If the valvular lesion is severe, it is essential for the proper
maintenance of the circulation that certain changes should take
place in the heart to compensate for or neutralize the effects of
the regurgitation or obstruction, as the case may be. In affections
of the aortic valve, the extra work falls on the left ventricle,
which enlarges proportionately and undergoes hypertrophy. In
affections of the mitral valve the effect is felt primarily by the
left auricle, which is a thin walled structure incapable of undergoing
the requisite increase in power to resist the backward flow
through the mitral orifice in case of leakage, or to overcome the
effects of obstruction in case of stenosis. The back pressure is
therefore transmitted to the pulmonary circulation, and as the
right ventricle is responsible for maintaining the flow of blood
through the lungs, the strain and extra work fall on the right
ventricle, which in turn enlarges and undergoes hypertrophy.
The degree of hypertrophy of the left or right ventricle is thus,
up to a certain point, a measure of the extent of the lesion of the
aortic or mitral valve respectively. When the effects of the
valvular lesion are so neutralized by these structural changes in
the heart that the circulation is equably maintained, “compensation”
is said to be efficient.
When the heart gives way under the strain, compensation is said to break down, and dropsy, shortness of breath, cough and cyanosis, are among the distressing symptoms which may set in. The mere existence of a valvular lesion does not call for any special treatment so long as compensation is efficient, and a large number of people with slight valvular lesions are living lives indistinguishable from those of their neighbours. It will, however, be readily understood that in the case of the more serious lesions certain precautions should be observed in regard to over-exertion, excitement, over-indulgence in tobacco or alcohol, &c., as the balance is more readily upset and any undue strain on the heart may cause a breakdown of compensation. When this occurs treatment is required. A period of rest in bed is often sufficient to enable the heart to recover, and this may be supplemented as required by the administration of mercurial and saline purgatives to relieve the embarrassed circulation, and of suitable cardiac tonics, such as digitalis and strychnin, to reinforce and strengthen the heart’s action.
2. Affections of the Muscular Wall of the Heart.—Dilatation of the heart, or stretching of the walls of the heart, is an incident, as has already been stated, in pericarditis and in the earlier stages of valvular disease antecedent to hypertrophy. Temporary over-distension or dilatation of the cavities of the heart occurs in violent and protracted exertion, but rapidly subsides and is in no wise harmful to the sound and vigorous heart of the young. It is otherwise if the heart is weak and flabby from a too sedentary life or degenerative changes in its walls or during convalescence from a severe illness, when the same circumstances which will not injure a healthy heart, may give rise to serious dilatation from which recovery may be very protracted.
Influenza is a common cause of cardiac dilatation, and is liable to be a source of trouble after the acute illness has subsided, if the patient goes about and resumes his ordinary avocations too soon.
Fatty or fibroid degeneration of the heart wall may occur in later life from impaired nutrition of the muscle, due to partial obstruction of the blood-vessels supplying it, when they are the seat of the degenerative changes known as arteriosclerosis or atheroma. The affection known as angina pectoris (q.v.) may be a further consequence of this defective blood-supply.
The treatment will vary according to the nature of the case. In serious cases of dilatation, rest in bed, purgatives and cardiac tonics may be required.
In commencing degenerative change the Oertel treatment, consisting of graduated exercise up a gentle slope, limitation of fluids and a special diet, may be indicated.
In cases of slight dilatation after influenza or recent illness, the Schott treatment by baths and exercises as carried out at Nauheim may be sometimes beneficial. The change of air and scene, the enforced rest, the placid life, together with freedom from excitement and worry, are among the most important factors which contribute to success in this class of case.
Disorders of Rhythm of the Heart’s Action.—Under this heading may be grouped a number of conditions to which the name “functional affections of the heart” has sometimes been applied, inasmuch as the disturbances in question cannot usually be attributed to definite organic disease of the heart. We must, of course, exclude from this category the irregularity in the force and frequency of the pulse, which is commonly associated with incompetence of the mitral valve.
The heart is a muscular organ possessing certain properties, rhythmicity, excitability, contractility, conductivity and tonicity, as pointed out by Gaskell, in virtue of which it is able to maintain a regular automatic beat independently of nerve stimulation. It is, however, intimately connected with the brain, blood-vessels and the abdominal and thoracic viscera, by innumerable nerves, through which impulses or messages are being constantly sent to and received from these various portions of the body. Such messages may give rise to disturbances of rhythm with which we are all familiar. For instance, sudden fright or emotion may cause a momentary arrest of the heart’s action, and excitement or apprehension may set up a rapid action of the heart or palpitation. Palpitation, again, is often the result of digestive disorders, the message in this case being received from the stomach, instead of the brain as in emotional disturbances. It may also result from over-indulgence in tobacco and alcohol.
Tachycardia is the name applied to a more or less permanent increase in the rate of the heart-beat. It is usually a prominent feature in the affection known as Graves’ disease or exophthalmic goitre. It may also result from chronic alcoholism. In the condition known as paroxysmal tachycardia there appears to be no adequate explanation for its onset.
Bradycardia or abnormal slowness of the heart-beat, is the converse of tachycardia. An abnormally slow pulse is met with in melancholia, cerebral tumour, jaundice and certain toxic conditions, or may follow an attack of influenza. There is, however, a peculiar affection characterized by abnormal slowness of pulse (often ranging as low as 30), and the onset, from time to time, of epileptiform or syncopal attacks. To this the name “Stokes-Adams disease” has been applied, as it was first called attention to by Adams in 1827, and subsequently fully described by Stokes in 1836. It is usually associated with senile degenerative change of the heart and vascular system, and is held to be due to impairment of conductivity in the muscular fibres (bundle of His) which transmit the wave of contraction from the auricle to the ventricle. It is of serious significance in view of the symptoms associated with it.
Intermittency of the Pulse.—By this is understood a pulse in which a beat is dropped from time to time. The dropping of a beat may occur at regular intervals every two, four or six beats, &c., or occasionally at irregular intervals after a series of normal beats. On examining the heart, it is found, as a rule, that the cause of the intermission at the wrist is not actual omission of a heart-beat, but the occurrence of a hurried imperfect cardiac contraction which does not transmit a pulse-wave to the wrist. It is not characteristic of any special form of heart affection, and is rarely of serious import. It may be due to reflex digestive disturbances, or be associated with conditions of nervous breakdown and irritability, or with an atonic and relaxed condition of the heart muscle. The treatment of these disorders of rhythm of the heart will vary greatly according to the cause and is often a matter of considerable difficulty. (J. F. H. B.)
Surgery of Heart and Pericardium.—As the result of acute or chronic inflammation of the lining membrane of the fibrous sac which surrounds the heart and the neighbouring parts of the large blood-vessels, a dropsical or a purulent collection may form in it, or the sac may be quietly distended by a thin watery fluid. In either case, but especially in the latter, the heart may be so embarrassed in its work that death seems imminent. The condition is generally due to the cultivation
