) New Remedies, 2nd Ed. Dose: the first dilution has been found most useful. Asclepias syriaca, as you will observe from the provings, will likely prove of service in endocarditis from renal affections, or from a retention of scarlatinal poison. Dose: the tincture, a few drops, in water. Baptisia will prove in your hands an unrivalled remedy in endocarditis during or following typhoid or other low fevers, especially when you have present its well known characteristic symptoms. Dose: the first decimal dilution, in drop doses. Cactus grandiflorus will never fail you, in the severest cases of the acute form, if that peculiar symptom, “Sensation of constriction of the heart, as if from a band around it, preventing movement,” is present. No other remedy equals it in controlling the severe nervous palpitations common to the disease. I get the best effects from the 1st dil. Cimicifuga must not muscular structure, would be chiefly indicated.
Definition – Anatomical Characters – Causes and Pathology – Symptoms – Physical Signs – Diagnosis – Prognosis – Treatment.GENTLEMEN : I shall, in this lecture, take up one of the most important of the inflammatory affections of the heart; more important than pericarditis, because of the serious valvular lesions which it usually leaves.
An inflammation of the membrane which lines the cavities of the heart, and is duplicated to cover the valves, is called endocarditis. It is not more than fifty years since this disease has been clearly described and recognized, but clinical experience has demonstrated that it is by no means infrequent. In the majority of cases it occurs as a complication of acute rheumatism. The inflammation may be acute, subacute, and chronic, but these distinctions are not of practical value.
ANATOMICAL CHARACTERS.
This inflammation is said to be confined, in the vast majority of cases, to the membrane lining the cavities of the left side of the heart. The lining membrane of the right auricle and ventricle is rarely inflamed, and when inflamed it is also present on the left side.
All portions of the endocardial membrane of the left side are not equally subject to inflammation. You must bear in mind that it generally attacks the membrane covering the valves and lining the orifices, and that it is in these situations that it leaves the most troublesome results. There are two reasons for the tendency to attack these localities. 1st. The membrane here is most exposed to the blood-currents; the valvular portion is in constant motion, and is almost constantly in a tense or strained condition. 2nd. The membrane is here underlined by fibrous tissue, and not, as in other situations, in close proximity to the muscular walls of the heart.
Flint believes there are grounds for believing that the foetus in utero is subject to endocarditis, and that the inflammation is then limited to the right side. He believes the malformations found in infants – cyanosis, etc. – may thus be accounted for.
In the occasional instances in which death has occurred during the inflammation, there has been found (a) redness from vascular injection, (b) alternations in the membrane itself, and (c) the presence of inflammatory products.
(a) Redness, due to endocarditis, is caused by injection of the vessels which ramify in the areolar tissue beneath the membrane, but it is not always found, and may disappear as a post-mortem change. But the redness, when found, is not always a proof of inflammation, for it may be the effect of the imbibition of haematin dissolved out of the red globules of the blood which the cavity contained after death. This redness from imbibition, however, is distinguished from that due to inflammation by these differences: (1) It is not an arborescent, but a uniform redness, and when examined with a lens, injected vessels are not visible; (2) It has a deeper and darker color than inflammatory redness; (3) It is not more likely to be limited to the valves and orifices, and is more conspicuous in the arteries than in the cavities of the heart. Moreover, in redness from imbibition, the membrane preserves its normally firm, polished appearance.
(b) Alterations in the membrane itself are much more indicative of inflammation than redness. These changes are: “loss of the smooth, polished appearance which the membrane has in a healthy state; instead of which it becomes opaque, rough, velvety, and felt-like; more or less swelling and softening; and brittleness of the subjacent areolar tissue.” (Flint.)
(c) The presence of inflammatory products will prove to you conclusively, if present, that endocarditis has existed. You remember that the endocardium, unlike other serous membranes, is not a shut sac, wherein inflammatory products may be collected and retained. Such products may be washed away by the currents of blood and carried along with the circulation. Another difference is that the free surface of the endocardium is in contact with the blood itself, and that while the fluid detaches and removes morbid products, it may also furnish deposits by yielding a portion of its fibrin; which undergoes coagulation.
