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Endocarditis, Acute.

Problems:

Synonyms:—Simple or benign endocarditis; verrucose endocarditis; papillary endocarditis.

Definition:—An acute inflammation of the membrane which lines the heart, but usually affecting the covering to the valves only, in which case it is designated as valvular endocarditis. If it attacks the membrane which covers the walls of the cavities only it is called mural endocarditis. Attacking both, it may be called valvulo-mural or general endocarditis.

Etiology:—No specific micro-organism has as yet been discovered as the invariable cause of this disease. In the vegetations that result from its progress the usual pyogenic organisms, with those found present in rheumatism, typhoid fever, influenza, pneumonia and tuberculosis, have been found present. Rheumatism is the most common cause of the disease. Thirty-five per cent of the cases in adults, and from sixty-five to seventy-five per cent in childhood are induced by this disease.

The severity of this disease is not always in proportion to the severity of the attack of rheumatism, a severe case of which may present no endocardial symptoms, while a very mild attack may be followed by severe and even fatal endocarditis.

As rheumatism seems to be associated with tonsilitis, so this disease may follow tonsilitis, even when rheumatic symptoms are not conspicuous. The disease is a common complication of all the eruptive fevers, especially of measles and scarlet fever, also of diphtheria, typhoid fever and specific fevers. It will follow local inflammation of the other structures within the thorax, as pneumonitis, pleuritis and pericarditis and myocarditis. The disease is also associated with certain nervous disturbance, notably with chorea. In this case the evidences of valvular disease are often present, existing in perhaps one-third of the protracted cases, and as it is not uncommon for chorea to be associated with a rheumatic diathesis the endocardial disease may have been caused by the rheumatism also.

Symptomatology:—The subjective symptoms of this disease are not distinctly marked. If fever has been present there will be an increase of temperature and the pulse will become more rapid, small and compressible. Pain over the heart is seldom present, but the patient may complain of pain in the left shoulder and arm. In any disease which may be followed by heart complications this symptom should be regarded with suspicion, and the heart should be subjected to the closest scrutiny and the patient should be kept very quiet. As the disease progresses, if the patient is moving around or at all active, palpitation, difficult breathing and perhaps some conspicuous evidences of heart weakness will soon appear.

While mitral or aortic murmurs do not prove the presence of endocarditis, their presence with the above named symptoms is a suspicious indication, although there are mild cases in which there are no valvular sounds, especially in the mural form of the disease.

While the pulse is usually more rapid and feeble, the heart impulse is increased, as may be readily seen upon inspection of the chest walls. Later, if the disease involves the myocardium, the impulse will be greatly lessened. There is no increase of the area of heart dulness, unless from the progress of the disease there is dilatation.

Upon auscultation it will be found that the heart sound is considerably prolonged, especially if rheumatism is the exciting cause of the disorder, and the systolic murmur over the mitral valve is mild and blowing in character. With these mitral sounds there may be a distinct regurgitative murmur over the aortic orifice, but in an occasional case only.

Diagnosis:—There are no pathognomonic phenomena that point unmistakably to this disease; the diagnosis must depend upon the presence or absence of the symptoms above named. A knowledge of pre-existing conditions which may cause the disease, and of the fact that endocarditis is by far the most frequent of heart complications of other acute disorders, will suggest its probable presence when heart symptoms appear. A sudden rise of the temperature, with valvular murmurs, not previously observed, are the symptoms to be depended upon.

Prognosis:—Except when ulceration occurs or unless this disease depends upon the previous existence of some serious malady, death seldom occurs as an immediate result. The disease, however, quickly becomes chronic and the changes which are produced in the endocardium or in the valves it covers, and consequent interference with the normal functional action of the heart, will result in structural changes, which ultimately result in death.

