CURABILITY OF VALVULAR DISEASE OF THE HEART IN THE ACUTE STAGE.
As I have stated before, it is not to be expected that old- established valvular disease should be altered, or destroyed valves restored, though even in these cases much may be done by remedies to restore the power of the heart when it is defective, and to bring about proper compensation, which is practically a cure. In recent cases of valve affection, on the other hand, it has frequently been my lot to observe the disappearance of all signs of disease under treatment. In my book on “Rheumatism” I have mentioned, among others, a case of this kind which particularly struck me when I was resident medical officer at the London Homoeopathic Hospital. It was that of a young girl who had a severe attack of acute rheumatism, with both pericarditis and endocarditis. Under treatment, the friction sounds of the pericardial inflammation quite disappeared, and when these had gone the bruits indicating endocardial mischief also subsided.
One of the chief difficulties in the treatment of endocarditis occurring in connection with rheumatic fever lies in the fact that there are so few symptoms indicating the mischief.
Pericarditis has generally abundance of symptoms, hence it is a much easier matter to cure cases of this. On the other hand, there may be very extensive endocarditis and no sign be given except on physical examination. In such cases the only thing to be done is to take the totality of the symptoms and to prescribe accordingly. If there are no symptoms elsewhere to guide, such medicines as have been found in practice or in provings to have an affinity for the lining membrane of the heart and arteries should be thought of, when the constitution of the patient and his previous medical history, with any former symptoms he may have had, will serve to distinguish the most similar.
The two valves of the heart which are most liable to inflammation are the mitral, which transmits the blood from the left auricle to the left ventricle of the heart; and the aortic, through which the contraction (or “beat” of the heart) propels the blood from the left ventricle into the arteries of the body. Any narrowing of these valves obstructs the flow of the blood, and any defect in their closure allows the blood to pass backwards through them. These defects give rise to certain abnormal sounds called bruits, or murmurs, which take the place of the proper sounds produced by the valves. The normal sound of the heart is a double sound which has been fairly represented by the syllables “lupp-dupp,” the first part of it occurring when the ventricles of the heart contract (systole), and the second when they open again (diastole).
The auricles which receive the blood-the right from the body, the left from the lungs-contract just before the ventricles, but as they have much less arduous work to do they are much less powerful than the ventricles, and normally their action is unaccompanied by any sound. When, however, these valves are narrowed (that of the right ventricle is called the tricuspid, that of the left the mitral), a murmur is heard over the area of the valve just before the heart beats, and is hence called pre- systolic. When the mitral valve is defective it does not close perfectly; when the heart beats the blood is driven back into the left auricle and causes a systolic murmur instead of a click. This explains the breathlessness that accompanies many forms of heart disease, for the pressure is thrown back on the blood- vessels of the lungs and the blood is not properly aerated. Thus a pre-systolic murmur heard over the area of the mitral valve (that is, roughly, over the point where the heart is felt beating) denotes obstruction to the flow, and a systolic murmur heard in the same area denotes regurgitation. The area at which aortic sounds are best heard is at the spot where the second left rib joins on to the breast bone. The opening of the aortic valve occurs at the time of the heart’s beat (systole or first sound) and then any narrowing of its orifice causes a systolic murmur.
If it does not close perfectly at the time of the second syllable of the “lupp-dupp” a murmur is heard and is called diastolic. When it is both narrowed and does not close perfectly a double murmur is heard, something like a sawing sound, replacing the proper sounds altogether.
The other two valves, which are much less frequently affected, are the tricuspid and the pulmonary. The tricuspid transmits the blood from the right auricle (which receives it after it has circulated through the body) to the right ventricle; and the pulmonary valve (which is in the pulmonary artery) transmits the blood, when the ventricles contract, from the right ventricle into the lungs. The sounds of the tricuspid valve are best heard on the level of the fourth rib close to the left edge of the sternum or breast bone (or, if the ventricle is enlarged, on the right edge of the sternum at the same level); the pulmonary area is in the interspace between the first and second ribs, close to the left edge of the sternum.
Sounds of blood regurgitating into the left auricle when the mitral valve is defective are often best heard just to the left and a little below the pulmonary area, where a part of the left auricle approaches the surface.
