Aortic Lesions – Mitral Lesions – Primary Effects of Valvular Disease on the Circulation – Symptoms and Pathological Effects of Valvular Lesions – Secondary Effects of Valvular Lesions – Pain – Palpitation – Cardiac Dropsy – Symptoms of the Respiratory System – Symptoms of the Nervous System – Symptoms of the Digestive System – Symptoms of the Genito-Urinary System – General Symptoms.
GENTLEMEN: I now come to those diseased conditions of the valves and orifices of the heart which go under the general name of Valvular Diseases. I have reserved this subject for my last lectures because these lesions are connected with, and are the results of the inflammatory affections hitherto treated of. Another and important reason is, that many disease and functional disorders of various organs of the body, which are often considered idiopathic by unobserving physicians, are really the result of valvular lesions. If the heart does not work in a normal manner, the circulation all over the body is imperfect, and every other organ becomes deranged.
The clinical study of these lesions is of great interest, on account of the wonderful precision with which modern diagnosis, by means of auscultation, enables us to locate the situation and nature of the lesion.
In treating of valvular lesions, my main object will be to describe their immediate and remote effects, and the means by which we can make a correct diagnosis, and finally, the appropriate homoeopathic treatment for these effects. The cause can rarely, if ever, be removed.
I shall first take up for your consideration the
AORTIC LESIONS.
Lesions affecting the aortic valves may be limited to one or two of the semilunar segments; but in most cases all are more or less affected. Thickening of the segments is one of the most frequent of the morbid changes. This will not specially impair the function of the valves, but their expansion will be somewhat sluggish, and the intensity of the aortic second sound of the heart must be in some measure diminished.
The segments are often contracted as well as thickened. Consequently a current of blood is forced backward from the aorta into the ventricle, by the recoil of the arterial coats. At the same time the aortic second sound of the heart must be weakened by the diminished size of the valves as well as by the thickening.
Rigidity of the valves from calcareous deposit is of frequent occurrence. The segments are sometimes expanded, and being encrusted with calcareous salts, appear to be completely petrified. This was formerly called ossification.
Another variety of lesion consists in the presence of warty excrescences or vegetations. These are generally attached at or near the free border of the segments, on their ventricular aspect.
These vegetations may be loosely attached, and liable to be separated by the force of the current of blood during life, and become emboli, and obstruct the circulation in the arteries.
Attenuation from atrophy is also a lesion to which the valves are liable. Rupture, under these circumstances, is liable to occur.
Perforations may occur at any point where the valves are softened, and perhaps at the same time thickened.
Lesions in the aorta, extending, to a greater or less extent, above the valves, are, in the majority of cases, associated with lesions of the aortic orifice. The artery may be dilated or contracted.
MITRAL LESIONS.
Lesions at the mitral orifice are essentially the same as aortic lesions, the points of difference relating chiefly to the differences, as regards form and arrangement, of the mitral valves. As a result of their insufficiency, a retrograde stream or current, from the ventricle into the auricle, takes place with each systole of the ventricle, the quantity of blood thus regurgitating, of course, being proportionate to the extent of the mitral insufficiency.
Rupture of the tendinous cords connecting the free margins of the valves with the papillary muscles occasion insufficiency of mitral valves.
The deposit of calcareous salts at the base of the valves gives rise to lesions, and reduces the auriculo-ventricular orifice to a small aperture.
Vegetations and warty excrescences occur in this situation as at the aortic orifice. But the most frequent mode in which contraction of this orifice is produced is by the union of the curtains at their sides, leaving a narrow slit through which the blood passes from the auricle into the ventricle.
Aneurism of the mitral, as well as of the semilunar valves, is another variety of lesion.
It is evident, that in so far as the different lesions which have been noticed interfere with the play of the mitral valves, the first sound of the heart must be weakened and modified by the diminution or extinction of the valvular element of this sound.
