Combined Valvular Lesions.

In the majority of all cases of valvular diseases, combined murmurs or lesions occur after a few months or years. When a valve or orifice becomes affected, increased work is thrown upon some other part, and this naturally brings about additional changes. There may be a double lesion of a single valve, as stenosis and insufficiency; or there may be a single or double lesion of two or more valves. The combination most frequently found is mitral regurgitation with aortic regurgitation and obstruction. Mitral stenosis with regurgitation comes next in order, other combinations being of rarer occurrence.

Many of these combinations are compensatory in character, and really prove beneficial to the patient, being the only way nature has of coming to the rescue and preventing a fatal issue. A positive ante-mortem diagnosis is many times impossible, owing to a combination of murmurs and thrills, though generally some one murmur is more prominent and distinct, directing attention to the chief lesion, and associated murmurs will suggest the additional wrongs.

The state of the auricles and ventricles will be determined by the amount of hypertrophy and dilatation.

Prognosis in Chronic Valvular Diseases.—In making a prognosis, several factors are to be taken into consideration, such as age, sex, constitutional vices or defects, previous diseases, parts affected, etc. We are to remember that valvular diseases of the heart do not necessarily mean either a sudden or early death, many patients having lived to a good age and having died from some other disease, the cardiac lesion having been discovered during an autopsy.

When a patient is able to lead a quiet life, avoiding any severe exertion or strain upon the heart, and anything that would give rise to great emotional excitement, the valve lesion should not materially shorten life.

When the nutrition of the heart begins to fail and compensation is disturbed and overcome, the prognosis is unfavorable, as death occurs sooner or later.

Osler says: '"When the apex beat is in the normal situation and the rhythm is regular, the ausculatory phenomena may be practically disregarded."

Valvular lesions in children are more unfavorable than when occurring later in life.

The fact that women do not lead such strenuous lives as men makes the prognosis more favorable for the fair sex.

Valves Affected.—Aortic insufficiency is the most serious, while mitral insufficiency is the most favorable.

Previous Diseases.—Infectious fevers, where they have been of a malignant character, predispose to more serious lesions, than where there has been an entire absence of infection. Acute rheumatism, followed bv the chronic form, also makes the lesion more serious. Tuberculosis, Bright's disease, and kindred lesions also render the disease unfavorable.

Treatment of Valvular Lesions.—There is no class of diseases that needs a more careful study with reference to treatment than chronic heart diseases. Recognizing some of the most prominent and common causes that lead to valvular lesion, the physician may, if thoughtful, either prevent or lessen their severity. Prophylaxis, then, will be first considered.

If there is a family history of heart disease, it is incumbent on the physician to outline a course of living that will not overtax the heart. While the patient should live in the open air and take well-directed exercise, any labor or exertion that would produce undue strain should be forbidden. The use of tobacco and alcohol should be absolutely restricted, and high altitudes avoided.

If rheumatism attacks such patients, great care should be taken during convalescence to prevent cold, and not overtax the heart. The patient should rest in bed for a week or two after all evidence of rheumatism has disappeared. The same precautions should be taken following the infectious fevers.

In the selection of medicines great care should be taken to select the right remedy. There is no better field for the display of specific medication than in heart troubles, and I think there can be little doubt that many cardiac affections have failed to recover because the right remedy was not selected.

Digitalis has been the David selected to slay this Goliath of disease, and he is marched to the front for all cardiac diseases. The remedy certainly is a good one in some cases, but to expect one remedy to act as a stimulant in one case, sedative in another, tonic in a third, and, in fact, correct every diseased condition the heart is subject to, is certainly asking too much of it. Yet the almost universal treatment as soon as a diagnosis has been made is digitalis. The selection of the right remedy will be determined somewhat upon the stage of the disease, whether it is the period of compensation or non-compensation.

