Decompensation


Categories: Uncategorized
Sources: Disturbances Of The Heart

To understand the physiology, pathology and the best treatment for

broken compensation, it is necessary to study the physics of the

circulation under the different conditions. With the mitral valve

insufficient, a greater or less amount of blood is regurgitated into

the left auricle, which soon becomes dilated. Distention of any

hollow muscular organ, if the distention is not to the point of

paralysis, means a greater inherent or reflex attempt of that organ

to evacuate itself; the muscular tissue begins to grow, and a

hypertrophy of the left auricle with the above-named lesion

develops. The muscular tissue of the auricle, however, is not

sufficient to allow any great hypertrophy. The blood flowing from

the pulmonary veins into the left auricle finds this cavity already

partly filled with blood regurgitated from the left ventricle. The

pulmonary blood, being impeded, tends to flow more slowly, and

therefore dams back into the lungs, causing a passive congestion of

the lungs. The pulmonary artery thus finds the pressure ahead

unusually great, and the right ventricle reflexly learns that it

requires a greater force to empty itself than before; in fact, it

may not succeed in completely accomplishing this until its

distention, by an incomplete evacuation of its contained blood plus

the blood coming from the right auricle, has caused the right

ventricle also to become hypertrophied. This increased muscular

action of the right ventricle relieves the pulmonary congestion, and

an increased amount of blood is forced into the left auricle. On

account of its hypertrophy, the left auricle is able to send an

increased amount of blood into the left ventricle, which in turn

becomes hypertrophied and sends enough blood into the aorta to

satisfy the requirements of the systemic circulation in spite of the

leakage through the mitral valve.



As long as this compensation continues, there are no symptoms. If

any dilatation occurs from disease, degeneration or from increased

work put on the heart (and it is readily seen how delicate this

equilibrium is), signs of broken compensation begin to occur. The

left ventricle with its enormous strain is perhaps the first part to

dilate, thus enlarging the opening of the defective mitral valve.

The left auricle is then unable to cope with the increased amount of

regurgitant blood, and there is in consequence congestion in the

lungs, and the right ventricle finds the pressure ahead in the lungs

greater than it can well overcome. The right ventricle, in its turn

being overworked, becomes dilated, and as a result of the inability

of the right ventricle to evacuate its contents perfectly, the right

auricle is unable to force its venous blood into the right

ventricle, and there is then a damming back and sluggish circulation

in the superior and inferior venae cavae. The results of these

circulatory deficiencies are, in the first place, congestion of the

lungs and dyspnea; in the second place, with the impaired force of

the left ventricle making the arterial circulation imperfect, and

with the impaired return of venous blood to the right auricle making

the venous circulation sluggish, passive congestions of various

organs occur and are evidenced in headache and venous congestion of

the eyes and throat, with perhaps cerebral irritability,

sleeplessness, and inability to do good mental work. The sluggish

return of the blood in the inferior vena cava causes primarily a

sluggish portal circulation with a passive congestion and

enlargement of the liver. This causes imperfect bile secretion and

an imperfect antidotal action to the various toxins of the body or

to any alkaloidal drugs or poisons ingested. This congestion of the

liver causes a damming back of the blood in the various veins of the

portal system, which causes congestion of the stomach and of the

mucous membrane of the bowels, and an imperfect secretion of the

digestive fluids of these structures. There is also congestion of

the spleen. The imperfect return of the blood through the inferior

vena cava also interferes with the return of the blood through the

renal veins, and more or less renal congestion occurs, with a

concentrated urine and perhaps an albuminuria as the result. The

same sluggish flow of the inferior vena cava blood, plus the

imperfect tone of the systemic arterial system, means that the

circulation at the distal portions of the body--the feet and the

legs--is imperfect when the patient is up and about, with the result

of causing pendant edemas, which disappear at night when the patient

is at rest and the heart more easily accomplishes its work.



The physical signs of such a heart, the increased valvular murmur or

murmurs, its irregular action, possibly intermittence or irregular

contractions of different parts of the heart, causing diocrotic or

intermittent pulse with a lowered blood pressure, are all signs

readily found. The quickened respiration is Nature's method of

aiding the return circulation in the veins by increasing the

negative pressure in the chest. The increased number of pillows the

patient requires at night is to aid Nature's need to have a better

venous return circulation in the vital centers at the base of the

brain.



The dry, troublesome, tickling cough is generally due to a

congestion of the blood vessels at the base of the tongue, in the

lingual tonsil region, or possibly in the larynx. Later the passive

congestion of the lungs may be sufficient to cause a bronchitis,

with cough and expectoration.



Sometimes, as indicative of primary cardiac distress, these patients

have sharp pains through the heart. Such pains are the exception

rather than the rule, and are more likely to occur in chronic

myocarditis or in coronary disease: in other words, in true angina

pectoris.



If there is considerable venous congestion there may be more or less

frequent recurrent venous hemorrhages. This frequently is an

epistaxis, or a bleeding from hemorrhoids, or in women profuse

menstruation or a metrorrhagia.



It is perfectly understandable from the physics of the condition of

broken compensation that anything which improves the tone of the

heart and makes it again compensatory removes all of these many

disabilities, congestions and subacute inflammations. If, however,

these passive congestions are long continued, some organs soon

become chronically degenerated. This is especially true of the liver

and kidneys.





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