A system of practical medicine. By American authors. Vol. 3

by Unknown

In aortic incompetence patients in sleeping should assume, as nearly as possible, a horizontal posture. By lying on their backs they lower the height of the distending column of blood, and thus relieve both the cardiac circulation and the tendency to pulmonary congestion. Sometimes, when defective aortic pressure reacts injuriously on both the gastric and hepatic secretions and limits both their supply and their efficiency, moderate alcoholic stimulation may be cautiously employed to tide over a weakly period. The bowels should be gently moved once daily. That the cutaneous circulation may be active the body should be warmly clothed. Any prolonged exposure of the surface to cold is to be avoided. In winter the warm bath may be occasionally used, and in summer the patient is frequently benefited by a warm sea-water bath.

Medicinal agents are not to be resorted to until the cardiac hypertrophy fails to be compensatory. Then relief is demanded for the failing heart-power. In aortic regurgitation with feeble heart-action the tincture of digitalis and the tincture of the perchloride of iron are to be given in ten-minim doses three times a day. The iron is especially indicated whenever anæmia is evidenced. Digitalis is given to produce a sedative action, and therefore should be given in very small doses and regulated according to its effects on each patient. An infusion of the English leaves is the preparation which is most reliable, although the tincture, if fresh and well prepared, is equally good. When rapid and immediate action is demanded, digitalis may be given hypodermically. There is one guide to its use not unimportant to remember: that is, as long as it causes an increase in the flow of the urine it is safe to continue its use. When vertigo and syncope are prominent symptoms quinine and strychnia may be given with the digitalis. When the heart in aortic reflux acts with violence and rapidity, and the arteries are in a state of high tension, aconite will be found of service in quieting the heart's action. In aortic incompetence small doses of arsenic seem to have a stimulating effect, especially when given with digitalis and iron. Iron may disturb the stomach, arsenic seldom if ever does. It is always a safe rule when giving iron to administer at the same time a bitter vegetable infusion, as quassia or columba.

When the hepatic and gastric vessels are engorged, three or four leeches over the liver or epigastrium, followed by a warm fomentation, will afford temporary relief.

At no time should a large quantity of fluid be taken into the stomach. Symptoms of angina pectoris, with local pain and dyspnoea, are evidences of aortitis. This demands the application of leeches over the sternum and continued small doses of mercury.

The treatment of dyspnoea, dropsy, pulmonary oedema, and other late and distressing symptoms will be considered in connection with mitral disease. Sometimes the pain of aortic disease is so severe as to require an anodyne for its relief: opium must not be given by the mouth, but the sulphate or the hydrochlorate of morphine can be safely given hypodermically. The severe angina-like pain of aortic regurgitation can often be promptly relieved by the nitrate of amyl.

Barlowe and Fagge both advise senega and ammonia carbonate for the less severe effects of aortic reflux. They advance no reason for the use of these drugs, but their cases show that they have a markedly beneficial effect. All authorities unite in regarding aortic insufficiency as less amenable to treatment than other valvular lesions.

In all cases the idiosyncrasy of each patient should be carefully considered.

No treatment can restore a diseased valve to its normal condition, or prevent, for any considerable time, cardiac dilatation and hypertrophy when the normal function of the valves is greatly interfered with.

The first step in the treatment of a serious lesion at the mitral valves is to make the patient clearly understand his exact condition, that he may see the reasonableness of the advice given, for his treatment for the most part must be carried on by himself. A patient must be fully persuaded of its necessity before he will regulate his habits and mode of life in accordance with the requirements of his case. The rules as to nutrition are the same as those to be observed in aortic stenosis and reflux. There should be a gentle and regular daily evacuation from the bowels. Straining at stool must be avoided, and any use of alcohol, strong tea, coffee, and tobacco is to be prohibited. If in either form of mitral valvular disease the patient is anæmic, iron should be given. This is given as a food to such patients, and is best administered about half an hour after meal-time. Ten or twenty grains of Vallette's mass may be given with benefit to anæmic patients two or three times a day for a long period.

Patients with mitral reflux should avoid a prolonged use of the voice, especially in speaking or singing. Small doses of quinine and strychnine, alternating with the administration of iron, are often of service. If there is anorexia, infusion of quassia or columba may be given with the iron. The triple phosphates of iron, quinine, and strychnine, or small doses of dilute sulphuric acid, will be found to improve the condition of these patients when they show signs of extreme debility.