managing the patient's mode of life. Cardiac tonics are not indicated and
are harmful. Fortunately we are getting beyond the time when the detection
of a cardiac murmiir was a signal for a prescription containing digitalis.
At present when the physician elicits the physical signs which lead him to
make the diagnosis of a chronic valvular defect he must decide whether or
not to tell the patient of his infirmity. The decision should be in the affir-
mative if the patient is of calm and steady mind and is leading a life preju-
dicial to the continuance of the compensated condition of his heart. If
the subject in hand is hysterical and his habits are such as are not damaging
to the cardiac condition it is better to let him continue in a state of blissful
ignorance; a member of the family or a near friend, however, should be
informed that heart disease is present. In certain instances, even in this
latter type of patient, when the habits of life must be regulated, it may become
necessary to appraise the individual of his condition even at the risk of render-
ing him hypochondriacal.
With regard to exercise during the stage of compensation no fixed rules
can be laid down but it may be stated in general that exercise which is not
followed by palpitation, dyspnoea and cardiac distress may be allowed, and
even may prove beneficial. The more violent forms of exercise should be
forbidden in mitral obstruction, but golf, slow bicycle riding, rowing in moder-
ation, bowling, etc., are allowable, while tennis, boxing, fencing, wrestling, run-
ning and the like should be tabooed. In young persons affected with aortic
insufficiency, the more strenuous varieties of exercise may be undertaken,
but only when the heart muscle is unaffected and the arterial system is in
good condition.
The occupations suitable for patients possessing valvular defects are of nec-
essity limited to those of sedentary type such as desk- work of the various kinds,
tailoring, shoe and harness making and the like. Aortic affections when
well compensated need not preclude the carpenter and machinist, when
heavy lifting is avoided, from continuing their avocations and out-door work of
light character may prove rather beneficial than otherwise. Professional life
such as that of the architect, designing engineer, newspaper worker, etc., may be
continued but the public speaking demanded in certain kinds of law practice
and of the clergyman is likely to put too great a strain upon the weakened
heart, as is the general practice of medicine; an office or consultation practice,
however, may be continued by the physician who is unfortunate enough to
possess a valvular lesion. Vocations which entail severe nervous strain are
quite as harmful as those which tax the muscular system.
Concerning habits it may be said that the use of alcohol is in most instances
harmful but there are patients whose custom it has been to take a moderate
amount of wine or beer with meals and in whom the appetite and digestion
576 DISEASES OF THE HEART AND BLOOD-VESSELS.
suffer if these are discontinued; to such we may allow the milder alcoholic
beverages in moderation, diminishing the amount as much as possible. To-
bacco in moderation may be indulged in if absolutely necessary to the patient's
comfort, but it is better if he can be persuaded to give it up entirely. Smoking
certainly can produce no benefit and may be productive of harm. With regard
to the mode of employment of the tobacco there is little to be said; it is the
amount of the drug which is taken which should be regulated. It makes
little difference whether the same quantity of tobacco is consumed in the
form of the cigar, the cigarette or in the pipe. Inhalation of the smoke is
especially harmful. Smoking, of course, shoiild be forbidden if it appears
to injure the patient.
While excessive indulgence in the sexual act is distinctly prejudicial, married
life and even the bearing of children need not, in many cases, be advised against.
Many women have passed through uneventful pregnancies and labors whose
heart valves have been far from normal. In general we may state that while
pregnancy is a grave consideration in compensated valvular disease it is by
no means always dangerous. Labor is, however, fraught with peril, particu-
larly when mitral lesions exist, and for its safe consummation depends upon
the character of the compensation. The physician is justified in advising
the artificial emptying of the uterus when danger of disturbance of the com-
pensation is imminent or this event has already taken place.
The clothing should be of weight adapted to the season of the year and
sufficiently warm to prevent chilling of the body. Woolen underclothing
is always to be advised and particular attention should be given to the extremi-
ties which should never be allowed to become cold or wet. Tight garments
especially the corset when laced so snugly as to constrict the waist to the
slightest degree, are harmful, and women should, if possible, be persuaded
to wear their skirts suspended from the shoulders.
