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.
