Sub-acute and Chronic Endocarditis. This is comparatively frequent, and may succeed the acute form. Valvular lesions are many, and their location different, but the mitral valves are most commonly affected, either alone or in common with the others. Porak found mitral insufficiency in twenty-two cases, stenosis in thirteen, both condi tions being present in twenty-two, making fifty-seven in all; the aortic valves were affected in thirteen cases, insufficiency being noted nine times and stenosis twice, both being present in two cases. In twenty two other cases, the two valves were simultaneously involved. These lesions may be well borne by the women, but cardiac troubles may arise, presenting, according to Porak, four variations, viz.: 1st. There may be disturbance of the heart's innervation, leading to palpitation of a more or less irregular character, which increases with the progress of the pregnancy and is accompanied by dyspncea, attacks of oppression, generally transient, but sometimes very violent and attended with ver tigo, head-ache, precordial pains, but no physical signs pointing to the lungs. More usually the woman is disturbed and oppressed, but has no attacks except on making strong efforts or movements. She com plains of short breath rather than palpitation and of syncope; in time the dyspncea increases, so that the patient is obliged to remain in bed in a semi-recumbent attitude, every movement being followed by palpi tation and syncope, and increasing the dyspncea. Most often the condition is complicated by pulmonary congestion and cedema, whiclt increases as the pregnancy advances, and may be accompanied by hwmoptysis, apoplexy, epistaxis, hematemesis, etc., troubles which ussume an exceptional gravity. A third variety is asystole, which may be more or less marked, and may cause greater or less disturbances of the general circulation leading to ascites hydro-thorax secondary affections of the liver and kidneys, etc. Emboli may occur in a fourth variety, which, when carried to the liver, kidneys, lungs. or brain, will cause various symptoms. A.11 the foregoing phenomena may bo con founded, united, or may appear more or less simultaneously and perfectly, according to the accessory circumstances umil C11111091, All heart-lesions do not present the same frequency and gravity. Thu mitral lesion is the most common; next to this, pulmonary congomtion /fir and oedema. Affections of the aortic valves are much more rare, are generally better tolerated, and give rise t,o few symptoms; finally, lesions involving the right side of the heart are still more grave, since they lead very rapidly to asystole and its consequences.
As a rule, the cardiac troubles of pregnancy do not acquire the maximum intensity until after the first congestion. Though borne pretty well at first, they reappear with more intensity at each new preg nancy, until the storm breaks forth with its full fury and attains its height at the moment of delivery. After delivery a marked amelioration usually occurs; there is, at the same time, to use Peter's words, "a maternal and cardiac delivery." But at each new pregnancy there is an exacerbation, and the patients succumb to the cardiac cachexia. Death usually occurs during the puerperal state. Porak noted the following conditions in eighty-four cases of pregnant women suffering from cardiac troubles: The condition remained stationary in twenty-one, was aggravated during pregnancy in fifty-five, and during labor in eleven. Ameliora
tion after delivery was noted in twenty-two cases, thirty-one women died, five before delivery, two during delivery, and twenty-Eve during the puerperium. We may say, then, without hesitation, that pregnancy hastens the course of cardiac diseases, and predisposes particularly to pulmonary congestion and embolism.
The Influence of Cardiac Diseases on Pregnancy.—Diseases of the heart show their influence on pregnancy, by c,ausing metrorrhagia, premature delivery, and abortion, and by causing the death of the fcetus, either directly on account of the mother's affection, or in con sequence of changes in the placenta..
I. Metrorrhagia.—Attacks of metrorrhagia may be produced at the usual time of the menstrual flow, and may thus give rise to the belief that menstruation persists during pregnancy, but they differ from it as regards both the amount and the quality of the -blood, and the duration of the flow. Duroziez has reported several case,s. Metrorrhagia may occur before the expulsion of the fcetus, but it is especially observed at the time of delivery; it accompanies premature delivery and abortion, and is usually referable to uterine inertia. The hemorrhage may be so excessive as to threaten the life of the woman.
II. _Abortion and Premature Labor.—These are very frequent, and the children who are born at full term do not live long. According to Casanova, they do not occur except in the case of women in whom the valvular lesion has already been manifested by symptoms more or less marked, as dyspncea and palpitations. They reappear with so much the more readiness, according as there have been previous pregnancies. He believes that, in more than half of the cases, the pregnancy is not com pleted, and that the child may be born in three conditions—dead, living, or expelled prematurely. According to See, the fcetus perishes from asphyxia and inanition, because it no longer finds in the vitiated blood of the mother either the oxygen or the other materials necessary for its nutrition. It then bocomes a foreign body, which is soon expelled from the uterine cavity.
The I'mtus is born most rational explanation of this is that of Brown-Sequard and Marty, which is as follows. Venous blood stimulates the nerve-centres and contractile tissues; oxygen furnishes the contractile force, carbonic acid sets it in motion. In this way is 'produced the contraction of the uterus, which is so useful throughout the entire course of pregnancy, in preventing stagnation of the blood in the uterine sinuses and plexuses. But, as soon as some cause disturbs the general cir culation, and increases the embarrassment of the uterine circulation (car diac or pulmonary disease), the uterine contractions become so strong as to exceed the physiological limit, producing either abortion, or premature delivery. Abortion re,sults from congestion and hemorrhage into the placental tissue, separating the placenta, and extending within the uterus as in other organs. Duroziez noted 21 miscarriages among 41 women with heart disease, 5 were delivered at six months. and 37 of the children who were born alive, died before reaching five years. Among 220 cases collected by Courrejol and Porak, 128 were delivered at terms.