The patients food should be properly cooked, easy of digestion and of
sufficient, but not too great quantity. Much liberty may be allowed in choos-
ing the dietary but regularity of meal times is important. With regard to
the different classes of foods it may be said that patients who engage in active
muscular exercise need more proteids than those who lead more sedentary
lives and that anaemic subjects should be fed liberally upon those articles
from which the organism may obtain iron.
Bathing shovdd not be indulged in to too great an extent and shoiild be
regulated in accordance with the reaction obtained. Hot tub baths often
have a weakening effect and for them daily sponging off of the body, with a
tepid tub once or twice a week, should be substituted. If the cool bath followed
by a brisk rubbing with a coarse towel is not followed by a healthy glow of
the skin and a sensation of stimulation it should not be allowed. Sea and
fresh water bathing influence the patient's condition both because of the shock
THE TREATMENT OF VALVULAR LESIONS. 577
caused by entering the usually cool water and through the exertion necessary
in swimming. These factors put a considerable strain on the heart and often
one which the organ is ill able to sustain, consequently this form of bathing
should hardly be indulged in by those with mitral defects and by others only
in the greatest moderation. The baths provided by the various hydro-
pathic institutions should be taken only upon the advice of a physician who
can watch the effect upon the case in hand.
All intercurrent illness should be promptly treated, particularly if the lungs
are involved and in the case of the acute infectious diseases, and any systemic
disorder such as anaemia, should be corrected. The digestive system needs
attention in many instances and constipation is an especially important con-
sideration.
Patients who are accustomed to living at a high altitude may be able to main-
tain life with comfort at such a level even after the incidence of a cardiac
lesion and it is probable that heart patients can endure considerable elevation
(6,000 feet or perhaps more) if they remain at rest when first coming to such
an altitude and, having become inured to the change, abstain from exercise;
yet it is hardly legitimate to advise the subjects of valvular defects to exchange
a low altitude for a high one unless the circumstances render it necessary.
The precordial distress that is often complained of even while compensa-
tion is good, together with the dizziness and palpitation which so often accom-
pany this symptom, may be relieved by a few days in bed and the adminis-
tration of small doses of strychnine or of 10 to 20 drops (0.66 to 1.33) of the
fluidextract of cactus taken three times a day. If there is tendency to vascular
spasm or arterial hypertension this may be combated by glyceryl nitrate
(nitroglycerine) in doses of tIi) of a grain (0.0006) three or four times a day.
2. The treatment of disturbed compensation. The earlier symptoms of
this stage are dyspnoea upon exertion or coming on during the night, loss
of flesh and anaemia; later the signs of cardiac dilatation are noted, the heart's
action becomes irregular, venous congestion is evident and oedema may
appear. Upon the onset of these symptoms absolute rest in bed should be
insisted upon and it is surprising, in many instances, to observe the effects of
this simple procedure when instituted in connection with the carefully regu-
lated diet and thorough clearing of the bowels. If the patient is unable to
breathe comfortably while in the recumbent position he may be propped up by
pillows or by the back rest which is in common use in hospitals.
With regard to drugs we have three factors upon which to base our treat-
ment. These are: -jirst and most important: The condition of the arterial
system. The consideration of this should dominate our entire management
of the patient and determines the result which we are able to accomplish. Sec-
ond: The condition of the muscular wall of the heart. Third and least to
be considered: The valvular lesion itself.
