I have observed obstinate cases of jaundice in several cases of valvular disease of the heart.
Sections of the organ then present that peculiar aspect commonly known as the “nutmeg liver.”
Extending beyond the liver to the portal vein and its radicles, the congestion affects finally the stomach and intestines, the spleen and the pancreas. Congestion of these organs is a secondary effect due directly to the mechanical obstacle to the passage of blood through the liver.
The successive steps, then, in the series of congestive effects dependent on valvular lesions are: obstruction or regurgitation at either the mitral or aortic orifice, or at both situations; dilatation of the right ventricle, following engorgement of the pulmonary vessels; over-distension of the right auricle, with or without tricuspid regurgitation, involving an impediment to the free transmission of blood from the vena cavae; congestion of the hepatic veins and their radicles, the intralobular veins; congestion of the terminal branches of the portal vein; congestion of the vena portae and its radicles in the abdominal viscera, these vessels furnishing the blood for the portal circulation.
Enlargement of the liver is an occasional effect incident to valvular lesions, as well as to enlargement of the heart without these lesions.
Cirrhosis is not a frequent complication of valvular affections of the heart. The event denoting co-existing cirrhosis is hydroperitoneum in a degree disproportionate to the general dropsy.
There are many other disorders in a measure incident and common, such as dyspepsia, haemorrhage from the bowels, haemorrhoids, enlargement of the spleen, etc., which you can study at your leisure in the various works on diseases of the heart.
SYMPTOMS AND PATHOLOGICAL EFFECTS REFERABLE TO THE GENITO-URINARY SYSTEM.
The renal or emulgent veins terminating in the vena cava descendens, the kidneys must participate in the congestion of the systemic venous system arising from an impediment at the right side of the heart. These organs are affected more directly than the abdominal viscera, which are tributary to the portal vein. So soon as valvular lesions have led to the anatomical conditions involving an obstruction extending to the vena cavae and their branches, renal engorgement necessarily ensues. Congestion of these organs is generally observed in examinations after death in valvular disease accompanied by dilatation of the cavities of the right side of the heart. Venous congestion, under these circumstances, does not uniformly occasion a greater flow of urine than in health. Indeed, the quantity of urine is oftener diminished than increased, a fact going to show that the diuresis depends on the amount of blood conveyed to the kidneys by the arteries, or on conditions pertaining to the blood itself, rather than on accumulation in the renal veins. The urine is frequently scanty, even when the venous obstruction is sufficient to give rise to general dropsy. We may have albuminuria, owing to the mechanical pressure incident to venous congestion. It does not constitute evidence of structural changes of the kidney, or Bright’s disease, when it is in small quantity, transient in duration, and notably fluctuating. (Flint.)
Moreover, hyaline casts are wanting when albuminuria is only a symptom of disease of the heart, and the specific gravity of the urine, instead of being diminished, is usually increased.
The degenerations of structure included under the name Bright’s disease, are sometimes associated with valvular lesions of the heart.
The co-existence of structural degeneration of the kidney is shown, as already intimated, by the degree and constancy of the albuminuria, and by the different varieties of casts of the uriniferous tubes, which the sediment of the urine is found to contain when subjected to microscopical examination. The tendency to general dropsy is augmented by this complication; renal and cardiac dropsy are, in fact, combined. As regards the generative functions, Flint has observed, that in cases in which lesions had existed for a considerable period before puberty, the genital organs, including, in females, the mammary gland, attained to a full development.
SYMPTOMS AND PATHOLOGICAL EFFECTS REFERABLE TO THE COUNTENANCE AND EXTERNAL APPEARANCE OF THE BODY.
Lividity of the prolabia and face, which may apparent over the whole surface of the body, denotes either venous congestion or imperfect oxygenation of the blood. The latter is incident to the pathological effects taking place in the lungs; the former, to obstruction at the right side of the heart. But both conditions may be conjoined. A dusky hue of the face, combined with oedema, is quite distinctive of cardiac, as contrasted with renal, dropsy. I need not mention the painful expression of the countenance in a patient suffering from what is known as cardiac asthma. Dr. Hope gives a graphic picture of the terrible sufferings of such patients.
Some cases of valvular disease are characterized by pallor of the complexion. The co-existence of Bright’s disease is likely to lead to this effect. But it is observed in some instances when the kidneys are not affected. It then depends on alternations of the blood proceeding from other causes.
An anaemic condition is incident, in a certain proportion of cases, to cardiac disease uncomplicated with an affection of the kidneys. Analysis of the blood shows a notable deficiency of albumen, together with a reduction in the relative proportion of the blood corpuscles and fibrin.
The accumulation of blood in the right chambers of the heart induces, in addition to abnormal fullness of the superficial veins, a congestive state of the capillary vessels, causing the surface of the body to present an appearance like that produced by exposure to cold. The redness disappears on pressure, and returns, more or less slowly, after the pressure is removed. The appearance is not unlike that observed in typhus and typhoid fever, although the rationale is by no means the same.
Erythema, affecting portions of the surface, occurs in some cases not associated with oedema. The lower extremities are most apt to be affected. Flint met with an instance in which the extremities of the fingers and a portion of the palms presented permanently an erythematic redness. On the other hand, in a patient with considerable mitral regurgitation, the fingers at times were bloodless, being as pallid and cold as those of a corpse.
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.