Treatment of Valvular Disease.

In no class of diseases is it of greater importance that the best of judgment and careful discrimination be exercised than in the treatment of valvular lesions. So intricate is the mechanism of the heart and its valvular control that medicine administered without discrimination can do harm. It is a common fault among prescribers to administer cardiac stimulants without regard to existing conditions. These can readily disturb the compensation and without doubt have contributed to its rupture. On the other hand, heart sedatives, while among our most important remedies, if not judiciously applied, may readily be made td exercise a harmful depressing influence.

During the stage in which there is sufficient compensation the treatment will necessarily differ from that of the stage in which compensation is lost. In either case it must be borne in mind that the treatment of heart disease should be constitutional in all its bearings. As constitutional conditions depend upon the heart for the perfection of all operations within the body, so inversely, disease of the heart is influenced by a perfection of constitutional conditions, and a normal performance of organic functional operation.

The first consideration in the treatment is rest. This is insisted upon by all authorities. While persistent, unremitting physical labor results directly in heart lesions, there is no doubt that disease of this organ is perhaps often more common among brain workers than among those who exercise persistent physical activity. Not only does brain work throw a great strain upon the heart muscle and on its arteries, but those who engage in severe mental labor neglect physical exercise, and consequently there is an improper balance between the nerve exhaustion and the proper exercise of physical force, resulting in progressive general physical debility. Rest, therefore, not only of the muscular system, but of the brain and nervous system as well, is of the utmost importance. A plan of life should be laid out for the patient in which there should be a fixed number of hours spent in bed, with an equally exact time for quiet, unexciting, out-of-door exercise, except when there is disturbance of the compensation of a serious character, in which the patient must remain in a recumbent position for days at a time. In cases where there is sufficient compensation the patient may be engaged in some pleasant employment which occupies the mind, but is not at all fatiguing to the body. He must avoid places of amusement which will produce excitement and must avoid anxiety, and especially anger, and must follow a somewhat "hum drum" course of life continuously. Under no consideration should active exercise, such as lifting, carrying, stair climbing or bicycle riding be indulged in, and the use of tobacco and stimulants must be sedulously avoided.

On the other hand, a protracted existence in the open air, and exposure to sun light are of direct benefit. These conduce to a good appetite, to cheerful spirits and to perfect sleep, all of which are of vital importance. These statements are especially true because the tunics of the heart and of its valves are easily influenced by defective nutrition, consequently the highest degree of nutrition must he maintained with the least possible effort on the part of the digestive and assimilative organs. Anemia not only results in influencing most materially the character of the heart tone, but it prevents oxygenation of the blood, and thus increases the essential work of the heart. In selecting any remedial agent, therefore, it must be borne in mind that nothing must be given which will in any way disturb the action of the stomach or intestinal tract. This is an important consideration in selecting digitalis as a remedy, because, while it is of value in many conditions, it often is not well borne by the stomach. These facts emphasize the statement previously made that all existing conditions of the system, or of organs other than the heart, must receive the most careful attention when adjusting a plan of treatment of valvular lesions.

Inasmuch as a large proportion of heart troubles depend upon the extent of those conditions which induce rheumatism it is of vital importance that rheumatic tendencies of all kinds be overcome entirely by the best selected methods. This can be accomplished in part by careful elimination and by the adjustment of a proper diet. In a large number of cases the exclusion of nitrogenous food will materially assist in eradicating the condition. Tea, coffee and tobacco must be excluded, as well as the use of alcoholic liquors, and cocoa also, with many patients, is injurious. In other cases a careful selection of meat diet and albuminous food is necessary, to the exclusion of starchy principles. Each case must be studied separately to determine a proper food adjustment.

As routine treatment we are safe in prescribing hydrastis, nux vomica and iron during a prolonged period. The result of the action of these three remedies is both direct and indirect restoration of the red blood corpuscles, and restoration of the highest degree of functional activity on the part of the gastric and intestinal glands, and of the large glandular organs. This greatly improves the tone of the nervous system and encourages the exercise of the best possible nervous influence upon all organs. In giving nux vomica the agent must be given in small doses, and when any irritation of the nervous system appears it should be discontinued for a short period or until it will not act as an excitant. Hydrastis is always acceptable. It may be given either in the form of a powder, which is desirable when the coats of the stomach are diseased; or as colorless hydrastis when there is evidence of weakness of the arteries or veins; in the form of a heavy fluid extract when the muscular system is out of tone, and the alkaloid hydrastin or berberin should be given when the remedy is required for its direct influence upon the central nervous system. In selecting a preparation of iron, I have for many years prescribed the ethereal tincture of the perchlorid, made according to the German Pharmacopoeia. I give this in doses of from two to eight minims, three, four or five times a day, diluted with water. I have had opportunity to compare this with our own tincture of the perchlorid and have in every instance decided that I obtained the best results from the German tincture. Other remedies with which to accomplish the result of those above named are the bisulphate of quinine in small doses, or an elixir of the calisaya and iron, and phosphorus. To this list could be well added collinsonia, avena sativa, gentian, colombo and occasionally cimicifuga and the arsenate of strychnine. When the function of digestion is greatly impaired, artificial digestives must be used with all food, and cod liver oil and malt preparations may be prescribed in selected cases to advantage.

