But, as I stated a few moments ago, you cannot give a positive opinion unless you have been watching for this murmur at a time before it existed, for if you heard it at the first examination, it may have previously existed from some valvular lesion of long standing. You will readily deduce from this caution, that will be very difficult, if not impossible, for you to detect endocarditis in a patient who has any organic disease of the heart.
As idiopathic endocarditis is the rarest of all diseases of the heart, I will not enter into discussion of its diagnosis. I must inform you, however, that pericarditis is so often associated with endocarditis, that you will rarely find the latter free from the former. In the diagnosis of endo-pericarditis, you will have to compare the signs of both: but, happily, the treatment of these affections is not materially different.
PROGNOSIS.
The prognosis of endocarditis is generally favorable, so far as any immediate danger to life is concerned. The symptoms may continue, and the condition become chronic, and cause great inconvenience, and exist for a long period. Chronic endocarditis may be suspected if the patient continues to complain of uneasiness in the heart, and that organ continues unnaturally excited. But this disease, when chronic, so nearly simulates valvular disease, that the prognosis depends on the extent of the structural lesion.
Certain accidental events may occur during endocarditis which may seriously endanger life, namely: the formation of fibrinous coagula; the detachment of vegetations or of masses of fibrin or lymph, constituting emboli; the admixture of disintegrated solid deposits; and purulent infection of the blood.
If we can judge of the prognosis from recorded clinical experiences, we can believe that, in a large majority of cases of endocarditis, recovery takes place without serious accidents. The cardiac symptoms gradually disappear. The patient, however, is generally left exposed to the evils arising from valvular disease, which may become developed at a period more or less remote, unless your treatment has prevented such a result.
TREATMENT OF ENDOCARDITIS.
The treatment of endocarditis cannot be diagnosed of so summarily as some authors have done, by asserting that there is “no essential difference” in the treatment of endocarditis and pericarditis. Not only is the treatment not the same, but the objects of treatment are dissimilar. Flint very tersely observes, that in pericarditis the compression of the heart by the accumulation of liquid within the pericardial sac is a source of distress and danger; and to prevent this accumulation, and promote its removal, are important therapeutical ends. In endocarditis, however, the action of the heart is free from all mechanical restraint. In pericarditis the inflammation is more generally diffused, and a greater effect is produced upon the muscular walls, first by excitation, and afterwards by paralysis. In endocarditis the inflammation is seated especially in the membrane connected with the valves and orifices, when it is not in contact with the muscular walls, and the latter are consequently affected in a less degree. In pericarditis the aim of the practitioner is often to avert impending death. In endocarditis there is little fear of a fatal result.
But although the two affections are so dissimilar in many respects, the general principles of management are in a great measure alike applicable to both.
The therapeutical indications in the treatment of endocarditis relate mainly to the alternations to which the membrane is exposed, and to the products of inflammation.
Your objects must be to diminish as much as possible the local effects of the inflammation; then to aid in restoration from these effects, and thus protect the organ from the remote consequences arising from incurable and progressive unsoundness. In other words, you must accomplish, if possible, the following results:
1. Abate the intensity of the inflammation.
2. Abridge its duration.
3. Limit the exudation of lymph.
4. Diminish the precipitation of fibrin.
5. Effect the removal of solid deposits.
The remedies to which you must resort to gain these ends are, mainly: aconite, veratrum viride, digitalis, arsenicum, spigelia, phosphorus, colchicum, bryonia, asclepias, lachesis, naja, sulphur, belladonna, rhus.
Aconite is useful in the first stage of the disease, when the pulse is hard, small, and quick, and there is pain of a sharp, pricking description in the cardiac region, with anxiety, fear of death, faintness, oppression, and tumultuous action of the heart, (see also “Aconite” in Pericarditis.)
