This condition may begin as a chronic inflammation or follow the acute
form, which is more often the case. There is a =sclerosis= of the
valves which causes deformity, owing to the contractions. The onset is
usually insidious.
It is well known that the larger percentage of valvular lesions are the
result of either acute or chronic endocarditis. Thus rheumatism stands
foremost as a cause of valvular defects. Alcoholism and overeating
(through introducing irritating influences into the blood, or by
causing rheumatism, gout and allied diseases) are important etiological
considerations. Nephritis and syphilis are considered among the
causative factors. Infections and senility, when associated with high
blood pressure, is a phase not to be overlooked. Chronic endarteritis
extending from the aorta to the valves, resulting in thickening and
degeneration of the tissue, may be an insidious source of valve
disease. This is probably often of syphilitic origin.
A potent cause of special interest to the osteopath (for the reason
that his treatment is so effective), is continued =muscular strain= as
seen in athletes and laborers. The heart muscle itself may be strained,
particularly the valve leaflets and the tissues about the valve, which
effect often terminates in valvular leakage. In addition, the orifice
of the valve openings may become stretched and distorted through strain
superinduced by prolonged exertion, by flabbiness of heart tissue, and
by dilatation of the ventricles. In these latter cases it is seen that
the leaflets of the valves may remain intact, but still they are unable
to stretch completely across the opening.
With the above condition it is readily noted that thickening, curling
and adhesions will take place when inflammation attacks the valves and
contiguous tissues, and following these, limy infiltration and fatty
degeneration may be a consequence.
Predisposing osteopathic lesions as noted in acute endocarditis, are
not to be neglected.
=Thickening and hyperplasia= are immediate consequents of connective
tissue overgrowth; and especially is chronic endarteritis accompanied
with atheromatous and calcareous degeneration. Thickening, at times, is
only slight and the function of valves is not impaired.
In curling or =retraction=, there occurs a shrinkage of the
hypertrophic or hyperplastic tissues. This condition is very apt to
become permanent.
=Adhesions= of the valve leaflets is a self-evident condition. It is
well to note here that in acute and chronic endocarditis some part
of the fibrous valve ruptures or is lacerated or eroded from strong
and rapid heart action; the =laceration= or rupture or erosion always
occurs at the point of maximum contact. Thus the eroded surface allows
an opportunity for the rheumatic or septic micro-organisms to lodge,
multiply and grow, and adhesions result. Carefully applied osteopathic
methods are very efficacious in impending acute heart disturbances, and
this without doubt is the reason why so many of our rheumatic cases get
well without any heart affections. Keeping the heart quieted and slowed
prevents the strong and rapid action and thus lessens the probability
of lacerations, ruptures and erosions of the valve tissues. General
resistance is increased and elimination improved, which have a decided
effect in preventing complications.
=Calcification and atheroma=, as has been mentioned, may follow the
above diseased processes. The calcification is sometimes so marked as
to be of the character of a bony ring.
The question arises here, What effect have =osteopathic lesions= as
direct =causative factors= in valvulitis? It appears reasonable that
the heart is not exempt from the influences of the vertebral and rib
maladjustments. Furthermore, clinical experience has abundantly proven
that the heart tissues are affected by these lesions in the same manner
as any tissue or organ is affected. Again, osteopathic dissection
reveals direct nervous connection from the upper dorsal spinal ganglia
to the heart ganglia.
No one will question that the integrity of heart function and life
are dependent upon normal coronary artery supply, upon vasomotor
equilibrium, and upon motor control. All of these functions are
influenced by the status of cervical vertebræ, upper dorsal vertebræ,
and rib relations. Just what the pathological affection is when
these anatomical parts are disturbed is beyond us until more careful
dissection and experimentation have taken place. How cervical and
dorsal sympathetics, vasomotor and motor nerves with their spinal
connections, vagi and phrenic, are so disturbed as to involve valvular
parts and induce inflammation, is a problem for us to investigate.
Through analogous reasoning from other organic ailments and through
the fact that osteopathic therapeutics corrects heart lesions, we know
in a general way that the correction of osteopathic lesions decidedly
influences the heart.
Two well known =physiological facts= relative to the heart are: first,
the heart increases in size up to adult life, and, second, the heart
muscle can actually be increased in size. This latter fact occurs in
physical development and training. A heart that is weak and flabby can
be increased in strength, tone and size. This helps us to understand
how certain strains and distortions of the heart, with consequent
valvular lesions, may be corrected through rest, exercise and
treatment; somewhat analogous to the correction of an atonic, prolapsed
and dilated stomach. Then it also seems probable that disturbed
innervation and blood supply to heart areas or to the heart as a whole
would predispose to congestions, inflammations and degenerations
whereby rheumatism, septic states, etc., and muscular strains would act
only as exciting causes, not true causes.
