacity to think, even if he does not tend to have a strong ability for abstraction. Only the capacity to abstract gives him the opportunity to awaken the abstractions to life. Everything depends upon this awakening. The consequential instruction of thinking is the basis for this.

It is obvious from this that auscultation is not only a determination of whether an iambus, spondee or trochee is present, but also of how these rhythms are manifested. Dull iambi in a school-age child lead one to assume there is little ability present, and normal schooling is put into question. But if the iambi are clear and dynamic (that is, lively in themselves) at this point, one has to do with an artistic soul which does not want to bind itself so strongly with the earth; it expands the light-filled time of childhood, yet strengthens its character by looking towards the earth. Such children begin school with a larger breath and carry the powers of Heaven into the classroom in a richer manner than it is possible for other first-graders.

These children obtain a spondee at the apex later and more quickly, whereby those children who lean more toward the intellectual can have it already two years before school begins. In artistically-inclined children, everything is more intense. Here the task of the teacher is to consider how these children can later unfold the strength to germinate the trochee in the heart. These children live in pictures, but they must learn to bring pictures into deed. Later, it will involve guiding them to independence of the soul, without making them turn back or being too brusque with them.

It is the opposite with children who tend toward intellectual capacity. They must be protected against becoming independent too early, because they are otherwise meeting death without understanding it and, through this, become materialistic. These children must learn to create pictures and to experience living creativity. In this way, trochee formation which is too early can be avoided. The appearance of the trochee is, namely, a death process that every child must go through around 9-10 years of age. Because of this, the healthy progression of the child toward experiencing the trochaic principle can only occur out of the strength of love.

More can be learned about this topic in my booklet The Squaring of the Circle (Zbinden Publishing Company, Basel 1979), in which it is shown that the child of this age actually carries out the squaring of the circle. That is to say, his body proportions become such that the areas of the square drawn around the body when it assumes the position of a cross by stretching out his arms, and the circle which is drawn around the outstretched arms and feet become equal.

The spiritual powers of life before birth and the powers of the body, — in short, the powers of Heaven and Earth — interact in the child of this age in such a manner that one can say that they are wrestling with each other.

Striving for the square is an expression for this, since the circle (as an expression of Heaven) and the square (as an expression of the attained, or Earth), are incompatible. However, a child of this age completes the squaring of the circle.

The struggle between the given forces, which in the body is a struggle between respiration and circulation, is seen in the heart as a constant struggle of dominance of the iambus and the trochee. I call such a heart tone "K", in which these rhythms struggle against each other. Usually this occurrence can be heard in the region of the heart apex.

If one is not sure whether an iambus or a trochee is present, one can first attempt to hear the tone as a trochee, then as an iambus, whereupon the domination of one rhythm or the other can be determined. If there is an equilibrium, a spondee is present. If the tones during normal respiration are iambic at inspiration and trochaic at expiration, this struggle reigns.

The iambi remain at the heart base for an entire lifetime, just as the "E"-point remains over the spleen. In puberty, the trochaic principle dominates the auditory picture of the heart, so that one easily finds the trochee in the middle of the heart and the iambus is weighted down to a spondee in the aortic region. This picture is common in the upper school grades.

However, an equilibrium develops later between the forces, just as described before: iambi are heard at the heart base, spondees are heard in the middle of the heart and trochees are heard at the heart apex. The pulmonary region must remain iambic, in this area, we remain children for our entire lives. Everything else can be weighed down; not, however, this region of the heart Here, youth and health reign; therefore, this tone quality of the heart should never cease.

3. Processes of illness identified in cardiac ausculation of adults

The questions to be answered by auscultation of adults are completely different from those asked concerning children. In this case, auscultation serves exclusively to understand the process of illness. In order to do so, one must consider the following: not until one becomes an adult is the development of the heart finalized. Until then, it was more an expression of general being; at maturity, it can become the instrument of an individual being.

There are three components which work together during this development. First, there are processes of nature in general, which bring forth the human heart. They are archetypally true for the development of every heart. They are modified through specific hereditary forces which cause racial and familial characteristics. However, the heart receives its unique molding from the individuality, which forms the organ from its beginning on.