There are many other variations from the normal in the quality of the “lupp-dupp” besides the occurrence of murmurs, each indicating some particular condition of the heart. For instance, if the two sides of the heart do not act absolutely synchronously either or both of the sounds may be reduplicated. On the other hand, the presence of a murmur is not an absolute sign of valve defects. It may be brought about by other causes such as the condition of the blood.
The size of the heart is estimated by the size of the area which gives a dull sound when percussion is made on the front of the chest.
The sphygmographic tracings (which show the rapidity of the heart’s beats and all the vibrations the wall of the artery goes through between one beat and the next) are all taken with Dr. Dudgeon’s pocket Sphygmograph (pulse-writer) which has superseded every other. Dr. Dudgeon has explained the instrument in an exceedingly interesting little work entitled “The Sphygmograph,” and published by Balliere, Tindall & Cox.
During the summer of 1892 a numbers of cases of endocarditis came under my observation in connection with acute fevers. There was at the time an extensive epidemic of German measles and the first case I shall describe is that of a young lady aged 19, who was one of its victims.
CASE III.-INFLAMMATION OF THE MITRAL VALVE OF THE HEART IN A CASE OF GERMAN MEASLES. RECOVERY UNDER TREATMENT.
On June 15, 1892, I called to see Miss L., who had been somewhat ill for four days. I found the rash of German measles, sore throat, the right tonsil being enlarged. There was a cough, and she raised a good deal of phlegm. There was some fever. The monthly period was on at the time. The pulse was 72. On listening to the heart I found a systolic mitral bruit. She had cold clammy feet. Under Belladonna 30 the symptoms of the fever left her, but the bruit remained. On the 22nd of June the bruit was audible in the mitral, tricuspid and left auricular areas when she was lying down, but disappeared when she sat up. There was slight giddiness when walking and she was tired on sitting up. I gave her Spigelia 30, and in a few days the bruit became less distinct. She afterwards received Nat. mur. and then Arsen. for other indications; but on June 29th, after a restless night, hot and perspiring, the pulse was 84, the mitral bruit was very distinct, and heard in all the areas of the heart, and the patient felt “queer,” so I again gave Spigelia 30. Two days after this I found her feeling much better, and I could not hear the bruit. A few days later I listened again, but could hear nothing of it, so I let her leave town for the seaside.
CASE IV.-ACUTE INFLAMMATION OF MITRAL VALVE ACCOMPANYING GERMAN MEASLES AND MENTAL STRAIN. RECOVERY.
About the same time I was attending another German measles patient, also a young lady, who developed in the course of it a similar affection of the mitral valve. Eventually this also disappeared, but as this case was more complicated, the attack having supervened on a long period of over-work and mental strain, much longer time was required. The medicine which had most effect on the heart symptoms in this case was Baryta carb., which was given in two-grain doses of the 3x. The sensations she complained of were a strained feeling referred to the base of the heart and a sharp pain about the apex. The 3x appeared to have more decided action in this case than the 30th which was given first.
CASE V.-ENDOCARDITIS OCCURRING IN MEASLES. PARTIAL DISAPPEARANCE OF MURMUR; COMPLETE COMPENSATION.
Charlie W., aged 10, had an attack of English measles in May, 1892. I saw him on the 28th, and all the classical symptoms of the disease were present, and, in addition, a mitral systolic bruit. There were no symptoms arising from the latter and I treated the case according to the symptoms in the ordinary way.
Under Belladonna 30, Mercurius sol.30, and Sulph.30, the disease ran a mild course, leaving the boy well, except for the bruit. On May 7th, as there were no symptoms, I put him on Lycopus virginicus 1x, which has a reputation in valvular disease. I could trace no effect to this, nor to Spongia 30, with which I followed it. On 17th of May, taking into consideration that he came of a consumptive family on one side of the house, and guided by the crenated appearance of his teeth, which Dr. Burnett has shown is an indication for the medicine, I gave one dose of Bacillinum 200, and as he had cold, clammy feet, I followed this with Calcarea carb. Under this treatment he made good progress, and on the 10th of June I ceased attending. The bruit was then inaudible when he stood up but could be heard if he lay down.