Veratrum viride you will find useful in those cases which are ushered in by a more violent congestion, pain, and intense force of the circulation. The bounding pulse – full, hard, and quick; the intense throbbing headache, without delirium, will indicate this remedy, in the lowest dilutions. With these two agents, aided by a low diet and absolute rest, you will be able to abate the inflammation and shorten its duration. But the disease is often so rapid in its course, that you will be obliged to anticipate the second stage, and alternate with the above:
Bryonia, if the pains are of the severe stitching character peculiar to the medicine. This remedy is powerful against the exudation of lymph, and is equally useful in endocarditis as in pericarditis.
Asclepias tuberosa, as I remarked when speaking of pericarditis, has nearly the same sphere of action as bryonia.
Colchicum is probably more suitable to pericarditis than endocarditis. I am of opinion, however, that it is not so much the local condition that indicates this remedy, as the condition of the blood. Colchicum causes an extraordinary increase in the secretion of uric acid, and it is this which makes it such an invaluable remedy in cardiac affections occurring during attacks of gout. It is, however, equally useful in rheumatic endocarditis.
Belladonna is an excellent remedy in endocarditis, especially when there is secondary irritation and congestion of the brain, and also where there occurs congestion of the chest. It is best indicated when the first is passing into the second stage, and we have the following symptoms: aching in the cardiac region, taking one’s breath away and causing anxiety; occasional intermittence of the pulse; irregular, unequal contractions of the heart; throbbing pain beneath the sternum, near the epigastrium; violent heart-throbbing, with jarring of the head and neck.
Digitalis, from the very nature of its action, cannot prove of much value in endocarditis, unless it be associated with pericarditis. As Baehr very properly remarks, “In endocarditis it seems almost impossible to indicate special heart-symptoms requiring the use of digitalis; in such cases, the constitutional symptoms will have to determine our choice.” However, as endocarditis rarely occurs unattended by some pericardial inflammation, digitalis should always be thought of, and selected according to the indications given under pericarditis.
Arsenicum will not control acute endocarditis, but will be found useful in those severe paroxysms of palpitation, or the attacks of cardiac syncope, which sometimes occur. It will be most indicated if Bright’s disease or pyaemia be the cause of the endocardial inflammation.
In direct contradiction to Baehr, Dr. C. Muller asserts that “Arsenic has been found serviceable in palpitations, carditis, endocarditis, rheumatic, and organic diseases, especially of the left side of the heart,” and he adds that “Arsenic possesses the most perfect specific and homoeopathic relation to endocarditis. It is indicated not only in the commencement of the disease, but also when exudations and vegetations have formed on the endocardium and valves, especially of the left ventricle. It is hence the main remedy in Bouilland’s so-called chronic endocarditis. It is indicated when the following physical signs are present: dullness over a greater extent than usual in the cardiac region, especially in a vertical direction; violent and irregular action of the heart, with feebleness or almost complete extinction of pulse; indistinctness, or roughness, of both sounds of the heart, or a bellows-murmur with the first sound, heard on the left ventricle and along the aorta, but loudest over the aortic valves, viz., at the edge of the third rib, near the left edge of the sternum.”
Spigelia, according to Baehr, is only useful in incipient endocarditis, or to endocarditis generally before marked valvular changes have taken place. For the special indications for spigelia, I refer you to your notes on pericarditis, and the remarks I shall make in the future consideration of valvular diseases.
Phosphorus will undoubtedly be of use to you in some cases of endocarditis. I can do no better than to give you the indications pointed out by Baehr, which I consider reliable. He says “Phosphorus is clearly suitable for inflammation of the endocardium and the muscular tissue, never for pericarditis. The constitutional symptoms would lead us to recommend phosphorus in endocarditis associated with pneumonia, against the cardiac inflammation, not against the pneumonia, for we have already stated that when pneumonia is complicated with cardiac inflammation, the presence of the latter constitutes an absolute obstacle to the absorption of the pneumonia exudation. In the next place, phosphorus takes the precedence over every other medicine in cardiac inflammation, when occurring as complications of such processes as lead us to infer a dissolution of the blood, like scurvy, puerperal fever, malignant exanthematous diseases, typhus, etc. Finally, we possess few remedies that embody in their pathogeneses as plain a picture of nephritic and cardiac inflammation as phosphorus.”
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.