In treating the conditions existing with the heart lesions each should, if possible, be considered separately. There is a class of cases—those of the diseases of the mitral and tricuspid valves, in which there is marked pulmonary congestion. Congestion also occurs in other heart faults, where the tension is low and where the capillary circulation is impeded. In these cases belladonna is a remedy of much importance. It should not be given continuously for weeks, but may be given for perhaps seven days and then discontinued for two or three days, to be prescribed again for a similar period and again to be discontinued. The doses should be small and its marked physiological influence upon the secretions should be avoided. Congestion of the liver and of the gastro-intestinal mucous membranes, which is common at this time, is directly antagonized by this remedy, which, if given with hydrastis and nux vomica, above referred to, promotes other influences which greatly enlarge their field.

It is often necessary to treat the liver directly. I have found, as a result of congestion of this organ, a diffused tenderness over its entire area, with small, quick, sharp, cutting pains. These indicate the use of bryonia, and it is surprising how quickly its influence will be observed. At other times stagnant portal circulation, with deficient excretion of bile, as shown by a slight jaundice and constipation, with clay-colored feces when passect, may be met with leptandrin, iris, chionanthus, euonymus or chelidonium as the indicated remedies. At other times sodium phosphate alone, in hot water, four or five times a day, will be of great service, or this salt and the bitartrate of potassium will be of service if there are evidences of excessive acidity. General symptoms may not appear until just before or attending an immediate rupture of compensation. At this time more active medication will be demanded. Belladonna, however, will meet many of the indications, as it is a mild stimulant to the capillary circulation, and sedative to heart irritability, while it overcomes congestion.

Perhaps no remedy in the treatment of valvular disease has had more attention than digitalis. It has been thoroughly studied, until its action is well understood. It is to be regretted that other of our heart remedies have not been as thoroughly studied. However, opportunity has not yet presented with several of them, as they are comparatively new. Digitalis, fortunately, acts to a better advantage when combined with the tonics which we have just named, and more particularly with iron. Its influence is slow, not pronounced in tonic properties until it has long been given, and as there is danger of cumulative influence it must be given in small doses, frequently repeated. From three to five drops of the tincture, every three or four hours, will be sufficient. This influence should be watched, for it diminishes the number of heart beats, increases the 'force of the pulsation and increases also arterial tension; at the same time it augments the urinary discharge. It conduces to a filling of the coronary arteries, and if there is a progressive improvement in the character of the blood, this improves the tone of the heart muscle. It must be remembered, however, that this agent increases the irritability of the febrillae of the heart muscle, and this condition at times is undesirable. If a pronounced action upon the kidneys is desired the remedy must be given in infusion. In dropsical conditions, when extreme excretion is desired, it is best to undertake this result through one set of emunctories only at a time. It is not desirable to stimulate the skin or kidneys and the intestinal tract at once. In fact, it is difficult to obtain simultaneously a free action from the kidneys and the skin. The free action of digitalis upon the kidneys has been accomplished by applying a poultice of digitalis leaves steeped in hot water, across the loins. The profound stimulating influence produced by large doses of digitalis upon a very feeble heart has resulted in sudden death a number of times when the patient, after having been lying down, would rise quickly to a sitting posture. The heart has not been able to quickly adjust itself to the changed conditions. There is dizziness, rapid and feeble pulse, difficulty of breathing and cyanosis. If, during the use of this remedy, these symptoms occur, with headache, vertigo and distorted vision, the remedy must be immediately discontinued. In aortic stenosis digitalis is positively contra-indicated.

The action of cimicifuga upon the heart is similar to that of digitalis when the cause of the disorder is in the muscular structure of the heart or when it results from a rheumatic diathesis. It removes the causes of the disease, improves the tone of the heart muscle, encourages nutrition and acts as a sedative to any existing nervous irritability. It is of value also in angina pectoris and in functional irregularity of the heart, where there is marked irritability. In the early stages of valvular disease, with no apparent heart weakness, the irritability will be relieved by the action of this remedy given in conjunction with gelsemium.

The action of cactus grandiflorus in this class of diseases we believe to be in many ways superior to that of digitalis. This remedy increases the musculo-motor energy of the heart, elevates arterial tension, increasing the height and force of the pulse wave. This is accomplished by increased heart action through stimulation of the vasomotor centers and stimulation of the spinalmotor centers. It increases their activity by improving the general nerve tone. It is the heart tonic par excellence, as it produces stimulation from increased nerve tone in the heart through improved nutrition of the entire nervous and muscular structure of that organ. It produces no irritation of the heart muscle like strophanthus, nor gastric irritation or cumulation like digitalis. It also exercises a direct influence over the sympathetic nervous system, regulating its action, restoring normal action, whatever the perversion, and acting directly upon the cardiac plexus, it regulates the functional operations of the heart.

