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Decompensation





Category: Uncategorized
Source: 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.





Next: Physics Of Mitral Stenosis

Previous: Precautions To Be Observed



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