In every case of mitral disease there comes a period when the pulmonary hyperæmia shows that the compensation of the right heart has failed. An adjustment of the heart to the circulation is now effected by the judicious administration of digitalis. Digitalis should only be given at those times when the heart-failure is imminent and there is marked pulmonary congestion. Half an ounce of the infusion every two hours for twenty-four or forty-eight hours is often required to overcome the heart-failure. The time will come when digitalis ceases to have its sustaining effect upon the heart-muscle; hence it should always be most sparingly and carefully used, and the patient should never be allowed to use it continually.
When the pulse is rapid, feeble, and irregular, more time is needed for the flow of blood into the ventricle, and greater force and regularity in the ejection of the blood from that ventricle are demanded. Digitalis fulfils all these conditions: the pulse becomes regular, beating about sixty per minute, full and forceful. The urine, before scanty, now becomes abundant and normal. Pulmonary engorgement diminishes, and commencing dropsy gradually but totally disappears.
Hayden advises ten minims of the spirits of chloroform and fifteen minims each of the tincture of digitalis and the tincture of the perchloride of iron in an ounce of water every three hours.
Whenever asystolism is present or suppression of urine is threatened, digitalis should be given whether the other indications are present or not. In most cases of mitral stenosis it is best to avoid the use of digitalis as far as possible.
The dropsy which accompanies advanced mitral regurgitation may be promptly relieved by compound jalap powder, combined with calomel in sufficient quantity to produce prompt and free catharsis. In some cases of cardiac dropsy, squill, juniper, brown cream of tartar, and copaiba act as diuretics. This latter drug is best exhibited in the form of the resin.
In mitral reflux a combination of digitalis and nitrous ether will often be found to act as a diuretic. In all cases when a diuretic is given in heart disease the loins should be cupped or warm poultices applied and the bowels freely purged. In copious hæmoptysis in cardiac disease ergotin may be given in full doses either by the mouth or hypodermically.
The hæmoptysis which accompanies pulmonary apoplexy of heart disease sometimes temporarily relieves the dyspnoea. On this basis Dickenson and Fagge and other English writers recommend venesection for the relief of the pulmonary engorgement or heart-failure. Pain in the præcordial region which accompanies valvular insufficiency may sometimes be relieved by the application of leeches over the præcordial space. Hyoscyamus, hydrochlorate of morphia, nitrate of amyl, chloroform, and a belladonna plaster over the præcordial space have all been employed for the same purpose.
It is to be remembered that such pain is the cry of the heart-muscle for a higher degree of nutrition.
Bleeding in heart disease favors dropsy by thinning the blood and by diminishing the heart-power. It should never be resorted to except in great emergencies. Niemeyer advises arsenic and antimony in mitral valvular disease, but does not say in what cases or for what reason they are to be used. When in the late stages of mitral disease the free use of digitalis fails to regulate the pulse and to relieve the pulmonary engorgement, its prolonged administration does harm rather than good; but in every case of mitral disease where the drug has not been used it may be safely affirmed that its administration will give prompt relief.
If it becomes necessary to use an anodyne or hypnotic at any period in the course of mitral valvular disease, morphia hypodermically is to be preferred to all others.