Dyspnoea is a symptom more or less prominent in the great majority of cases. It occurs earlier and is more marked in cases of mitral than aortic lesions, because the former tend more directly, and in a greater degree, to engorgement of the pulmonary vessels. In most cases of either mitral obstruction or regurgitation, dyspnoea is the first symptom which occasions inconvenience. The patient often complains of this symptom alone, or chiefly, for a considerable period. In cases of aortic lesions it occurs later, and is oftener preceded by palpitation or other symptoms, referred by the patient to the heart.
The intensity of dyspnoea varies greatly in the different cases of valvular affections in which this symptom is present, and in the same cases at different periods. It consists, at first, of a slight deficiency of breath on exertion. This progressively increases until active exercise becomes insupportable. Other cases are characterized by paroxysms of difficult breathing when not provoked by exercise, and by more or less difficulty which is constant. Affections of the pulmonary organs, super-added to congestion, contribute to increase the amount of dyspnoea. This dyspnoea has been designated as orthopnoea when extreme, and also as cardiac asthma.
Cough and expectoration are usually present when valvular lesions have induced considerable pulmonary engorgement. The expectoration is muco-serous in its character. The prominence of the cough and the character which the expectoration presents will serve to indicate, on the one hand, merely congestion of the bronchial membrane, or, on the other hand, a superinduced pulmonary affection.
Haemoptysis is a system which occurs in a pretty large proportion of cases of valvular lesions attended with a marked degree of engorgement of the lungs.
Haemorrhagic extravasation, pneumorrhagia, or pulmonary apoplexy, involves the same pathological explanation as haemoptysis, but occurs much more frequently than the latter. It is an occasional effect of engorgement. In most of the cases in which it occurs there exists mitral contraction.
Haemoptysis and haemorrhagic extravasation occasionally co- exist.
Pulmonary oedema is another pathological effect attributable directly to over-distension of the vessels of the lungs. This event takes place much more frequently than extravasation of blood. Occurring alone, or irrespective of dropsical effusion elsewhere, it belongs among the events incident to an advanced stage of valvular lesion. As a rule, whenever events of importance referable to the respiratory system become developed, valvular lesions have existed for a considerable length of time, and have led to more or less enlargement of the heart. Certain pulmonary affections, not due directly or exclusively to the congestion proceeding from valvular lesions, are more apt to occur under these circumstances than if the latter did not exist. The lesions thus indirectly predispose to the development of these affections. Emphysema of the lungs is one of these affections.
The congested state of the bronchial mucous membrane renders it prone to inflammation. Bronchitis is a frequent complication of valvular lesions after they have induced pulmonary engorgement. This complication developed when the lungs are already congested, in connection with cardiac lesions, dyspnoea becomes more or less prominent. The co-existence of bronchitis not only adds to the distress incident to valvular lesions, which interfere with the pulmonary circulation, but, if severe or extensive, often places the patient in immediate danger – the accumulation of mucus within the bronchial tubes, together with the diminished calibre of the tubes from swelling of the membrane, inducing suffocation.
Dropsical effusion into the pleural sacs rarely occurs to much extent independently of general dropsy. When it does take place, the compression of the lungs by the effused liquid abridges their functional capacity, aggravates the dyspnoea, and hasten a fatal issue.
SYMPTOMS AND PATHOLOGICAL EFFECTS REFERABLE TO THE NERVOUS SYSTEM.
It is a common impression that various symptoms denoting cerebral disorder, such as cephalalgia, vertigo, tinnitus aurium, muscae volitantes, etc., etc., are usually observed, sooner or later, during the progress of cardiac disease. These symptoms are often observed in persons not affected with disease of the heart, and hence would possess small diagnostic significance were they more frequently present; but, the truth is, they occur in only a small proportion of cases, at least in a marked degree.