37
578 DISEASES OF THE HEART AND BLOOD-VESSELS.
Probably no drug has enjoyed a greater vogue in the treatment of valvular
heart disease than digitalis although its field of usefulness is limited. Its
advantages are that by slowing the pulse rate it gives the heart opportunity
to rest and improves the nutrition of the walls of the heart by its stimulating
influence upon the pneumogastric nerve, as well as by increasing the blood
supply of the cardiac muscle by rendering the systole more complete and
prolonging the diastole. By its action the pressure in the coronary arteries
is increased and more time is allowed for thejr filling. It may produce per-
mar^nt benefit by reason of the assistance which it affords in the production
of compensatory hypertrophy. The constriction of the peripheral vessels
caused by it is an objection to its use but this may not be sufficient to seriously
interfere with the increased cardiac power seciired, and even if this is the
case, this effect may be counteracted by drugs which have an opposite action,
such as the nitrites; the exhibition of these also will lessen the tendency to the
exertion of the so-called cumulative effect of digitalis. The particular indi-
cations for the administration of this drug are a rapidly and irregularly acting
heart, low tension pulse and the presence of venous congestion. In mitral
regurgitation as regards the employment of digitalis we may divide the condi-
tion into three groups : i . Those in which the left ventricle is but little enlarged,
while the nutrition of its muscular wall is well preserved, and which may be
attended by no inconvenience other than dyspnoea (often slight) upon exertion.
2. Those with oedema of greater or less extent. 3. Those in which, with
extensive dilatation, there is little or no oedema but well-marked pulmonary
congestion. By increasing the force of the contraction of the left ventricle
an approximation of the mitral cusps is caused which reduces the amount
of the regurgitation and diminishes the venous congestion. Under the action
of the drug the increased force of the systole wiU throw proportionately more
blood through the aortic orifice than through the partly open and obstructed
mitral valve, and the large orifice eventually gaining on the smaller, more
blood will pass into the general circiilation and the pulmonic vessels will be
relieved. The lengthened diastole will also be of service in allowing more
time for the blood to flow into the left ventricle. Thus both auricles and
ventricles gain increased power to empty themselves and the longer intervals
between pulsations enable the former to more completely discharge their
contents into the ventricles. The general improvement in the circulation
caused by the drug has an excellent effect in relieving the cardiac pain and
distress and the dyspnoea and cyanosis, and the more dropsy characterizes
the case the more efficient will the drug prove.
One of the most prompt results of its administration is a marked increase
in the quantity of urine, hence it is of essential service in relieving cardiac
dropsy; here it not only regulates the circulation and causes evacuation of the
surplus fluid through the kidneys, but also acts directly on the vessels by
THE TREATMENT OF VALVULAR LESIONS. 579
increasing vasomotor force. In some instances the diuretic effect of digitalis
is materially assisted by its combination with an alkaline diviretic such as
potassium bitartrate or citrate and occasionally it may be found that diuresis
can be established only after free purgation. When sleeplessness is a marked
symptom it is due to the non-maintenance of the relationship between the
cerebral vessels and the general circulation — by restoring this balance digitalis
enables the patient to sleep. Dyspncea is relieved by the action of the drug
in establishing a more efScient pulmonary circulation. By improving the
venous flow toward the heart it will be of service in counteracting the venous
engorgement and oedema of the lungs, the right heart, the liver, the kidneys,
and the subcutaneous tissues, so frequently observed.
In some patients with mitral regm-gitation digitalis may seem to be indicated
and yet prove injurious rather than beneficial; this may be due, in part at
least, to its causing too great a strain upon the auricle, since with a very patu-
lous mitral valve the blood is readily backed upon the auricle, and this, being
already too weak for the ventricle, is unable to withstand the strain imposed
upon it by the stimulated ventricle. Conversely to the previously made
statement, the less closely a case of mitral regurgitation approaches the
cedematous type, the less the benefit which is likely to be derived from digitalis
in it.
In most instances of mitral obstruction the same benefit will accrue from
the administration of digitalis as in mitral regurgitation, the increased resist-
ance here leads to the same general results as in the leakage of mitral insuffi-
ciency and like the latter these can be successfully combated by the strength-
ening effect of the drug upon the heart-beat. The resulting lengthening of
the diastole will allow more time for the auricle, the contracting power of
which is at the same time increased, to empty itself into the ventricle through
the obstructed orifice. The ventricle thus more perfectly filled sends more
blood into the systemic circulation and the circulation is further improved
by the stimulation of the right ventricle induced by the digitalis which affords
it greater power to force the blood through the lungs. It is possible, however,
that the increased work of the right ventricle, combined with the mitral
obstruction, may produce pulmonary congestion with the result of lessening
the oxygenation of the blood and so interfering with the nutrition of the heart,
so that in well-selected cases the beneficial effects of digitalis exceed in great
measure any possible evil ones. The general amelioration of symptoms
which the drug will bring about is much the same as in the case of mitral
insufficiency.