No one is going to expect that thickened, retracted, adhered, or
ruptured valves are to be made anatomically correct; but the right
treatment will certainly reduce the morbid state to the minimum. Then
there are cases where osteopaths have eliminated all murmurs when
specialists stated the disease was incurable; showing that it is
impossible by signs and symptoms to always diagnose the morbid tissue
state. Only the resulting effects of size and of leakage are definitely
revealed by auscultation and percussion. Hence there is a class of
valvular diseases that can be successfully treated by osteopathic
measures, which, if left to terminate under drug medication, will
reveal (at post-mortem) the pathological signs of valvular heart
disease.
Downward displacement of the =first rib= may interfere directly with
the subclavian artery and thus cause constriction of that vessel and
a consequent regurgitation; also, cardiac fibers of the recurrent
laryngeal nerves may be impinged by a dislocation of this rib. Many
lesions which interfere with the right side of the heart occur at
the =second= and =third ribs= and lesions of the =third=, =fourth=
and =fifth ribs= may interfere with the valves. Lesions of the
=corresponding vertebræ= produce the same results as the ribs. These
lesions are probably to the sympathetic nerves along the dorsal region.
Lesions may be found anywhere along the cervical vertebræ which may
involve inhibitory (vagi) fibers or accelerator (sympathetic) fibers
to the heart. Also, in some cases the =floating ribs= are dislocated
downward and cause a prolapse of the diaphragm, and thus a constriction
of the aorta, which may result in regurgitation and valvular disorder.
=Mitral Regurgitation.=—Mitral regurgitation is a leakage of blood from
the left ventricle, through the mitral valves, into the left auricle.
The opening of the valve may be distorted, or the valve leaflets
thickened, rigid, or retracted, thus allowing an escape or reflux of
blood from ventricle into auricle. The tendinous cords may also be
thickened and adhered, with consequent prevention of free action.
By a forcing back of a portion of the blood from ventricle to auricle
at the same time the pulmonic veins are emptying into the auricle, an
overdistention of the auricle takes place. The auricle, then, from the
extra amount of work required, becomes hypertrophied and dilated. There
may be no noticeable symptoms at first. Later on shortness of breath,
cough, irregularity of heart’s action, indigestion, liver congestion,
and so on, occur.
The =apex beat= is forcible and downward to the left. Of course the
area of dullness is to the right and left. There is a =systolic murmur=
in the mitral area, which is transmitted to the left axilla.
Every osteopath should understand the mechanism of this most frequent
valvular lesion. Following hypertrophy and dilatation of the left
auricle, the reflux may be so excessive that a residue remains. The
auricle not being able to handle all the =blood=, stasis of the
pulmonary vessels takes place, and pulmonary edema and hydrothorax are
sequelæ. Then comes dilatation of the right ventricle and back pressure
on tricuspid valves and right auricle. The =veins= throughout the body
become turgescent, and the liver is apt to be indurated. It should be
emphasized, however, that “back pressure” is only an effect commonly
due to myocardial degeneration, caused by some infection, of which
auricular fibrillation is an important part of the pathology.
Before the breaking down of the left heart compensation, osteopathic
methods, as all know, are effective in maintaining balance. Even after
the lungs begin to be affected, careful and thorough treatment will
result in good, and in cases of general venous sluggishness treatment,
particularly to liver, diaphragm, bowels and limbs, will generally
materially help in slowing the downward course of the disease.
=Mitral Stenosis.=—In stenosis there is narrowing or constriction of
the valve opening. Thus in mitral stenosis the free flow of the blood
from left auricle to ventricle is hindered.
The =cusps= are usually thickened, rigid and adhered. The valve opening
may be so stenosed as to be but a narrow slit. In all cases stenosis
is a =structural defect=. It can occur by strains, as regurgitative
effects sometimes result.
The =symptoms= of mitral stenosis are practically the same as those of
mitral regurgitation, owing to similar effects upon the circulation.
Under =physical signs= we find the apex-beat is only slightly
displaced. Palpation will reveal, near the apex, a rough presystolic
thrill. The increased area of dullness is to the right. There is an
abruptly terminating, rough, presystolic murmur.