Stage of Compensation.—Unless of a very nervous or excitable temperament, the patient should be made to understand his true condition, that he may the more readily carry out the restrictions placed upon him; namely, to avoid severe physical exertion and great mental excitement, and to abstain from the use of coffee, tea, spirits, and tobacco, to avoid overloading the stomach, and to observe regular habits.

In some cases there is excessive force or power of the heart, as shown by the full, bounding pulse. This excess in power, if not overcome, will hasten the period of non-compensation, and should be controlled.

Veratrum acts nicely in such cases, but its action must be carefully watched, and as soon as the pulse begins to come under its influence, lessen the dose. The indication is the full, bounding' pulse.

Crataegus Oxyacantha.—This remedy has recently been very highly extolled in valvular troubles, some even claiming for the remedy wonderful solvent power in crustaceous and calcareous deposits on valves and in the lumen of arteries. While these claims no doubt are extravagant, it undoubtedly is a very good remedy in improving cardiac functions, and does lessen valvular deposits. It does not overstimulate, and thus is highly beneficial during this stage. It should be given in from three to ten drop doses.

Cactus, when given in the small dose, is also a good remedy during this period, assisting to maintain the tone of the organ. Care must be taken not to overstimulate the heart and thus hasten its exhaustion, which is followed by dilatation. Whatever remedy is used, too early results must not be expected, but the remedy should be given a fair trial.

The diet should receive special consideration. Nourishing but easily digested food should be taken in moderate quantities. Fluids should be restricted to the smallest quantity compatible with health.

Stage of Non-Compensation.—This stage is recognized by dyspnea, nocturnal seizures of shortness of breath, and irregular action of the heart. It is the evidence of heart exhaustion to be followed by dilatation. Perfect rest in bed is of absolute necessity, the patient occupying the recumbent position. This measure alone will prove greatly beneficial, and may for a short time restore compensation. The diet should be nutritious and highly concentrated, and given in liberal quantities. All excitement is to be avoided; hence unnecessary conversation should be prohibited.

Digitalis.—As a stimulant to the overburdened heart, digitalis will be found one of the best remedies. It rests the heart by prolonging the asystole, thus allowing the chambers to become better filled with blood. When dropsy is present, an infusion of the leaves, one or two drams to eight ounces of boiling water, of which one tablespoonful may be given every two hours, will give speedy results. It adds tone to the heart, and at the same time stimulates the kidneys.

Cactus may also be used during this stage as a heart-tonic. Convallaria and strophanthus have a similar action to digitalis, and are not so apt to disturb the stomach.

Apocynum will be very useful when dropsy is present for it not only adds tone to the weakened heart, but stimulates the kidneys and bowels to increased action, thus relieving the distended blood-vessels. Under its administration the dyspnea is greatly relieved. Should rheumatism be present, the anti-rheumatics, bryonia, macrotys, rhamnus Californica, apocynum, etc., should be given according to indications.

Carduus Marianus is highly extolled by the homeopaths, especially where the liver is involved, and should be tested.

Gastric complications will be relieved by nux vomica, rhus tox., bismuth, and mint-water, and by regulating the quantity of nourishment taken. The bowels should not be allowed to become constipated. Hepatic congestion may be somewhat relieved by uvedalia, leptandra, Podophyllin, and carduus marianus.

Should there be hemorrhage and expectoration, much relief may be experienced from it, and unless profuse, needs no attention. For the pain, which is sometimes very severe, crataegus, echinacea, and bryonia should be tried before resorting to morphia. When the patient is unable to sleep, passiflora may give the desired result, or trional in ten-grain doses may be given. The old diaphoretic powder, in five or ten-grain doses, often gives relief. When absolutely required, morphia may be given.

Should compensation be restored, the patient should be carefully watched and medicated for several months. In no case should the patient be allowed to undergo physical or mental strain. Light exercise in the open air, and a good, liberal, nourishing, but easily digested diet recommended. Change of climate to one, where there is the least call for expenditure of force, is to be advised.

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.