Endocarditis

=Endocarditis= is an inflammation of the lining membrane of the heart.

The process is usually confined to the valves; the lining of the

cavity of the heart may also be affected, especially in severe cases.

Three forms are recognized: simple acute endocarditis, ulcerative

endocarditis, and chronic endocarditis.

=Simple Acute Endocarditis.=—This form usually results from acute

articular rheumatism. Tonsillitis may be associated with endocarditis.

It may also be caused by other infectious diseases, especially scarlet

fever, but rarely, by typhoid fever, measles, chicken-pox, diphtheria,

smallpox and erysipelas. Acute endocarditis is frequently found in

chorea. It is also met with in diseases attended with emaciation and

general weakness, as cancer, gout, Bright’s disease and diabetes. It

is not uncommon in phthisis. Micro-organisms play an exciting part,

but back of this the osteopath finds lesions of the heart innervation

important predisposing features. Prophylactic osteopathic treatment

is a potent factor in preventing endocardial changes in the above

diseases. Keeping the muscles relaxed and the osseous tissues intact is

of great value.

=Pathologically=, the left side of the heart is most commonly involved.

The disease is characterized by the presence of small vegetations on

the segments or on the lining membrane of the chambers, although in

mild cases there is simply swelling of the valves. The mitral valves

are more often affected than the aortic. The vegetations appear,

usually, on the auricular surface of the mitral and the ventricular

surface of the aortic valves, a little back of the valve edge. Their

seat corresponds to the point of maximum contact (Sibson). These

growths are liable to be broken off at any time and carried as emboli

by the blood current to distant organs, particularly the brain, spleen

and kidneys. This is not uncommon in acute endocarditis or chronic

valvulitis. In favorable cases the vegetation is ultimately absorbed

and the valve is but slightly altered beyond a simple sclerotic

thickening. This is often the starting point of sclerotic valvulitis.

Osteopathic measures undoubtedly lessen the liability of cardiac

involvement, prevent extensive changes and promote absorption of

disease products, by lowering heart tension and improving the cardiac

nutrition, as well as increasing free elimination of the toxins in the

blood.

During the fetal life, the right side of the heart is most commonly

involved. The chorda tendinæ are sometimes affected, but rarely alone.

The vegetations are composed of proliferated connective tissue cells.

The superficial elements undergo a coagulation-necrosis and fibrin

is deposited from the blood. Micro-organisms are found and are the

specific agent in causing acute endocarditis.

=Symptoms.=—A large number of cases are latent, the autopsy first

disclosing the lesion. In many cases there are slight fever, a

frequent, sometimes irregular, pulse, palpitation and dyspnea. There is

seldom any pain.

=Physical signs= are very uncertain. They may not be present in mild

cases and in those in which the valves are not affected. Usually

auscultation furnishes the only indication of endocarditis—a soft,

blowing, systolic murmur which is heard most frequently at the apex,

as the mitral valves are the ones generally involved. When the aortic

valves are affected, the murmur is heard at the second interspace at

the right edge of the sternum.

=Diagnosis.=—This depends entirely upon the etiology and physical

signs. The greatest danger is in the disease becoming chronic.

=Treatment.=—The patient should be kept as quiet as possible, so

that the work required of the heart may be reduced to a minimum. The

disturbed circulation can be controlled by careful attention to the

vasomotor nerves at the various centers along the spine. Attention

should be given the disease that is causing the endocarditis. Keep the

patient well protected by flannels and beware of damp rooms and sudden

changes of temperature.

Treatment should be given to correct any lesion found in the upper five

dorsal vertebræ or ribs and to raise and spread all of these ribs so

that the heart’s action will not be unduly disturbed by interferences

with its innervation. The vasomotor nerves to the heart’s vessels are

found in the vagi nerves, consequently care should be taken that

lesions to these nerves do not exist. An inhibitory treatment to the

suboccipital nerves acts reflexly on the vasomotor nerves and tends

to equalize the general vascular system. This treatment quiets the

heart’s action. Ice applied locally is advocated by many practitioners.

Flannels should be placed next to the skin and the ice-bag placed

over the flannel. This reduces the fever, lessens the pulse-rate and

quiets the heart action. The same points are obtained by the inhibitory

treatment at the suboccipital region. The ice-bag also relieves pain

and oppression. Be very careful in the use of ice when there is much

cardiac dilatation. Treatment of the middle and inferior cervical

regions may have some effect in controlling the heart’s action. A

general treatment to quiet the patient is effective. Do not allow any

overexertion. The patient should have nourishing liquid food.

Emery[100] says: “Many of us have been in the habit of saying, just

because we hear a decided murmur in the heart region, that the patient

has valvular heart trouble; that the patient has organic heart trouble.