On December 14th I saw him again for something else, and had the opportunity of examining the heart. He told me he had no shortness of breath on running up stairs, and he could run as well as ever he could. The apex beat was felt in the fifth space, further to the left than normal, and the area of cardiac dullness was greater than normal. On standing no bruit was audible; there was a little accentuation of the first sound at the apex and of the second over the pulmonary artery. On making him lie down I found that the bruit reappeared in all the areas, loudest over the apex, and the action of the heart became irregular.
I have not been able satisfactorily to account to myself for this condition in which there is competence of the valve in the erect, and incompetence in the recumbent position, but it is a condition I have often observed. In one case, that of a child who had at one time unmistakable incompetence of the mitral valve with attacks of violent palpitation and flushing of eyes and face following whooping-cough, I found, after some years, that the bruit could only be heard when she lay down; and still later it could not be heard at all. There was no anaemia in this case. Some defect of the posterior flap of the valve, or irregular action of the columnae cardiae may possibly account for it.
I will now relate another case of very extensive heart inflammation which resulted in a practical cure.
CASE VI.-ACUTE INFLAMMATION OF THE PERICARDIUM AND VALVES OF THE HEART. PROMPT ACTION OF Spigelia. RECOVERY.
On the 22nd June, 1889, James T., a chimney-sweep, aged 44, came to my hospital clinic on the recommendation of a private patient of mine who had persuaded him to try Homoeopathy. When he entered my out-patients’ room it was easy to see he was exceedingly ill.
Like most of his class he had led a hard, reckless life. He commenced chimney-sweeping as a tiny boy in the days when boys were sent up the flues instead of the machine brushes now used. Naturally he was a man of powerful physique; but now it had been with the greatest difficulty that he had succeeded in reaching the hospital. He had the blurred, heavy look of countenance-a sort of indistinctness of features-sometimes noticed in sufferers from heart disease. He felt just as ill as he looked, for he afterwards told me that he never expected to reach home again alive.
Fourteen days before, he had taken cold from getting wet during a trip to Oxford on the river. This was followed by a cough with raising of thick phlegm, the cough being so painful that he had to hold himself, and this had continued. The chief thing he now complained of was a pain at the heart as if it were swelling up. The pain gradually moved down, and the night before his visit to me was in the left flank; then it moved up to the heart again. Sensation as if a big knife went through it, aggravated on taking a breath. The pain prevented him from sleeping; it was impossible for him to lie on the left side. Tongue white; appetite good, but he could not eat, because eating brought on the pain. Bowels confined; he had a choking sensation in the epigastrium, and a dizziness in the eyes.
On examining the heart I found there was an increase in size, a pericardial rub, and bruits in the aortic and mitral areas; that is to say, there was pericarditis with effusion and endocarditis as well.
The knife-like pain in the heart singled out Spigelia from all the other medicines related to his condition, so I gave it him in the third centesimal dilution, a dose every hour.
He slept well that night, as he was able to breathe better. The next day I called at his house, and I found a decrease in the pericardial rubbing sound, and a diminution in the area of cardiac dullness.
June 24th.-Still better; sleeps well; has no pain; appetite good. On this day I made the following notes of the state of the heart:- Slight rub heard over centre of heart.
Mitral area: double bruit, the systolic portion being heard in the axilla.
Tricuspid area (right border of sternum on level of fourth rib) : a double rough grating sound.
Aortic area : a double bruit.
On the night of the 25th-26th (as his wife informed me) his breathing seemed to be arrested; it began again with a gasp.
The Spigelia 3 was continued all this time, though it was not given so frequently as at first. From the 25th it was given every two hours.
A few weeks after this he mentioned a circumstance which occurred during the time he was taking Spigelia-the loss of a pain in the right knee which had troubled him for eighteen months. If he knelt on it he was unable to get up without going down on the other knee as well, and then stretching out the right leg. The pain was as if the knee got out of joint. He had been sometimes for hours at night before he could get it into the right position in bed. He asked me if my medicine could have had anything to do with its disappearance; for as he had not told me anything about it before, he did not see how I could have cured it. On referring to Allen, I found this in italics: Tearing pain, like a sprain, in the left knee, only when walking, so that at times he limped, since he could not bend the knee as usual. Other similar symptoms refer to the right knee and both knees. That the Spigelia must have the credit of this bye-cure I proved later on, for the pain in the knee returned; but a few doses of the Spigelia 1m F.C. permanently removed it.