Valvular lesions, accompanied by enlargement of the heart, have been supposed to involve a strong liability to apoplexy. We may conclude that apoplexy is very rarely due, distinctly or exclusively, to the condition of the heart, but that the changes which the cerebral vessels undergo, or other circumstances, generally play an important part in its production. And of the two conditions which tend directly to affect the circulation in the brain, namely, obstruction at the right side of the heart, and hypertrophy of the left ventricle, the former must be considered as most likely to lead to serious results.
Apoplexy occurring in connection with cardiac lesions, generally depends on extravasation of blood. Under these circumstances, paralysis of course ensues; if the apoplectic attack do not prove suddenly fatal, the patient is found to be hemiplegic. Vegetations, or masses of fibrin from within the cavities of the left side of the heart, being detached, are liable to become fixed in an artery of the brain, and give rise to apoplectic seizures with hemiplegia, or to the latter without the former.
Arterial obstruction gives rise to apoplectic phenomena and paralysis, by lessening the supply of blood to certain portions of the cerebral substance.
Aside from apoplexy and paralysis, various symptoms already mentioned, namely, pain, vertigo, tinnitus, etc., are occasionally associated with valvular lesions. Apoplexy and paralysis, depending either on an extravasation which involves a morbid condition of the cerebral vessels or an arterial obstruction from emboli, are usually not preceded by premonitions referable to the brain. This is a practical point to be borne in mind, in order that needless apprehension be not entertained on the part of physician or patient, and measures employed with a view of warding off an attack of apoplexy or paralysis, which, being uncalled for, will be likely to be not only unnecessary but injudicious. In the cases in which there is of necessity more or less cerebral congestion, the superficial veins of the neck being swelled or pulsating, marked cerebral symptoms are by no means uniformly present. Headache, dullness of the intellect, listlessness, drowsiness, etc., are symptoms which, in a certain proportion of cases of this description, are more or less marked, and are probably due to abnormal fullness of the cerebral veins. These symptoms of cerebral oppression are sometimes marked in cases in which, either from obstruction of the right side of the heart, or imperfect oxygenation of the blood, the prolabia and surface of the body present a livid appearance.
The sleep of patient affected with cardiac disease is frequently imperfect. They complain often of frightful dreams. This is generally associated with dyspnoea, and appears to be owing to disturbed respiration rather than to disordered cerebral circulation. Moaning in sleep is a symptom observed in some cases when the patient is not wakeful nor conscious of any morbid sensations.
A symptom which may be included among the events referable either to the nervous or respiratory system, is noticed in some cases, namely, a choking sensation analogous to that experienced in painful emotions when an effort is made to refrain from weeping. The mental condition of patients affected with organic disease of the heart may be noticed in this connection. The contrast presented, in this respect, with patients affected with merely functional disorder, has been already referred to. Persons with organic disease which has given rise to grave symptoms, such as palpitation, dyspnoea, dropsy, etc., are generally free from excitement and apprehension. They often seem to be remarkably indifferent or apathetic.
SYMPTOMS AND PATHOLOGICAL EFFECTS REFERABLE TO THE DIGESTIVE SYSTEM AND NUTRITION.
The phenomena manifested in connection with the digestive apparatus, in cases of valvular lesions, proceed from congestion of the systemic venous system. Assuming the lesions to be either mitral or aortic, or both, congestion of this order of vessels depends on the effects of these lesions on the right side of the heart. It may be stated that, as a rule, the systemic congestion is not sufficient to give rise to important symptoms or pathological effects until dilatation of the right ventricle has taken place, involving over-distension of the right auricle, and, in certain cases, tricuspid regurgitation. The impediment to the free admission of blood from the venae cavae into the right auricle, occasions cerebral congestion, as has just been seen. The congestion throughout the body thus induced, as has also been seen, gives rise to venous turgescence and general dropsy. The abdominal viscera indirectly participate in the effects of this impediment at the right ventricle, owing to their vascular relations to the venae cavae being through the intervention of the portal system. In view of the anatomical peculiarities of the latter, it is obvious that, of the organs comprising the abdominal viscera, the liver is first affected by an obstruction at the right side of the heart. The pressure of the portal branches on the biliary tubes may occasion an undue accumulation of bile in the latter. (Flint.)
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.