Thus, the heart whose tones we are attempting to investigate has resulted profoundly from the collaboration of these three forces of shape and form. We grasp the general principles by auscultating many hearts, and slowly obtain a generally auditory expression of the heart, just as we have acquired the name “lion" from single encounters with lions. In a similar manner, we obtain an understanding for hereditary factors. However, the individual nature of a heart must always be newly comprehended.

General tendencies show themselves in the years of youth. In the auscultation of the adult, only the individual qualities are of interest. They are announced by the heart tones, as one learns to penetrate their general nature through hearing. Auscultation of children's hearts of different ages is therefore very good preparation for the auscultation of adult hearts. The more familiar one is with the general nature of a matter, the easier it is to grasp its individual traits.

An acquired trochee can completely disappear again. Its first appearance is an indication that the capacities of the head are emancipated from the general connection of the body to nature. The head becomes an independent organ of thinking. This process begins during the process of maturing for school and intensifies up until puberty. Although the small child is still entirely "head", this head is a part of the entirety. Not until 9-10 years of age is it finally independent.

Every human being goes through this development, with greater or lesser intensity. One whose destiny requires a high intelligence will develop a strong trochee on his path to puberty. The formation of a trochee is not accomplished in the case of debility, nor is the weighing down of the iambus or the spondee. These people carry the general forces of nature unconsciously into the life of their physical maturity and preserve the pure iambic tone. In cases of severe developmental retardation of the soul, even the embryonic tone persists; it remains as a seed until it is awakened. Between the auditory picture of a strong trochee and those just described above, there are all types of differentiations.

Thus, the heart of a human being is formed during development according to the requirements of destiny. The adult encounters it when, at 3 x 7 years of age, the capacity of the "I" awakens in him. A human being lives his first seven years as a general being of nature; the individual nature developing out of the general nature in him in the second seven years; and the individual becoming strong and largely replacing the general nature in the third seven years. In the first seven years of adulthood, the individual nature harmonizes with the general nature in its search for true mankind. The trochees become calmer and spondees or iambi take the place of the trochee. The search for mankind's true rhythm begins. We encounter this search in the auscultation of adults. Illness is really the expression of this searching.

If the trochaic element still dominates in an adult after his 35th year, at the latest, one would not choose to compare him with an adolescent, rather, it could be said that there is a pathological tendency towards hardening. People who have strong trochees have a predisposition towards tumor formation.

Let us glance once more at the developmental period of puberty, specifically at the head-forming process. It is during puberty that the head is first to be completely separated from the body. From then on it leads an independent existence, but nevertheless lets itself be served by the rest of the body, in a manner very similar to a tumor.

The occiput undergoes the strongest hardening process, along with the temporal bone which is placed in front of it and harbors the hearing organ. As the entire head separates itself from the body, so the back of the head with the hearing region now becomes separated from the front, fragile principal part, in which the capacity to see becomes fully developed. This stressed development of the head in comparison to the body and that of the posterior head to the anterior head is due to trochees which have become organic.

Rudolf Steiner described the ear as being the normal formation of what would be a tumor anywhere else in the body. Tumor formation is a disease only when it occurs at the wrong site and at the wrong speed. However, it always develops from a trochaic principle, exactly as the head - and, in the head, the ear - did. And if one considers one of the realities of the corresponding notion of the heart and its function, it appears less and less strange that tumor formations can be heard in the heart. One can hear what the heart, as a sensing organ, perceives.

All tumor formations create a trochaic heart tone at the apex. This is the site at which the heart itself is mostly "head" or mostly "ear". The name "ear of the heart" is appropriate for the so-called auricles, since they are for blood what the auricle of the ear is for tone. They receive the blood which is within the heart. The muscle fibers of the heart spiral together at the apex, the vortex Gordis, which reminds one of the cochlea.

If a tumor is growing in the body, the trochee also overgrows the auditory field of the heart. I had a patient with an enormous lung tumor. The entire heart was overgrown with trochees, even the pulmonary point. The progression was lightening-like. For many years, I have been treating a female patient who has lung metastases following surgical removal of a mammary carcinoma. The trochee always proliferated in the heart when the tumor was active, for example, when a type of therapy lost its efficacy. However, every time dose-strengthening or changes in therapy caused the tumors to regress again or prevented them from growing further, it retreated.