But to go back. By July 1st he was quite free from any chest symptoms: he could lie on either side. But he was weak in the calves, had giddiness, and suffered from constipation with straining. Nux 1m relieved the latter condition.
On July 3rd he was still complaining of weakness in the legs, so I put him on Baryta. c. 1m, after which there was rapid improvement.
He continued on this medicine, with a rest, till August 10th. Occasionally he had palpitation on lying down at night; on the 5th there was slight pain in lower part of left chest; on the 12th numbness of left shoulder and arm. On August 1st he had an attack of giddiness in the evening whilst walking in the street. He resumed work on the 9th of August. On October 11th he declared he felt as well as ever he did in his life. Being an enthusiastic member of the Volunteer force, he had been testing his powers by practising ball-firing. The following Easter he went through the fatigues and exposure of the Easter Volunteer manoeuvres, indulging himself even (without asking my permission, I need hardly say) in bathing in the cold spring sea.
On the 19th of March, 1893, I called upon him to make an examination of his present condition. For the last eighteen months he has been better, he says, than for years before. His pulse was 72, regular, steady and of good force. I append his sphygmogram, taken from the left radial, standing, with a pressure of 3 1/2 ounces. It does not differ from a normal tracing except, perhaps, in the strength and sharpness of the upstroke and sudden though quickly arrested return.
Examination.-The area of dullness is still greater than normal; the apex beat is felt in the sixth interspace and more to the left than normal. Coming to the heart sounds, I find, of course, no pericardial rub. Also the mitral bruit and the grating sound (probably pericardial) in the tricuspid area are no longer to be heard. The double aortic bruit still remains. In the tricuspid area the first sound is clear, and a soft bruit replaces the second. This is probably the aortic diastolic propagated downwards. In the mitral area the first sound is somewhat impure-not the clear, sharp click of a normal valve-but there is no bruit, showing that the valve is competent.
In this case I conclude that under the treatment-that is, under the action of Spigelia and Baryta carb. chiefly-the inflammation of the heart, which affected both the outer and inner lining, was subdued, and the affection of the mitral valve was so far remedied that it has been restored to competence. The aortic valves remained still as they were, but the softness of the systolic portion of the double bruit shows that the degree of obstruction to the blood-flow is but slight, and the softness of the diastolic part that the regurgitation is not considerable. This shows that there has been, at any rate, an arrest of the disease process, and I am disposed to think that the aortic trouble dates from before the time when I first saw him.
I may say that after having been a very heavy drinker, he suddenly gave up alcohol in all forms seven years before this illness began. What made him give it up was that he lost nerve when at his work on roofs, and even on stepping from a curbstone into the street felt as if he would fall. Afterwards he suffered much from “indigestion,” and in the night violent palpitation and sometimes arrest of breathing, as noticed by his wife. Loss of nerve is a very common symptom in heart affections, and the probability is that the aortic disease was commencing at that time.
CASE VII.-ULCERATIVE ENDOCARDITIS ENDING FATALLY, THE AUTOPSY REVEALING A HEALED PATCH ON A SPOT WHERE INFLAMMATION HAD OCCURRED DURING AN EARLIER ATTACK OF ACUTE RHEUMATISM.
Before proceeding further I would like to refer to a case of ulcerative endocarditis following pneumonia, with delirium tremens, which I published in the November number of The Homoeopathic World for 1884 (vol. xix., p. 497). The case ended fatally, but the point I wish to refer to was made evident at the post-mortem examination. The heart weighed thirteen ounces.
On the under surface of the aortic valves (which were competent) grew abundant granulations like cauliflower excrescences, exuding purulent matter. These granulations pressed against the aortic segment of the mitral valve, constricting the orifice artificially. The mitral valve itself was healthy, except that the remains of an old deposit were found between its laminae.
Now this patient (who was a groom, and, like many of his class, addicted to spirit drinking) had been in the hospital under my care some years before with a severe attack of acute rheumatism, and during the attack there were no signs of the heart being affected. But that there had been some inflammation of the valve, and that it had healed without causing deformity, this white patch found on the mitral valve at the post-mortem examination proved. In the second attack, the aortic valve was the one which was affected by the morbid process.