SYMPTOMS OF AORTIC AND MITRAL LESIONS.
As symptoms referable directly to the heart may be noticed: pain, palpitation, abnormal changes of the pulse, turgescence of the veins, and venous pulsation.
Pain. Absence of pain is the rule, but occasionally patients complain of painful sensations referred to the praecordia. A sense of constriction, uneasiness, or undefinable distress, is oftener met with than actual pain.
Palpitation. Is due, not directly to the lesions of the valves or orifices, but to the hypertrophy to which they have given rise. When the patient complains of the beating of the heart, the impulse is found, on applying the hand over the praecordia, to be abnormally forcible. This increased force is observed when the patient is not aware of any such palpitation. Palpitation, therefore, may be present as an objective, when it is wanting as a subjective symptom.
Other things being equal, the increased violence of the heart’s action is proportionate to the amount of hypertrophy, and especially hypertrophy of the left ventricle.
Usually, if the patient complain of undue violence or of irregularity of the heart’s action, exclusive of other circumstances, the presumption is that organic disease does not exist.
Palpitation from functional disorder always occasions great uneasiness, and generally intense anxiety and alarm.
It is quite otherwise with palpitation incident to organic disease. As a rule, then, and you may consider it a safe one, palpitation, when accompanied with great uneasiness and uncomplicated, indicates or will suggest to you the non-existence of structural lesion.
Palpitation due to organic disease is less violent. Functional palpitation occurs often when it cannot be traced to any exciting cause, and is more likely to occur when the patient is at rest.
Pulse. You must accustom yourselves to the movements as given by the pulse in heart affections, as well as in other disorders, and it is only by close observation at the bed-side that you will attain that peculiar sense of touch necessary to aid you in your investigations.
You will observe the size, strength, as compared with the heart’s impulse (which never overlook), rhythm, its quickness or slowness, the duration of the movement of the artery under the finger, etc.
Frequency of the pulse, although important as representing the general condition of the circulation, and the state of the vital forces, has no special significance as regards valvular disease.
In mitral lesions attended by regurgitation, the size and strength of the pulse are diminished in proportion to the quantity of blood driven backward by the systolic contraction of the left ventricle, into the left auricle. This weakness and smallness of the pulse are in contrast with the impulse of the heart, as felt by the hand applied over the praecordia, provided the ventricle be hypertrophied and the action of the heart vigorous. The pulse may be regular, but often, in an advanced stage of the affection, its rhythm is disturbed; it becomes irregular or intermitting. Variation of successive beats as respects size, force, etc., is frequently observed, although it is less characteristic of mitral regurgitant lesions than of those attended by obstruction. The frequency of the pulse in this, as in the other varieties of valvular lesions, depends on the vital condition of the heart.
In case of mitral regurgitation, the pulse is rendered small and weak by the deduction of the blood which regurgitates from the quantity which would otherwise be propelled into the aorta with each systole.
Mitral contraction, when extreme, renders the pulse not only small and weak, but often irregular, intermitting and unequal. When from any cause the supply of blood preceding the ventricular systole is less than usual, the pulse, which represents the systole of the left ventricle, is unusually small and weak. Under these circumstances the heart acts with irregularity. Intermittency of the pulse may represent intermittency of the heart’s action, but it is sometimes observed where there is not a corresponding interruption in the heart’s action.
Intermittency of the pulse is a peculiarity of the circulation in some persons. It is not, therefore, intrinsically a symptom of disease. Weakness, smallness, and irregularity, as well as Intermittency, and even inequality, it is to be borne in mind, are not distinctive of mitral or other valvular lesions. All may occur in functional disorder of the heart. A distinguishing point pertaining to functional disorders is, they occur only during paroxysms of palpitation presenting the distinctive features of palpitation from nervous disorder, whereas, occurring in connection with valvular lesions, they are either constant or frequently recurring, and unattended by the feature which distinguish functional palpitation.
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.