Such observations on different patients led me to the relationship between tumor and trochee, and I began to auscultate my tumor patients systematically using this criterion. The result was clear - the heart was burdened with trochees in all tumor carriers. Up until now, I have never found a carcinoma patient with a purely iambic heart picture. Many adults have purely iambic pictures, but most of the "iambus" types have a spondee at the heart apex and perhaps a second one next to that. Such people have no or only a very slight tendency toward tumor formation.

All tumors act upon the heart in a trochaic manner, whether they are malignant or benign. It seems to be possible to differentiate between malignant and benign tumors by using the strength of the trochaic tone. For example, the myoma of the uterus causes a softer trochee than a carcinoma. If a trochee does not exist at the beginning of treatment, tumor formation can be excluded, in my opinion.

However, not every trochee is the expression of a tumor. This is illustrated by the following small episode. From the foregoing observations, it can be concluded that iambi are the expression of a burdening of the archetypal spondaic "E" tone in infants. A 2-month-old infant was lain on an examination table and peacefully allowed itself to be examined. Infants of this age still have an "E" over the entire heart. However, there was an iambus in the center of this small patient's heart. I did not believe my ears, but it was true. When I examined further, this child let out a good, hearty "fountain" as often occurs when this examiner's hands are somewhat cool. With that, the iambus disappeared, and a calm spondee in the "E" sense sounded out of the middle of the heart again. Full urinary bladders are also "tumors".

I experienced in a woman that a trochee gave way to an iambus at the apex after micturition. A man had a spondaic apex tone which became more iambic after micturition, but it remained spondaic. Usually, micturition does not give way to changes by an entire step, so that the auditory picture of life is still valid; that is, without specific preparation. Pregnancy burdens the mother-to-be in a trochaic manner; when the child is born, the iambi return.

However, if one finds a trochee at the heart apex in a small child and it persists over a period of time, a tumor is to be suspected. I have a small patient for whom I have cared since his birth. He is very intelligent and, thus, I found it rather unusual, but not completely impossible, to discover a trochee in him at 7 years of age. The relationship between trochee and tumor was not yet known to me. Upon clarification of the situation, a stomach tumor was discovered which, histologically, was a leiomyoma. After the operation, the trochee disappeared.

People can be burdened with trochees for years, without developing a tumor. They have a tendency toward the formation of tumors, but they can divert this through other processes. Occurrences such as habitual obstipation or similar compacting processes, hypochondria and developing deafness can divert tumor formation tendencies – this was stated by Rudolf Steiner in 1920 in the 14th lecture of his first course for physicians. This statement becomes especially clear in this report and, in addition, it is proven in a new way.

Trochaically burdened patients often include those who are obstipated, people who are hypochondriacs, and especially people with above average hearing capacities. For decades, I have observed that carcinoma patients almost always have excellent hearing. This fact mirrors itself in the trochee. This excellent hearing is the "long" compared to seeing. The loss of hearing compensates the tendency toward carcinoma formation; it can "use it up", so to speak.

The case of hypochondriacs and chronically obstipated patients is similar. One can say that older people who are not ill with a tumor but who have trochaic hearts are, upon closer examination, burdened in one of these three directions. The question is then only whether a treatment of these occurrences always makes sense. An older lady who developed massive metastases after obtaining a hearing aid had been operated on earlier for mammary carcinoma and diverse local residual tumors. Her difficulty with hearing had developed after the first operation. The goal will always be to attain "detrochaization". Whether symptomatic therapy is correct can, of course, only be decided from life occurrences. To increase knowledge in this direction is, however, not unimportant.

Sometimes, however, one must also seek the process in which the tendency toward tumor formation exhausts itself. After I had laid out the above-described thesis for myself, I discovered a trochaic auditory picture in a woman undergoing menopause which caught my attention. I thought I could exclude a malignant tumor, hypochondria did not exist, similarly there was no obstipation, and hearing was good. After a few days of pondering I told myself that a myoma must be present. And there was one, an enormous one. I did not have it operated on, as I saw a correlation with obstipation, being a benign safety valve for the tendency toward tumor formation. However, I provided her with Iscador. Logically, one should give Iscador in cases of chronic obstipation in older people, especially when they can not get by without laxatives.

