349 
SOME CONSIDERATIONS IN THE TREATMENT OF 
? VALVULAR HEART-DISEASE.1 
By Augustus A. Eshner, M. D. 
ADJUNCT PROFESSOR OF CLINICAL MEDICINE IN THE PHILADELPHIA POLYCLINIC. 
Gentlemen :-This case presents certain features of interest 
that may be profitably enlarged upon. It is that of a girlr 
20 years old, who has been employed as a child's nurse. 
She first presented herself rather more than three months 
ago, looking pallid and distressed, and complaining of a 
sense of oppression upon both sides of the chest that had 
existed for a month, and was the more pronounced upon 
the right side. 
At first there was some cough, unattended, however, with 
expectoration. There had been considerable loss of flesh 
during the preceding two months. There was a history of 
acute articular rheumatism a year before, complicated by 
endocarditis. The appetite was much impaired, and the 
digestion was enfeebled. The bowels were regular. There 
was inability to sleep at night, on account of the dyspnea 
induced by the recumbent posture, with a sense of feverish- 
ness and sweating about the head. There was no edema 
1 Clinical lecture at the Polyclinic Hospital. 350 
ESHNER, 
and no noteworthy derangement of micturition. The urine 
presented no abnormality. The menstrual period has twice 
been missed. The anemia was profound. The family his- 
tory was good. 
On physical examination the chest was seen to be some- 
what chicken-breasted. The cardiac impulse was violent 
and diffuse, extending beyond the line of the left nipple. 
The area of cardiac percussion-dullness was appreciably 
increased. The action of the heart was rapid. Over a 
large area in the precordium both a systolic and a dis- 
astoliclmurmur could be heard. These were transmitted in 
the course of the great vessels, and could also be heard to 
the left of the vertebral column in the dorsal region. There 
was a deficiency in the pulmonary resonance at the apex 
of the left lung, with some roughening of the respiratory 
murmur upon both sides. 
The girl was instructed to go to bed, to place herself at 
absolute rest, and to partake of a generous diet of easily as- 
similable character, the basis of which should be milk, eggs, 
and meat. Teaspoonful doses of the elixir of quinine, iron, 
and strychnine, to be taken thrice daily, well diluted after 
food, were prescribed. 
In the course of a week we learned that the girl was im- 
proved in some respects, though the pain in the right side 
of the chest was still a source of annoyance. I now pre- 
scribed digitalis, giving two drams of the infusion, with five 
mimims of the tincture, thrice daily. 
The next report brought word of decided improvement. 
After having continued the digitalis for two weeks, tincture 
■of strophanthus, in ten-drop doses, was substituted, the ad- 
ministration likewise being continued for a period of about 
two weeks. With this alternation the treatment has thus 
been kept up for these three months and more, the girl al- 
ways doing best, however, while under the influence of 
digitalis. She has been able to be out of bed, has spent two 
weeks in the country, and, as her mother states, "is quite 
another girl." TREATMENT OF VALVULAR HEART-DISEASE. 
351 
This case presents several interesting considerations. The 
diagnosis was clear. There was aortic obstruction and in- 
competency, with ruptured compensation. The origin of the 
lesion was to be ascribed to the attack of acute rheumatism 
of a year before. The practical question that presented it- 
self was: What is the best that we can do for the case? 
Before attempting to answer this question, let me say a few 
words concerning the etiology of endocarditis. 
I am inclined to believe that too much importance-per- 
haps I should say too exclusive an importance-is attached 
to the influence of rheumatism as a cause of endocarditis. 
I do not mean to imply that rheumatism is not a potent 
and a frequent cause of endocarditis; on the contrary, the 
etiologic factors upon which rheumatic polyarthritis de- 
pends often, very often indeed, also give rise to endocardi- 
tis; but we must not ignore the fact that many other con- 
ditions may likewise cause endocarditis. Accumulating 
experience points to the conclusion that any of the infec- 
tious diseases or any infectious condition-e. g., measles, 
varicella, variola, scarlatina, enteric fever, influenza, gonor- 
rhea, syphilis, septicemia-may be complicated by inflam- 
mation of the endocardium. 