=Aortic Regurgitation.=—Aortic regurgitation is a reflux of blood
from aorta to left ventricle, following ventricular systole. This is
considered the =most serious= of the valvular diseases. The valve
opening is either too large, so the valve leaflets do not fit tightly,
or the segments themselves are thickened and retracted. Structural
defects of the aortic valves are largely of the same character as in
diseases of the mitral valves.
The =regurgitation= first causes dilatation of the left ventricle.
This is followed by hypertrophy. If the mitral valve holds intact, no
further effects result. But if the mitral valve is diseased or becomes
incompetent from the dilated ventricle, the same morbid states follow
as was noted under mitral regurgitation.
There is a forcible apex-beat, displaced downward to the left. The
increased dullness is to the left. There is a long, loud =diastolic
murmur=. The well known “water-hammer” pulse is felt.
=Aortic Stenosis.=—Aortic stenosis indicates a narrowing of the
aortic orifice. It is a structural defect. The free flow of blood is
obstructed from the left ventricle into the aorta.
Aortic stenosis is much less frequent than regurgitation. Aortic
stenosis and regurgitation are very apt to be associated. The beat is
commonly forcible, and the increased area of dullness is to the left.
There is a systolic murmur, heard best at the right second interspace,
which is conducted into both carotid arteries.
=Tricuspid Regurgitation.=—Tricuspid regurgitation is the most common
valvular lesion affecting the right heart. It is rare as a primary
lesion. The affection may be of a structural character, or functional.
Hypertrophy of the right ventricle occurs after the manner of left
ventricle hypertrophy in mitral regurgitation. The sequelæ of venous
turgescence follow, also, in the same way as was given under the mitral
lesions. Tricuspid regurgitation rarely exists independent of some
other cardiac or pulmonary ailments.
The apex-beat is diffused toward the epigastrium. Increased cardiac
dullness is toward the right. There is a systolic murmur, which is
heard best just above the xiphoid cartilage. The jugular vein pulsates;
in severe cases there is pulsation of the liver.
Osteopathic treatment is usually effective in relieving the engorgement
of the veins, and particularly in reducing liver congestion.
=Tricuspid Stenosis.=—This affection is said to be the =most rare=
of valvular lesions. Thickening, obstruction and adhesions from
endocarditis cause the stenosis. As in other lesions of the heart,
there is a congenital form. There is presystolic murmur, heard best at
the xiphoid cartilage. The pulse is small and weak.
=Pulmonary Regurgitation.=—This is another rare lesion, and is seldom
met with in a simple form.
There is forcible pulsation in the epigastrium. Increased cardiac
dullness is downward. There is a diastolic murmur, heard most
distinctly at the left second intercostal space.
=Pulmonary Stenosis.=—Another rare lesion. The effect of this lesion
on the right ventricle is the same as that of aortic stenosis on the
left. The congenital lesion is apt to occur with a patulous foramen
ovale.
There is a systolic murmur, heard best at the second intercostal space
on the left. =Many systolic murmurs= heard over the pulmonary opening
=are functional=.
=Combined Valvular Lesions.=—When two or more lesions occur at the same
time the terms, combined or associated, are employed. This is a very
common occurrence. Two, three or all of the valves may be affected at
the same time. =Stenosis= and =regurgitation= at the same orifice is
the most common association of any two valvular lesions. When there
is a joint affection of two or more valves, the =aortic= and =mitral=
are most commonly associated; then mitral and tricuspid; then aortic,
mitral and tricuspid.
=Prognosis and Treatment of Valvular Diseases.=—It is impossible
to outline with exactness either prognosis or treatment of heart
lesions. All will agree that the character of the lesion is the
first consideration, and before records of these cases can be of any
scientific benefit, we must look well to the nature of the valvular
leakage or obstruction and note precisely what effect our therapeutics
has. Perhaps of greatest consideration in the matter of prognosis
is, to what extent =compensation= has been maintained. We know that
compensation may be perfect; that hypertrophy and dilatation may
balance the valvular defect so thoroughly that even the patient is not
aware of a heart lesion. As soon as compensation begins to fail, when
palpitation, irregularity of pulse, dyspnea, edema, etc., appear, we
know that our treatment should pass from the realm of the defensive
to that of the offensive. Then when compensation fails still more,
prognosis and treatment must necessarily be changed according to the
increasing gravity.