In diseases of the aortic valve there is a diversity of opinion concerning
the advisability of giving digitalis. While certain observers assert that its
advantages more than offset its disadvantages, there is but little question
that the drug is better omitted in instances of aortic insufficiency. It increases
580 DISEASES OP THE HEART AND BLOOD-VESSELS.
the work of the heart and the prolonged diastole which it causes favors the
return of blood through the imperfectly closed orifice and exposes the ventric-
ular wall to excessive strain so that there is danger of syncope. In aortic
obstruction, before the incidence of compensatory hypertrophy, it may prove
of service. There is some obstruction to the outflow of blood from the heart
and digitalis will increase the ventricular force so that it may overcome the
difficulty. After compensatory hypertrophy has become established the
drug is useless and its administration may result fatally; but when aortic
obstruction leads to mitral insufficiency it may be given with advantage.
Likewise in aortic insufficiency, when complicated by relative mitral insuffi-
ciency, when there is considerable dilatation of the left ventricle, perhaps of
sudden onset and associated with dyspnoea, precordial pain and anxiety, the
drug may be given with beneficial results. While digitalis is usually contra-
indicated in aortic insufficiency especially when associated with aortic obstruc-
tion, yet when the heart muscle fails and the hypertrophy is not compensatory
it is useful, but here, as well as in all cases of aortic disease, its effects must
be very carefully watched.
The indication for giving or withholding digitalis in valvular disease rests
far less upon the particular lesion present than upon the results of this defect
upon the cardiac wall. A knowledge of the relation of the heart muscle to
the work required of it in any individual instance is, therefore, much more
important from a therapeutic standpoint, than the recognition of a patholog-
ical condition of the valves. It may be stated in general terms that digitalis
is of special value in all conditions in which dilatation of the heart cavities
has resulted in valvular disease from failure of the muscular wall.
In tricuspid lesions, both obstruction and insufficiency, digitalis is useful
in the same manner as in mitral disease and particularly so in insufficiency
associated with dilatation of the right ventricle; as a rule, however, the bene-
ficial results are less marked than in mitral defects and as in the latter the
rational signs usually furnish clearer indications for the employment of the
drug than do the physical. Thus, it is indicated when the pulse is rapid
and feeble and the pulse tension low, and when cough, dyspnoea, pulsation of
the jugular veins, cyanosis, scanty urine and anasarca are present.
Constriction of the peripheral vessels, which is one of the chief physiological
effects of digitalis, is often so marked as to interfere materially with the suc-
cessful use of the drug in cardiac disease. Here it should be given in asso-
ciation with remedies which cause dilatation of the vessels, such as the
nitrites; of these glyceryl nitrate enjoys the greatest vogue but as its effects
last but a short time in comparison with those of digitalis it should be given
more frequently, usually six to eight times daily; its dosage should be meas-
ured by the effect obtained but is generally from ywq to -g-^ of a grain (0.0006
to 0.0012). Sodium nitrite — dose 5 grains (0.33) — may also be employed
THE TREATMENT OF VALVULAR LESIONS. 58 1
but it is difi&cult to obtain in a pure state, being usually contaminated with
the nitrates. Better than either is erythrol tetranitrate; this drug is less used
than its merits deserve and there is little question that for constant employ-
ment it is superior to the more evanescent glyceryl nitrate and the somewhat
uncertain sodium nitrite. Its dose is from tV to ^ a grain (0.006 to 0.032)
and in compounding it its explosive properties should be remembered. It is
best administered in pill form with kaolin as an excipient. To return to
digitalis, since it acts very slowly and maintains its effect for a long time, it
is often sufficient, after the primary effects have been obtained, to administer
it but once a day, for the purpose of continuing its influence.
With regard to the value of the different preparations of the drug those
most used are the tincture — dose 15 drops (i.o) — and the infusion — dose 2
drachms (8.0); the latter being particularly indicated when a diuretic effect
is desired and it is said to be less disturbing to the stomach than the tincture
or the fluidextract which last enjoys considerable vogue among certain thera-
peutists; its usual dose is i minim (0.065). When it is desirable to give the
drug hypodermatically digitalin eV to "o" of a grain (o.ooi to 0.002) may
be employed.