This is a common error... When there is an anemic condition of the

body, apparently the cusps of the valve will be so weakened, and the

attachment will be so weakened that the blood will force its way

between the valves and back into the heart, causing regurgitation

murmur, when as an actual fact there is no deformity and no real

disease of the valves, and as soon as the general condition of the

anemia is improved, the valve will do its work fully and the murmur

entirely cease. So if you have the murmur without the hypertrophied

condition, which at once follows such a valvular lesion, you must

be guarded in your statements, for if an actual valvular lesion

existed, compensation would take place, and it would be the means of

corroborating such a valvular condition; if no hypertrophy is found,

then we are not justified in definitely stating that a valvular or

organic lesion exists, for such a weakened condition as has been

mentioned might be the only pathology present, and be the cause of the

murmur.”

=Ulcerative or malignant endocarditis.=—This is an acute, infectious or

septic disease, characterized locally by necrosis or ulceration of the

valve. It is generally a secondary affection to septicemia, pneumonia,

erysipelas, scarlet fever and acute rheumatism. Acute endocarditis

often precedes the ulcerative variety, the latter being simply an

increase in severity of the former.

=Etiology and Pathology.=—It is doubtful if there can be a primary

form of ulcerative endocarditis. Chronic valvular defects are the most

important predisposing causes. Pneumonia is most frequently, of all

the acute diseases, associated with severe endocarditis. It is rare

in tuberculosis, diphtheria, typhoid fever and chorea. It occurs in

association with erysipelas, gonorrhea and rheumatism. Septicemia,

pleurisy, meningitis and puerperal fever are other possible causes of

ulcerative endocarditis.

Deep seated lesions, which means firmly anchored lateral flexions

and rotations due to fibrotic changes, are important predisposing

local factors, while other lesions that disturb blood elaboration and

resistance and lessen elimination, are predisposing systemic causes.

=Pathologically=, the lesions are either vegetative, ulcerative or

suppurative. The vegetations are composed of granulation tissue,

granular and fibrillated fibrin, and colonies of micro-organisms. They

become necrotic and break down into ulcers. The ulcerative changes

may lead to perforations or produce valvular aneurisms. Of the valves

the mitral is the most frequently affected; then the aortic; then

the mitral and the aortic together; then the heart walls; then the

tricuspid; then the pulmonary. In a few cases the right heart alone

is involved. The lesion is not always confined to the valves, but may

involve the mural endocardium. The most common organisms found are the

pneumococcus, streptococci and staphylococci. The bacillus diphtheriæ,

bacillus coli, gonococcus, bacillus anthracis and other organisms have

been found. Associated pathological changes include the lesions of the

primary disease and the changes due to embolism. The spleen, kidneys,

brain, intestines and skin may be the seat of embolism. When found in

the lungs, they originate in the right heart.

=Symptoms.=—If in the course of any of the diseases previously named

under etiology, chills followed by fever and sweats occur, ulcerative

endocarditis should at once be suspected and a thorough examination

be made. The general symptoms are high, irregular fever, delirium,

sweating, great prostration, rapid pulse, hurried breathing and

sometimes jaundice and diarrhea occur.

The occurrence of delirium, coma or hemiplegia points to involvement of

the brain; pain in the region of the spleen, with increased dullness on

percussion, point to trouble in that organ; hematuria may occur from

involvement of the kidneys. More rarely there will be impaired vision

from retinal hemorrhage; and there may be suppuration and sometimes

gangrene in various locations, depending upon the position of the

embolism.

The =septic type= is secondary to suppurating external wounds,

puerperal sepsis or acute necrosis. Occasionally gonorrhea is the

cause. The symptoms presented are rigors, irregular fever, sweats and

exhaustion—the signs of septic infection. The symptoms may resemble a

quotidian or a tertian ague. The =typhoid type= is the most common.

The characteristic symptoms are irregular temperature, sweating,

prostration, delirium, drowsiness, diarrhea, petechial and other

rashes, distention of the abdomen and pain in the right iliac region.

The heart symptoms may be overlooked, as in the septic type. The

=cardiac type= are cases of chronic valvular diseases in which fever,

rigors and sweats, and the symptoms of embolism may develop. In the

=cerebral= cases the symptoms may simulate meningitis. Acute delirium

may be the distinctive symptom. Heart symptoms may be overlooked.

=Physical Signs.=—The heart symptoms may be latent. Even after a

careful examination, there may be no murmur present. When murmurs are

present it is often difficult to locate them.

=Diagnosis.=—The previous history should be considered and this,

together with the symptoms, makes a correct diagnosis possible, even

though physical signs are absent. The duration is from a few days to

several weeks.

=Treatment.=—The treatment of this form of endocarditis is likely to be

of little avail, although in a few cases where the source of infection

can be eradicated the condition may be considerably improved and life

prolonged. About the same treatment as in simple endocarditis should

be followed. Absolute rest is essential and this, coupled with the

local treatment of simple endocarditis and a nourishing liquid diet,

constitutes the principal treatment.