Encyclopaedia Britannica, 11th Edition, "Hearing" to "Helmond" / Volume 13, Slice 2

by Various

1. Valvular Disease.—Inflammation of the valves of the heart, or endocarditis, is one of the most common complications of rheumatism in children and young adults. More severe types, which are apt to prove fatal from a form of blood poisoning, may result when the valves of the heart are attacked by certain micro-organisms, such as the pneumococcus, which is responsible for pneumonia, the streptococcus and the staphylococcus pyogenes, the gonococcus and the influenza bacillus.

As a result of endocarditis, one or more of the valves may be seriously damaged, so that it leaks or becomes incompetent. The valves of the left side of the heart, the aortic and mitral valves, are affected far more commonly than those of the right side. It is indeed comparatively rarely that the latter are attacked. In the process of healing of a damaged valve, scar tissue is formed which has a tendency to contract, so that in some cases the orifice of the valve becomes narrowed, and the resulting stenosis or narrowing gives rise to obstruction of the blood stream. We may thus have incompetence or stenosis of a valve or both combined.

Valvular lesions are detected on auscultation over appropriate areas by the blowing sounds or murmurs to which they give rise, which modify or replace the normal heart sounds. Thus, lesions of the mitral valve give rise to murmurs which are heard at the apex beat of the heart, and lesions of the aortic valves to murmurs which are heard over the aortic area, in the second right intercostal space. Accurate timing of the murmurs in relation to the heart sounds enables us to judge whether the murmur is due to stenosis or incompetence of the valve affected.

If the valvular lesion is severe, it is essential for the proper maintenance of the circulation that certain changes should take place in the heart to compensate for or neutralize the effects of the regurgitation or obstruction, as the case may be. In affections of the aortic valve, the extra work falls on the left ventricle, which enlarges proportionately and undergoes hypertrophy. In affections of the mitral valve the effect is felt primarily by the left auricle, which is a thin walled structure incapable of undergoing the requisite increase in power to resist the backward flow through the mitral orifice in case of leakage, or to overcome the effects of obstruction in case of stenosis. The back pressure is therefore transmitted to the pulmonary circulation, and as the right ventricle is responsible for maintaining the flow of blood through the lungs, the strain and extra work fall on the right ventricle, which in turn enlarges and undergoes hypertrophy. The degree of hypertrophy of the left or right ventricle is thus, up to a certain point, a measure of the extent of the lesion of the aortic or mitral valve respectively. When the effects of the valvular lesion are so neutralized by these structural changes in the heart that the circulation is equably maintained, “compensation” is said to be efficient.

When the heart gives way under the strain, compensation is said to break down, and dropsy, shortness of breath, cough and cyanosis, are among the distressing symptoms which may set in. The mere existence of a valvular lesion does not call for any special treatment so long as compensation is efficient, and a large number of people with slight valvular lesions are living lives indistinguishable from those of their neighbours. It will, however, be readily understood that in the case of the more serious lesions certain precautions should be observed in regard to over-exertion, excitement, over-indulgence in tobacco or alcohol, &c., as the balance is more readily upset and any undue strain on the heart may cause a breakdown of compensation. When this occurs treatment is required. A period of rest in bed is often sufficient to enable the heart to recover, and this may be supplemented as required by the administration of mercurial and saline purgatives to relieve the embarrassed circulation, and of suitable cardiac tonics, such as digitalis and strychnin, to reinforce and strengthen the heart’s action.

2. Affections of the Muscular Wall of the Heart.—Dilatation of the heart, or stretching of the walls of the heart, is an incident, as has already been stated, in pericarditis and in the earlier stages of valvular disease antecedent to hypertrophy. Temporary over-distension or dilatation of the cavities of the heart occurs in violent and protracted exertion, but rapidly subsides and is in no wise harmful to the sound and vigorous heart of the young. It is otherwise if the heart is weak and flabby from a too sedentary life or degenerative changes in its walls or during convalescence from a severe illness, when the same circumstances which will not injure a healthy heart, may give rise to serious dilatation from which recovery may be very protracted.

Influenza is a common cause of cardiac dilatation, and is liable to be a source of trouble after the acute illness has subsided, if the patient goes about and resumes his ordinary avocations too soon.

Fatty or fibroid degeneration of the heart wall may occur in later life from impaired nutrition of the muscle, due to partial obstruction of the blood-vessels supplying it, when they are the seat of the degenerative changes known as arteriosclerosis or atheroma. The affection known as angina pectoris (q.v.) may be a further consequence of this defective blood-supply.

The treatment will vary according to the nature of the case. In serious cases of dilatation, rest in bed, purgatives and cardiac tonics may be required.