Of the drugs which may be substituted for digitalis strophanthus deserves
first mention. It possesses several advantages over the former, namely:
(i) greater rapidity of action, modifying the pulse rate within an hour; (2)
less marked vasoconstrictor effect; (3) greater diuretic powers; (4) no diges-
tive disturbance from properly made preparations; (5) absence of cumula-
tive effect; (6) greater value in children, whose vasodilators are easily affected;
and (7) greater safety in the aged in whom the vasoconstriction is often present
primarily. The especial indications for the employment of strophanthus
are: i. Rapidly recurring cardiac systoles of lessened force and irregular
rhythm. Here we get, first, a more vigorous ventricular contraction with
slowing of the pulse rate and a consequent lengthening of the diastole, which
is the period of rest for the heart, next the irregularity disappears, and lastly,
from improved nutrition of the heart we obtaiji a permanent strengthen-
ing of its muscle. 2. The comparative insignificance of the vasomotor
effects permits the use of the drug in those instances of permanent high tension
which are met in some forms of nephritis and in the rigid arteries of the aged.
3. Whenever diuresis can be promoted by increased blood tension resulting
from more vigorous cardiac contractions this may be expected from the employ-
ment of strophanthus. 4. The rapidly appearing effects of its adminis-
tration, together with its regular elimination, make it the drug of choice when
the symptoms are urgent. 5. The absence of digestive disturbances
from therapeutic doses and slight likelihood of habituation make it important
when long-continued use is necessary. It should, therefore, be the remedy
of choice in all cases, (i) in which we wish to establish compensation; (2)
582 DISEASES OF THE HEART AND BLOOD-VESSELS.
of arterial degeneration when more energetic cardiac contraction is required;
(3) of cardiac disease when a diuretic is necessary; (4) of weak or irritable
heart action; (5) of cardiac disease in childhood or old age. Failure will
follow its administration in: (i) advanced degeneration of the heart muscle;
(2) extreme mechanical obstruction to the circulation from valvular insufi&-
ciency or obstruction; and (3) a combination of these. The drug should not
be employed in too large or too frequently repeated doses; usually a dose of
5 minims (0.33) of a reliable tincture three or, possibly, four times a day is
sufficient. Given with erythrol tetranitrate it affords absolute control of the
blood-vessels.
Erythrophloeum may also be employed as a substitute for digitalis. Its
effects are practically the same but it is rather less reliable. Its employment
should, be confined to instances of a fairly competent heart with low arterial
tension and to those cases in which digitalis has lost its usefulness or has
utterly failed. The dose of the tincture is from 5 to 10 minims (0.33 to 0.66).
Caffeine is chiefly useful in heart affections in cases attended with dropsy
where by its marked diuretic action it is often very efl&cacious; it may often
be combined with digitalis, strophanthus and other heart tonics. When given
for considerable periods it may produce insomnia or even marked hallucina-
tions similar to those of delirium tremens; its usual dose is from i to 3 grains
(0.065 to 0.2), or it may be administered hypodermatically, when a rapid
effect is desired, as caffeine sodio-benzoate, of which the dose is 2 to 10 grains
(0.13 to 0.66).
Strychnine is a reliable cardiac stimulant in instances of valvular disease
where digitalis is contraindicated and may be often combined to advantage
with other heart tonics, such as caffeine. When there is imminent danger
of failure of the heart's action, and especially in pulmonary oedema, this
drug administered hypodermatically in large and frequently repeated doses
very often is of the greatest service. Here as much as to (0.003) o^ even
To of a grain (0.006) may be given and repeated if necessary, but as soon as
muscular twitchings are noticed it must be discontinued.
Sparteine sulphate may be employed, especially when diuresis is desired;
its dose is -5- to ^ a grain (0.012 to 0.033) and it is also said to be valuable
in producing regularity of the heart action. It quickens the beat when a
weak, atonic state is present and is quick in action. On the whole it is inferior