Treatment:—When acute disease, especially rheumatism or the exanthemata exist, which may result in endocarditis, the utmost care should be exercised to prevent the occurrence of so serious a complication. As overtaxation of the heart will bring it on, all exercise of any kind should be prohibited, the patient should be kept quietly in bed, a mild transpiration from the skin should be encouraged and sudden cold, draught or anything that would even temporarily suppress the secretions must be sedulously guarded against. The bowels should be kept in a mildly soluble condition, free action from the kidneys should be maintained and acidity of the stomach and intestinal tract should be guarded against. It is the author's opinion that many of these cases can be prevented if close attention be paid to elimination, and no morbific matter be allowed to accumulate within the system, as there is no doubt that autotoxemia is a common underlying cause of the disease.

When the first symptoms of heart lesion occur, especially with children, the utmost quiet must be enjoined, as violent exertion may result seriously with these patients.

In selecting the remedies particularly adapted to the cure of this disorder the cause must be borne in mind as well as the fact that inflammatory process must be arrested without depression. If there is no marked asthenia a very excellent combination in the first stage is that of aconite and bryonia. These two remedies can be given conjointly, but in very small doses frequently repeated. They act directly upon the inflamed membrane, as they would upon the pericardium or upon the pleura. Asclepias and small doses of the potassium acetate may be given at the same time to promote elimination, which, as has been stated, is of the utmost importance. If the disease is a sequel of rheumatism bryonia is especially indicated and will serve a double purpose. The salicylate of sodium or lithium may be given with benefit at the same time, or these agents may be given alternately or even in combination in properly adjusted dosages in rheumatic cases. If, however, there is marked feebleness, as when the disease follows a severe case of scarlet fever, diphtheria or measles, a remedy must be given which will act as a sedative to the heart's action and temperature, and will yet increase the strength and power of the heart. Paradoxical as this may seem this can be readily done with cactus, or if effusion has taken place into other tissues, with apocynum, but these remedies will not act satisfactorily where there is a marked sthenic condition or temporary exaltation of the nerve force. If congestive phenomena elsewhere are present, belladonna may be combined with cactus most satisfactorily. The author treated a typical case of endocarditis in a young man twenty years of age who was recovering from double pneumonia, which in its turn had been induced by a severe protracted case of measles, with recession of the eruption. When called, the temperature had risen very suddenly, the difficulty of breathing was most distressing, the face was bloated and dusky, with pronounced cyanosis. The head was thrown back to facilitate the respiration, and the pulse was so rapid that it was impossible to count it. Death seemed imminent. Hot applications were immediately applied to the chest, and a mixture of ten minims of the fluid extract of belladonna with thirty minims of cactus in four ounces of water was prepared and administered every half hour or hour. The result of this simple treatment, which on the author's part was something of an experiment at that time, seemed almost miraculous. When the next call was made fourteen hours later, the precordial oppression was relieved, the pulse was beating regularly at one hundred and twenty, soft and full, the bloated and discolored condition of the face had disappeared and the respiration was comparatively easy. This plan of treatment was persisted in with subsequent use of other remedies, as suggested, and although convalescence was greatly protracted, the patient ultimately recovered.

If the condition progresses favorably and the temperature abates, the heart may be supported by remedies that influence the nerve centers without irritating the heart muscle. These are avena sativa, the strychnin arsenate and hydrastis canadensis, which at the same time improves the gastro-intestinal functions, promoting the appropriation of food and encouraging general nutrition. Digitalis and strophanthus should not be given, as their influence is largely upon the fibrillae of the heart muscle, acting as irritants rather than exercising a soothing and nutritional influence.

The indications for treatment, further than those just named, will be similar to the indications in pericarditis, and should be met with the same remedies. There are times when counter-irritation should be advantageous, but this is only auxiliary. For anemia and subsequent prostration judiciously selected tonics should be administered, and food should be selected with the utmost care, that will be easily digested and readily appropriated.


The Eclectic Practice of Medicine with especial reference to The Treatment of Disease, 1910, was written by Finley Ellingwood, M.D.



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