Tricuspid lesions, not congenital, are in most instances associated with lesions of one or more of the valves of the left side of the heart. One case is reported of the diagnosis being based on the fact that the presystolic murmur was heard, not only around the apex, but at, and to the right of, the ensiform cartilage.
Regurgitant and obstructive lesions, situated at the tricuspid orifice, do not produce those immediate effects on the respiratory system and the pulse which pertain to analogous lesions seated at the mitral orifice. Their immediate effects are manifested in the systemic venous system. Congestion of the systemic veins is a direct result, tending to general dropsy. Cerebral apoplexy is more liable than in mitral or aortic lesions.
DIAGNOSTIC CHARACTERS OF PULMONIC LESIONS.
Physical signs. – Lesions situated at the pulmonic orifice may give rise to a murmur with the first sound of the heart, which may be called a pulmonic direct murmur. This murmur has its maximum of intensity in the second intercostal space on the left side of the sternum, the situation where the pulmonic second sound of the heart may be isolated from the aortic second sound.
Pulmonic lesions, however, exclusive of congenital malformations, are so rare, that the opportunities of any clinical observer, however large his experience, for studying the physical signs, are extremely limited.
Hypertrophy of the right ventricle, which is produced by obstructive or regurgitant lesions of the pulmonic orifice, involves augmented intensity of the tricuspid valvular element of the first sound, and an impulse in the epigastrium.
The primary effect of obstructive or regurgitant lesions situated at the pulmonic orifice, is enlargement of the right ventricle. The secondary and remote effects, and the symptoms thereon dependent, are essentially those which are occasioned by tricuspid lesions, being due to distension of the right auricle, tricuspid regurgitation, and congestion of the systemic veins.
TREATMENT OF DISEASES RESULTING FROM VALVULAR DISEASES OF THE HEART.
It is evident that the anatomical changes which the valves and orifices of the heart have undergone, are not amenable to any medical treatment. The lesions existing must remain. The most that can be done is to retard their progress and control their primary effects.
Cases may, however, occur where suitable remedies may set up such an action in the system, as may result in the partial or complete removal of certain morbid products deposited on or about the valves. A thorough trial of those remedies known to us as antipsorics may give you excellent results.
You need not feel discouraged in the treatment of valvular diseases, nor should you discourage your patients, for in general no immediate danger is present, even when those lesions exist which involve more or less obstruction or regurgitation.
For the treatment of the primary effects of valvular diseases, I refer you to the treatment of enlargement of the heart.
The secondary effects of valvular lesions do not generally appear so long as the enlargement of the heart is by hypertrophy, unless, from fatty degeneration or some other cause, weakness of the organ has been induced. Flint says that obstruction and regurgitant lesions tend first, as a rule, to produce hypertrophy, the muscular walls increase in thickness upto a certain limit. when this limit is reached, dilation of the cavities ensue, and, finally, predominates over the hypertrophy. So long as the hypertrophy lasts the increased power of the heart compensates for the immediate consequences of the obstruction and regurgitation.
But when dilatation takes place, the real danger appears. It is then that other organs become affected, and a train of evils follow which will require your watchful care to relieve and arrest.
The main objects of treatment, before these resulting affections have appeared are mainly preventive. (1) You must seek to prevent or retard the progressive anatomical changes. (2) You must strive to prevent weakness and consequent dilatation of the heart.
As I have just now stated, you will find this treatment fully set forth in your notes on hypertrophy and dilatation.
You must ever bear in mind, that in the treatment of the secondary and remote effects of these lesions, the condition of the heart should not be forgotten. You cannot successfully treat the local congestions in such cases by specific remedies directed solely to the organ affected. For example, leptandra will not as often remove a jaundice caused by cardiac disease as will digitalis, because the latter has a specific influence over the heart.
These secondary affections are mostly dependent on passive congestion, and as they arise from a weakened circulation, those cardiac remedies which strengthen the force of the circulation will give the most relief. I have enumerated these in Classes I., II., and III. in “Dilatation.”
Dyspnoea, otherwise known as cardiac asthma, or breathlessness, will often claim your special attention. In advanced cases you can only palliate, but you can do much with such medicines as digitalis, hydrocyanic acid, arsenic, lobelia, cuprum aceticum, phosphorus, and tartar emetic.
Cough can be alleviated by the same remedies, aided by hyoscyamus, conium, lycopus, etc.
Expectoration in valvular disease should be encouraged rather than checked, for it often relieves the congestion. When it becomes too profuse, it may be lessened by squilla, tartar emetic, cubebs, copaiva, ammonia, ipecac, and similar remedies.
Intercurrent pulmonary affections, such as bronchitis. Pleurisy, pneumonia, are to be treated in the ordinary manner.
The disorders of digestion and hepatic affections are sometimes quite obstinate. If you will study the provings of digitalis, you will observe the peculiar and prominent derangement of the gastric and hepatic functions which causes. It causes these disorders by deranging the action and impulse of the heart. Digitalis is our most reliable remedy in similar cases; and next in value come nux vomica, ignatia, china, cornus, aesculus, hydrastis, podophyllum, leptandra, lycopodium, sulphur, and benzoic acid.
Cerebral congestions are to be met with digitalis, nux vomica, opium, glonoine, agaricus, arnica, solanum, aided by hot mustard foot and hand baths. The extremities must be kept warm and full of blood.
General dropsy is one of the most troublesome of the secondary effects, and will tax your skill greatly. Remember that the kidneys are not primarily in fault. The co-existence of Bright’s disease gives the disease a double character.
Any remedy which will aid the heart by giving it increased power will benefit the dropsy. It is not necessary that the remedy should be a kidney remedy. The best remedies for cardiac dropsy may be arranged in two classes, namely:
I. Those which act primarily on the heart: digitalis and its analogues; nux vomica and china and their analogues.
II. Those which act specifically on the kidneys: apocynum cann., asparagus, eupatorium purp., benzoate of ammonia, colchicum, asclepias syriaca, squilla, potass nitras and acet., etc.
In cases of co-existing Bright’s disease, I have found sulphuric acid to act in a wonderfully efficient manner.
It is a significant fact that allopathic authorities are quite unanimous in asserting, that from experience they find that by combining a remedy of my Class I. with one of Class II., they are enabled to remove cardiac dropsy more rapidly than in any other way. A favorite combination with them is digitalis and squills. Now, we need not combine medicines to get these good effects. Better results can be gained by alternation. You will, according to my experience, get prompt action from an alternation of digitalis and apocynum cann., or china and asclepias, or nux and benzoate of ammonia.
Obstinate cases have been reported where the internal administration of remedies failed to remove this form of dropsy, but in which their external application over the abdomen and kidneys was successful.
If your dropsical patient is anaemic, give him ferrum (the iodide is the best,) and advise a strong nitrogenous diet.
Finally, gentlemen; do not always inform your patients of the presence of organic disease of the heart. Such an announcement will militate against your best chosen remedies, by depressing your patient’s spirits, and thus lowering the vital energies. Better is it to encourage; and only allude to the heart in a vague or indirect manner.
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.