Children have a trochee in situations in which they feel fear. This can be easily observed when, for example, only fear of the physician exists. One can hear then, how the tones become high-pitched as the anxiety disappears, how the dear sound of childlike iambi returns after the trochaic thundering. The heart is a wonderful mirror of the soul in this age. In adults, the heart's signature of fear and relaxation becomes the expression of organic processes in the sense of contraction and expansion in adults. The tumor is basically nothing else but fear at an organic level. Soul nature in children is still very strongly bound to the physical body; therefore, soul nature is directly audible in the heart. In adults, the soul separates itself from the body and, therefore, the heart tone announces more bodily occurrences.

The tendency toward tumor formation is opposite to the development of inflammation. In patients with the latter tendency, the iambus expands outward from the aortic region and can dominate the entire auditory picture. The appearance of the trochaic element at the apex is the sign of improvement in this case. Often, the iambus is still suppressed during fever, the most meaningful manifestation of inflammation. Then, a strong embryonic 'T" tone makes itself known over the entire heart. In this way, one can hear in a highly febrile patient how he is reshaped, how the entire body enters into an ancient condition, from which it emerges newly formed, newly built. The appearance of iambi and spondees, then, indicates recovery. Calm trochees are, especially in younger people, the expression of stable recovery.

Allergic illnesses and peripheral inflammations also cause auditory pictures of the iambic type. Also, urticaria reshapes people - it is not for nothing called "nettle fever", even if it rarely causes a fever. Does not a real cold make us new?

However, since one is so attached to the old, one does not like to have oneself reshaped. We react in a similar manner with respect to the flu. One wants to remain as before and does not notice that hardening tendencies have already established themselves, tendencies which could be dissolved by an efficient fever.

We are living in between inflammation and tumor processes as human beings. Health is an equilibrium between these processes, an unconscious, enduring search and attainment of the middle. Illness throws us out of this middle, so that we can consciously seek it These exceptionally fine and dynamic processes are perceived by the heart; the tones which we hear in the heart are expressions of these perceptions.

Observations show that the effects of tumors and inflammations are audible between the aortic region and the heart in auscultation. All disease processes unfold acoustically within this axis. The struggle of the powers is audible in this area. One can follow this especially well in arrhythmias. For example, one experiences this struggle literally in paroxysmal tachycardia which can occur intermittently (that is, through the formation of short, consecutive attacks) between tumor and inflammation.

Tachycardia is a correlate of inflammation. When a normal rhythm begins again after a paroxysmal tachycardia, the first beats are especially strong, they can be felt like blows of a hammer at the apex. These strong beats are always trochaic; they are an expression of the tumor nature of the organism, which becomes a healing agent here. However, tachycardic beats always have a tendency toward iambi.

Abdominal pressure after the Valsalva maneuver is an artificial tumor formation in the abdomen, which often stops an attack in this manner. Compression causes a trochaic force in the heart which counters an iambic force. With this, holding the breath during abdominal pressure and careful expiration is very effective. Expiration slows occurrences in the heart and trochaisizes them; inspiration stimulates, iambically. During inspiration in Valsalva's maneuver, the heart beats faster, until it is forced through compression and the holding of breath into slow beats. Compression is, above all, that which forces. However, if trial expiration were not allowed to follow, the tachycardia would set in again immediately. Expiration calms the opposing iambic force. Compression causes trochaic hammer blows, but, through that, the iambic force opposingly becomes quite wild and must be tamed through subsequent expiration. A number of expirations can be necessary until the iambic force has quieted and calm ensues.

Interestingly, one hears trochees in the heart during paroxysmal tachycardia. At least, that is my experience. One could correctly ask, where the iambus could be. Tachycardia is iambic and this iambus retains the trochee in its region, incorporating it in itself, so to speak, and isolating it. Compare this with a large drop of mercury from which a small drop has separated. Mercury has, of course, the characteristic of becoming scattered upon impact with something. However, it is immediately ready to reunite the many drops, when these come together again.