In our osteopathic work we should never forget that the condition of
the lesion may be greatly influenced by environment. Habits, occupation
and general daily life may affect the heart ailment for good or
bad. Thus in =prognosis= we have =three features= in particular to
note: character of heart lesion, extent of systemic involvement, and
environment. In the immediate prognosis, the extent of general venous
stasis, if any, is of great importance. In other words, the gravity of
the complications is of first consideration.
Aortic regurgitation is ranked by heart specialists as the most serious
lesion. Aortic stenosis is a grave lesion, but not so serious as aortic
regurgitation. It is often stated that the character of the lesion is
not of so much consequence as the extent of involvement the lesion has
engendered. Mitral stenosis is more grave than mitral regurgitation.
Right side heart lesions are usually relative, and, naturally, when the
right heart is diseased from extension of the ailment from the left
side, the situation is serious.
It should be remembered that a heart normal in size and beating
regularly is usually in a fairly healthy condition even if a murmur is
present.
In our =treatment= the first point indicated is to improve, if
possible, the =integrity= of =heart muscle= and lessen the =valvular
defects=, if such can be done. Owing to a dearth of statistics, it is
impossible to state to what extent improvement in organic lesions has
been accomplished. Very likely if we had statistics and no post-mortem
findings, we would still be in the dark as to much of our work. This
much is positive: osteopaths have time and again apparently cured
grave valvular lesions; cases that eminent specialists diagnosed
as absolutely organic lesions. Our practitioners have eliminated
the murmurs, reduced the size of the heart, and removed any and all
systemic symptoms. These patients are well, have been well for years,
and are leading active lives. But were these cases suffering from
organic lesions? No doubt there was valvular leakage, hypertrophy and
dilatation, but was the valve defect a functional one? In other words,
was it due to strain and distortion? In all probability the patients’
days were numbered and post-mortems would have shown grave lesions and
quite likely more or less organic changes.
Does it not seem likely that some functional lesions may terminate
in organic lesions? Through continued stretching of the valves and
their immediate tissues, fatty degeneration may take place; the same
as fatty degeneration of the heart muscle, occurring in dilatation of
the chambers. If we can remedy functional lesions through specific
work upon nerve centers and fibers, why cannot we influence organic
lesions and at least reduce the gravity to a minimum? We know
functional diseases of the heart, as palpitation, rapid heart, slow
heart, etc., can be corrected, and from all indications, functional
valvular leakages are generally easily and quickly remedied; it is
only a step farther to affect truly organic lesions. The same valves,
the same nerves, and the same osteopathic lesions are noted. Then it
is only a continuation of the same process from functional disease to
organic disease. Indeed, no one is able to draw a line between the
two. Probably, as was intimated before, careful osteopathic treatment
in rheumatism and other diseases that are apt to predispose to heart
affections, will keep the heart so strong functionally and organically
that resulting valvular lesions are not nearly so likely to develop.
The heart can be treated and controlled as can any tissue or organ. It
certainly stands to reason that osteopathic therapeutics is rational
in both preventing and curing valvular lesions. The M. D. gives his
drugs with the hope of maintaining heart muscle integrity, of lessening
a too forceful beat, of increasing waning power, of promoting general
circulation, of preventing and lessening complications. We can do
the same thing with our methods, even more effectually, and with no
probability of harmful effects.
It would appear there are at least two ways in which organic lesions
may develop. =First=, as stated above, through =functional distortion=,
the normal heart muscle being strained from severe exercise, or a weak,
flabby, or disused heart muscle being overtaxed by ordinary exercise.
Here it will be seen that in the first instance immediate rest will
probably correct the weakness; in the second, rest and general
building up of the body if the atonic heart muscle resulted from some
debilitating disease. If from local causes correction of the specific
osteopathic lesion should be effective.
=Secondly=, through strong and rapid heart action the =valves= are
=ruptured= or =lacerated=, always at the point of =maximum contact=,
and thus present a favorable surface to micro-organisms.
Owing to the valves being a reduplication of the endocardium, they
have no muscles or blood-vessels, so that in =functional leakages=,
inflammation does not play a part, hence, a possibility of degeneration
occurring from excessive stretching.
The large majority of =osteopathic lesions= are unquestionably found
in the upper five dorsal vertebræ and the first five or six ribs on
the left side, although cervical lesions, in many instances, play an
important secondary, if not the primary, role. These maladjustments
affect vasomotor nerves to the heart, that is, to coronary vessels,
the dorsal and cervical sympathetics, the vagi, and the phrenic. We
are unable to state just how these lesions disturb nerve conductivity;
what present anatomy and physiology teach us does not fully explain.
Osteopathic dissection must be the means to the end of the explanation.