In each of these conditions, including acute rheumatism, 
it would appear that the endocardial lesion is but one mani- 
festation of the action of a virus which is the ultimate eti- 
ologic element. For some of these a bacterial origin has 
been demonstrated ; for others the demonstration is yet 
wanting. It is probable that in some instances the inflam- 
mation results from the lodgment of micro-organisms upon 
and within the delicate lining membrane of the heart, 
while in others the inflammation depends upon the pres- 
ence in the circulation of certain toxic substances genera- 
ted by bacterial activity. This distinction between infec- 
tion and intoxication I believe to be an important one. 
Therapeutically the corresponding difference is that be- 
tween a germicide and an antidote. 
What shall we say of the prognosis? We can never re- 352 
ESHNER, 
store the integrity of the valvular apparatus, but we can 
hope to re-establish the balance of the circulation, and to 
this end we shall direct our treatment. The outcome of the 
case depends largely upon its management. This heart 
differs from the normal heart in that it has lost its reserve or 
latent capability, and perhaps some of its essential capability 
as well. If the demands placed upon it do not exceed its 
functional ability, it will serve its purpose well, but should 
this limit be transgressed the organ will give out and fail. 
At the same time the nutrition of the heart and the general 
nutrition will demand consideration. With judicious 
management and in the absence of complicating conditions, 
I see no reason why this girl's life may not be prolonged for 
many years. It must, however, be borne in mind that she is 
less well able to withstand the effects of an attack of inter- 
current disease, or to submit to the risks of pregnancy and 
childbirth than if her circulatory apparatus were intact. 
Returning to the treatment of our case, what were the 
therapeutic indications? A failing left heart,beginning to 
dilate, with consequent pulmonary stasis. Mechanically 
and physiologically two alternatives offered-i. e., either to 
stimulate the flagging power of the heart or to diminish its 
work. The choice was obvious. The demands upon the 
heart, as upon the whole system, were curtailed by rest in 
bed, with quiet, and the nutrition of the organ, as also of 
the whole body, was improved by the same measure and 
additionally by a generous assimilable diet. Having thus 
prepared the heart for an additional burden we were ready 
to use our cardiac stimulants. 
In considering the therapeutic measures to be employed 
I have not spoken of the character or situation of the lesion. 
This omission is intended, for in our treatment we do not 
deal with the valvular defect, but with the condition of 
equilibrium, the compensation, as it is called. In your ex- 
perience you will encounter cases of valvular disease that 
present no symptomatic evidence of the lesion, while in 
other cases you will be unable to discover auscultatory signs TREATMENT OF VALVULAR HEART-DISEASE. 
353 
to explain the distressing and alarming symptoms due to 
heart-failure from myocardial degeneration. Our object is 
to establish harmony between the action of the heart and 
the demands of the system, and our choice of measures or 
remedies is governed by the disparity between these that 
may exist. When a heart-tonic that is not merely a heart- 
stimulant, but at once a stimulant and a nutritive agent, is 
needed, digitalis is the best we have at our command. As 
a tolerance to the drug may be established, it is well to alter- 
nate its use with that of some other heart-tonic; and next 
to digitalis strophanthus is perhaps the most reliable. In 
this case strophanthus disappointed, perhaps because the 
dose was not large enough, but in an out-patient it was 
deemed wise not to prescribe large doses. 
The girl is now taking digitalis. After two weeks we 
shall tentatively give her cereus grandiflorus, of the fluid 
extract 10 minims, cautiously increasing the dose to 30 
minims, thrice daily. In administering digitalis I give 
both tincture and infusion together, believing that I thus 
most nearly obtain all of the soluble active principles of the 
crude drug.