Disturbances of the Heart / Discussion of the Treatment of the Heart in Its Various Disorders, With a Chapter on Blood Pressure

by Oliver T. Osborne

MITRAL STENOSIS: MITRAL NARROWING

This particular valvular defect occurs more frequently in women than in men, and between the ages of 10 and 30, and is generally the result of rheumatic endocarditis or chorea, perhaps 60 percent of mitral stenosis having this origin. Other causes are various infections or chronic disease, such as nephritis. Of course, like any valvular lesion, it may be associated with other lesions, and sooner or later in many instances, when the left ventricle becomes dilated or weakened, mitral insufficiency also occurs.

It has sometimes seemed that high blood pressure has caused the left ventricle to act with such force as to irritate this mitral valve, and later develop from such irritation a sclerosis or narrowing, and stenosis occurs. It has been suggested that, though lime may be of advantage in heart weakness, as will be stated later, if the blood is overfull of calcium ions the valvular irritations may more readily have deposits of calcium, in other words, become calcareous, and therefore cause more obstruction. It is quite likely, however, that this sort of deposit is only a piece of the general calcification of tissue in arteriosclerosis and old age, and could not be caused by the administration of calcium to a younger patient, and might then occur in older patients even if substances containing much calcium were kept out of the dict. Calcium metabolisim in arteriosclerosis and in softening of the bones is not well understood.

Patients with this lesion are seriously handicapped when any congestion of the lungs occurs, such as pneumonia, pleurisy, or even bronchitis. Asthma is especially serious in these cases, and these patients rarely live to old age.

The pulse is generally slow, unless broken compensation occurs; dyspnea on exertion is a prominent symptom; the increased secretion of mucus in the bronchial tubes and throat is often troublesome, and there is liable to be considerable cough. If these patients have an acute heart attack, a feeling of suffocation is their worst symptom and the dyspnea may be great, although there may be no tachycardia, these hearts often acting slowly even when there is serious discomfort. When compensation fails, there is an occurrence of all the usual symptoms, as previously described.

The distinctive diagnostic physical sign of this lesion is the diastolic and perhaps presystolic murmur heard over the left ventricle, accentuated at the apex and transmitted some distance to the left of the heart. There is also an accentuated pulmonary closure. To palpation this lesion often gives a characteristic presystolic thrill at and around the apex.

The first symptoms of weakening of the compensation are irregularity in the beat and venous congestion of the head and face, causing bluing of the lips, often nosebleed, and sometimes hemoptysis and insomnia. Later the usual series of disturbances from dilatation of the right ventricle occurs. As previously stated, with the absence of good coronary circulation and the consequent impaired nutrition, the left ventricle may also dilate and the mitral valve may become insufficient. Sudden death from heart failure may occur with this lesion more frequently than with mitral insufficiency but less frequently than with aortic insufficiency.

A particularly dangerous period for women with this lesion is when the blood pressure rises after the menopause and the patients become full-blooded and begin to put on weight. Also, these patients always suffer more or less from cold extremities. In most cases they sleep best and with least disturbance with the head higher than one pillow.

Besides the usual treatment for broken compensation in patients with this lesion, digitalis is of the greatest value, and the slowing of the heart by it, allowing the left ventricle to be more completely filled with the blood coming through the narrowed mitral opening during the diastole, is the object desired. This drug acts similarly on both the right and left ventricles, and though there is no real occasion for stimulation of the left ventricle, and it is the right ventricle that is in trouble, dilated and failing, still a greater force of left ventricle contraction helps the peripheral circulation. The action on the right ventricle contributes greatly to the relief of the patient by sending the blood through the lungs and into the left auricle more forcibly. and the left ventricle receives an increased amount of blood, the congestion in the lungs is relieved, and the dyspnea improves. Perhaps there is no class of cardiac diseases in which more frequent striking relief can be obtained than in these cases of mitral stenosis.

If the congestion of the lungs is very great, and death seems imminent from cardiac paralysis, if cyanosis is serious, and bloody. frothy mucus is being expectorated, venesection and an intramuscular injection of aseptic ergot may be indicated. Digitalis should also be given, hypodermically perhaps, but its action would be too late if it was not aided by other more quickly acting drugs. The physician may often save life by such radical measures.