We have many clinical results, but not the physiological knowledge, as
yet, to support it.
The dropping down of the first rib, as well as the clavicle, interferes
with the large blood-vessels, especially the subclavian, and causes
increased resistance of the heart’s action and probably a certain
regurgitative effect. This regurgitative effect would also occur in
cases of obstruction to the aorta by constriction of the diaphragm
from dropping of the floating ribs. To what extent this latter
feature has been demonstrated is not known. In valvular diseases
it is practical to divide them for treatment into, =first=, where
the =lesion= is =compensated=; =second=, where =compensation= is
=incomplete=; =third=, where =compensation= is =lost=. With all cases
we should give consideration to environment, temperament, habits, food,
clothing, exercise, etc. Often these secondary matters are of vital
importance, especially when compensation is failing. The Schott method
of treatment may be of some avail; this treatment, which is composed of
a series of resistant exercises, tends to lessen peripheral resistance,
develop heart muscle, and remove heart stasis.
Speaking in general, =hypertrophy= and =dilatation= follow valvular
leakage, as a =secondary effect=. It is a compensatory condition, and
whenever compensation is failing, there is naturally a breaking down of
the structural tissues of the heart; that is, the muscular hypertrophy
is losing in integrity. Our primary aim, then, should be to keep up the
compensation, which is represented in the hypertrophy, although there
are cases that fail rapidly, especially in emphysema and cirrhosis
of the lungs. Generally, in hypertrophy and dilatation, there is a
=disproportion between= the =amount of work the heart has to do= and
its =ability= to do it. One of two things has occurred; there is an
increase in peripheral resistance or the volume of blood through the
heart is abnormal in quantity[101]. Loudon[102] says: “The treatment of
chronic disease of the heart requires a longer time, as a rule, than
the same disorder in the acute stage. Some cases cannot be materially
helped; a vast majority may be greatly benefited after a thorough
trial; while more than we might at first suppose, can be entirely
cured. We desire to quote at length from Hare relating to this point.
He says: ‘A chronic structural change in the heart resulting from an
acute process is not always synonymous with chronic heart disease.
Thus, acute endocarditis occasions a variety of changes of the mitral
and aortic valves which long may indicate their presence by their
characteristic murmurs, and yet in time these may wholly disappear.
That many such cases outgrow the valvular trouble, especially mitral
lesions, there can now be no doubt. The majority, even of those in
whom valvular murmurs permanently continue, do not have their health
unfavorably affected for years, and in many of these, the duration
of life is not appreciably shortened.’” This statement, from such an
author, gives the osteopath great encouragement; for add to those
above referred to, which recover in time from all valvular trouble,
the many cases of valvular insufficiency, due to dilatation, owing to
osteopathic lesions to the trophic nerves, and which may be cured by
removing such lesions, we find that quite a percentage of cases are
thus disposed of.
“It is doubtless true, also, that the cases above mentioned having
valvular thickening and vegetations, could have been cured in quicker
time and greater number had osteopathic treatment been given to
tone the heart, upbuild the general circulation and increase the
activities of the excretory organs. The importance of the lungs is
often overlooked in the treatment of cardiac diseases. The osteopath’s
ability to expand the chest and increase the capacity of the thorax
should be demonstrated in both cardiac and pulmonary troubles. It is
said to be a universal law throughout the animal kingdom ‘that muscular
power is directly proportional to the amount of oxygen consumed.’ Hence
give the power, and have your patient live as much out of doors as
practicable. =Exercise= should be =moderate= and always =stopped= short
of =fatigue=.”
Treatment of the abdominal organs should not be neglected, for improved
circulation here and thorough removal of effete products will influence
the heart. Freedom from worry, strains, etc. are essential. Tepid baths
are best.
A person may have a valvular leakage and not be aware of it. Probably
it is best to inform them, except in certain neurotic individuals. For
then they can take special care of themselves, as to overwork, strains
and intercurrent infections, and their life and usefulness be greatly
prolonged.
When compensation begins to break, certain symptoms are noticed,
as heart irregularity, difficult breathing, particularly at night,
shortness of breath, and more or less anemia. Later there is
disturbance of rhythm, cyanosis, dilatation of heart and dropsy.
Frequently, considerable can be accomplished through the upper dorsal
treatment, attention to the chest mobility, manipulation of the
abdominal organs and diaphragm, and special attention to the diet, rest
and some exercise. A light general treatment will assist the labored
circulation and improve assimilation, and a change of climate may be of
benefit.