Investigations have proven that this remedy increases the contractile power and energy of the heart muscle through the intercardiac ganglia and accelerator nerves. It certainly improves the nutrition of the heart, as we have noticed the entire removal of progressive valvular murmurs after its continued use. It will thus be seen that it is indicated in a larger proportion of valvular disease and seldom contra-indicated. It may be prescribed with confidence whenever the heart muscle is enfeebled and whenever there is a progressive valvular insufficiency, with irregular, intermittent, feeble pulse, and in any form of regurgitation. It is of wider value than digitalis, as it also materially assists in the restoration of the nervous system and in the improvement of the nervous tone. The remedy need not be given in large doses usually. From two to five drops of specific cactus every three or four hours will be sufficient ordinarily, yet, in an occasional case of extreme weakness of the heart muscle, from ten to thirty minims may be given with impunity, as no toxic properties have as yet been observed.

Strophanthus is given as a remedy for valvular disorders when there are disturbances of compensation. Its influence, however, is narrower than that of either digitalis or cactus. There is good authority for believing that it acts by contact upon the heart muscle, producing muscular contraction by irritation of the muscular fibrilUe. It dees not influence the vascular system to any great degree. It does not greatly improve the tone of the heart, or of the nervous system. This explains its limitations. Vacci claimed that strophanthus materially assists in the appropriation of iron. This, if true, would be an important influence in those cases accompanied with extreme anemia.

Germain-Sée mentioned the following influence of convallaria majalis in valvular disease. In mitral constriction, especially when it is accompanied by failure of compensation on the part of the left auricle and right ventricle, the contractile force augments visibly under the convallaria, as the sphygmograph testifies. In mitral insufficiency, especially where there are pulmonary congestions, and when, as a consequence, there is dyspnoea, with or without respiratory neuroses, and also in dilatation of the left ventricle, without compensatory hypertrophy, it restores energy of the heart, which tends to 'become more and more feeble and dilated. In dilatations of the heart, with or without fatty degeneration, with or without sclerosis of muscular tissue, the indications for convallaria are clear. In all cardiac affections indifferently, from the moment that watery infiltrations appear, convallaria has an action evident, prompt and certain.

Lycopus has a field in this class of troubles that is important, although limited. It tranquillizes the action of the heart, removes irritability and promotes normal capillary activity throughout the entire respiratory apparatus. This is especially important when in mitral or tricuspid stenosis the marked pulmonary congestion results in hemoptysis, with more or less cough. It has no depressing influence, but rather promotes the tone of the heart muscle.

Caffeine is of importance when from failure of compensation immediate exhaustion is threatened. It stimulates the heart without irritation, overcoming depression from any cause, and encouraging a smoothness of action. It is indicated where extreme feebleness results from dilatation in the presence of valvular insufficiency or fatty degeneration. It is an important remedy in proper combination in certain cases of dropsy.

A remedy of great importance in valvular insufficiency is apocynum. It has been given when strophanthus and convallaria had failed. It acts similarly to digitalis and enhances the influence of cactus in dropsical conditions. It promotes actively the removal of pericardial effusions and increases the tone of the heart muscle. It will often cure extreme cases of dropsy which depend upon valvular disorders. Its influence must be carefully studied. In the ordinary preparations it occasionally irritates the stomach and intestinal tract, except when given in very small doses, but the distilled extract is perhaps fully as efficient as any other form and does not produce irritation.

Crataegus oxyacantha was brought before the profession a few years ago as a remedy for atheromatous conditions and valvular troubles resulting therefrom. While a few startling results have been announced in pronounced cases, even where there was failure of compensation, there are other similar cases in which the remedy has been prescribed by a number of physicians with no marked results. I have obtained the best results from this remedy, in that class of cases where, from violent exercise, from prolonged exhausting overwork, or nervous shock, sudden or acute neurasthenia had occurred, and from which evidences of heart weakness, with perhaps some dilatation, accompanied with severe dyspnoea on any exertion, was accompanied with regurgitant murmurs. In these cases the influence of the remedy was pronounced, all heart sounds disappearing after using it for a few weeks. Nerve tonics, however, were given conjointly and rest was enjoined with concentrated nutrition.

The dropsy resulting from valvular insufficiency, or from heart disorder, must be directly combated. In addition to the use of apocynum we have a number of other remedies which are efficacious, but which do not, like apocynum, act directly upon the heart. Among these are haircap moss, birch leaves, sourwood leaves, as well as the well-known hydragogue cathartics, such as elaterium, magnesium sulphate and potassium bitartrate. These may be selected with reference to other and more exact action, and the dosage should be adjusted to the patient. In some cases large, active doses only will be beneficial, while in weak and more prostrate cases small doses, frequently repeated, will often accomplish a more desirable result.

Massage and proper muscular movements are advantageous in the treatment of valvular disease. These all are conducted with reference to encouraging the movement of the blood through the veins and promoting a free return of the blood into the right auricle, in order to relieve as much as possible the strain upon the muscular structure of the heart. The benefit in such a case is sometimes pronounced from the first. This idea has received considerable attention at times and a number of systems have been evolved, a knowledge of which may be readily acquired and easily applied. So serious are these lesions and of such vital import, that not only direct treatment must be used, but every auxiliary measure possible must be adjusted to each case.

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