These products of inflammation, then, may be derived from two sources, namely: the exudation of lymph, and the coagulation of fibrin from the blood. The extended lymph occurs on the free surface of, as well as beneath, the endocardium. That on the free surface, if not washed away, forms layers, as in pericarditis. The roughness of the exuded lymph attracts – as it were – fibrin from the blood, as the threads did when passed through the arteries in Dr. Simon’s well known experiments. When we consider that in acute rheumatism the fibrin of the blood i in excess, we can see how the tendency to fibrinous depositions is greatly increased in endocarditis from that cause.
Various morbid growths are to be enumerated as the result of endocarditis. They are commonly called vegetations, and are found either at the base or the free extremities of the valves. They occur in the form of small granular masses, or beads, from the size of a pin’s head to a millet seed, studding the margins of the curtains of the mitral valve, and fringing the crescentic extremity of the fibrous portion of the segments of the valves of the aorta.
Virchow denies the occurrence of the exudation of lymph in endocarditis. He charges the formation of excrescences and membraniform layers wholly to proliferation or morbid growth, and the coagulation of coagulated fibrin from the blood within the cavities of the heart. Flint, however, believes that morbid growths may have, as a nucleus, the true vegetations or exuded fibrin, to which may be added the coagulated fibrin from the blood.
Other morbid changes may occur, namely: loss of substance by ulceration and erosion; perforation of the valves; lacerations; and even gangrene. Among the rarer occurrences are adhesions of the valves of each other, or to the walls of the heart.
The remote effects of endocarditis will be considered in future lectures, when we come to consider the Organic Diseases of the Heart. I will only say here, that in a very large proportion of cases, valvular lesions, involving either obstruction or regurgitation, or both, owe their origin to the anatomical changes which occur as a result of endocarditis. It may be months or years before serious structural changes obtain; but you should carefully watch your patients who have had this disease, and be on the look-out for the first symptom of organic affection, for it is rare that they are escaped altogether.
CAUSES AND PATHOLOGICAL RELATIONS.
Endocarditis is rarely an idiopathic affection. Like pericarditis, it is usually associated with acute articular rheumatism. It differs, however, from the former, in occurring independently of that affection, and is a comparatively rare affection as occurring in other pathological connections. When the two diseases occur together, the combined affections are designated endo-pericarditis.
Of 474 cases of rheumatism, collected and analyzed by Fuller, endocarditis existed in 214, the ratio being 1 to every 2.25 cases. Of 204 cases, endocarditis existed in 138, pericarditis in 19, and endo-pericarditis in 38. Bamberger says endocarditis occurs in 20 per cent. of all cases of rheumatism.
The connection of endocarditis with acute rheumatism is the same as that of pericarditis. It is not developed as a metastasis, but depends upon the same morbid condition that causes the rheumatic affection.
Endocarditis may become developed in connection with renal disease, owing to the analogy of structure between the endocardium and the serous membranes. (See Pericarditis.)
It is said that in non-rheumatic endocarditis the aortic valves are more likely to be the seat of inflammation than the mitral; the reverse being true, as has been seen, of rheumatic endocarditis.
Endocarditis and pericarditis are frequently associated. Fuller says that in 204 cases, analyzed by him, this combination existed in 38. Either affection may take precedence in point of time.
Hale wrote Lectures On Diseases Of The Heart, Materia medica and special therapeutics of the new remedies Volume 1, Materia Medica And Special Therapeutics Of The New Remedies Volume 2, Saw Palmetto: (Sabal Serrulata. Serenoa Serrulata), The Medical, Surgical, and Hygienic Treatment of Diseases of Women, New Remedies: Their Pathogenetic Effects and Therapeutic Application, Ilex Cassine : the aboriginal North American tea, Repertory to the New Remedies with Charles Porter Hart, The Characteristics of the New Remedies, Materia Medica and Special Therapeutics of the New Remedies, The Practice of Medicine, Homoeopathic Materia Medica of the New Remedies: Their Botanical Description etc.