The drop can be described as a trochaic element, the state of dispersion an iambic one. A larger drop, which is trochaic in itself, is thrust into the region of scattering processes in paroxysmal tachycardia and can never return. Therefore, such an attack is a condition which, once it has begun, no longer represents a struggle, but rather remains fixed, sometimes for hours or even days.

The Valsalva maneuver is an attempt to have the original drop approach the little ones having come about by dispersion. If it succeeds and they touch one another, reunion occurs instantly and the tachycardia disappears. In such a case, the beat acoustically becomes iambic again, but the totality is trochaically slow. Such an attack (which is a slipping over of the trochaic into the iambic region) is very suitable for studying the struggle of forces, because the same forces pervade. Every paroxysmal tachycardia attack is initiated by a trochaic event, for instance, by being startled, by the movement of bending down (through which the abdomen is unconsciously compressed), or an emotion. The initial beat is usually intonated, with which the trochee remains attached. Through such occurrences, the expiration is blocked and the iambic force released. Then, the iambus races, in order to rid itself of the trochaic enclosure. Quiet, calm breathing, that is, breathing in the soul equilibrium, prevents paroxysmal tachycardia from occurring.

Meteorologic influences sensitize the heart toward rhythmic disturbances. Atmospheric low pressure as a trochaic force can often induce disturbances. One is then confronted with the fact that the heart, in combination with the lungs, is the site where the processes of nature are perceived, even where their influences finally culminate. In arrhythmia, a process which continually occurs in healthy people is magnified to a degree which becomes pathological. Analogous processes accompany this occurrence in liver and kidney metabolism, in the liver more in the sense of stress, in the kidneys more in the sense of calming, equalization effects. All sensations of weather have their origin here.

One can experience through observation that the so-called "axis of illness", which is heard concentrated in the heart, extends over the entire human being and out through him. In situations of health, they are unconscious. Illness can bring them into appearance. In paroxysmal tachycardia, the patient feels the iambic-tachycardial element more in the base of the heart or "in the neck". Contrarily, however, the trochaic-bradycardial element is felt at the heart apex or "in the abdomen". Thus, he can feel this axis in his own body. Even those who have the flu feel this. The headache has a iambic element which is a metabolic process taking place in the head – the head "explodes". Limb pains are trochaic elements, nerve/sense processes in the area of metabolism. Thus, every illness allows what the physician hears objectively in the heart to be felt.

However, there is still a second axis. And it is interesting to note that it is scarcely touched by the before mentioned struggle. It is the first of these axes to be generally known as the zone of similar tone qualities and runs from aortic point to mitral point (apex). The other axis can not be distinguished as well. It also arises out of the areas of similar tone qualities and proceeds from the pulmonary point to the auscultation point of the tricuspid valve. I call these axes the "AM" and “PT" axes in my drawings.

Their tone qualities are very different. Jagic stated that the second PT is "deep and muffled" and the second AT is "high-pitched and short" (See Nikolaus Jagic, Percussion and Auscultation, Urban and Schwarzenberg, 9th edition, Vienna, 1948). This characterization is very exact. If they were to be made into images, one could speak of wooden and metallic sounds. One hears the waves of respiratory air through the pulmonary point - wooden. The effect of blood is heard through the aortic point - metallic. The region of metallic ringing is the axis of illness, the region of active wooden tones is the axis of health.

The axes cross each other. Information about the prognosis comes from their interpenetration. Each of these axes can override the other. For example, if the third auscultation point described at the beginning (middle of the sternum) is iambic and related to the sound of the pulmonary tone, the axis of health is strong. The prognosis is principally favorable in illnesses which are becoming trochaic in nature; however, if the crossing point of the axes is spondaic or even trochaic, the axis of health is weak and the axis of illness is strong, on the side of the tumor. The prognosis is not so good in the face of this discovery. As was mentioned earlier, the trochaization of the pulmonary point has the least favorable prognosis.

 

Address of the author:

Kaspar Appenzeller, M.D.
CH-7500 St. Moritz
Switzerland.

 

Subsequent chapters of this research will follow: 4. The auscultation points and their inner organization 5. From the embryonic tone to the tone of mankind or the riddle of the spondee 6. Practical comments 7. From whence do the heart tones come?





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