High intestinal obstruction presenting as acute renal failure.

A group of patients with severe mitral stenosis but with multiple features has been analysed separately. Inevitably the operative risk was greater and the prospects of obtaining a good result were poorer, but the majority maintained worth-while improvement for some years. A subgroup with considerable cardiac enlargement, congestive failure, and atrial fibrillation were thought to have important myocardial damage and fared less well. Some degree of traumatic (operative) mitral incompetence, as judged by auscultation, was produced in 97 (20%) of cases. In 72 of these there is nothing to suggest that the systolic murmur reflects mitral incompetence of dynamic significance. In 14 patients (2.8% of the whole series) it is thought that the incompetence produced was responsible for death or for subsequent deterioration, and in another 11 (2.2%) it is a possible contributory cause; but other adverse factors are also present which could be responsible. Since the introduction of the transventricular dilator there has been a higher incidence of systolic murmurs produced but not of traumatic incompetence of dynamic significance. Clot was present in 107 of the 500 patients and systemic embolism occurred in 20% of those with clot. Clot is most likely to be present in those with atrial fibrillation, large hearts, calcified valves, and relatively advanced years. Embolism with sinus rhythm is rare but occurred in 10% of all those with atrial fibrillation. This incidence has fallen during the past five years. Subsequent embolism has occurred in 16 patients, but it is not yet possible to assess if this would have been greater without valvotomy. It is concluded from this analysis that, although most patients with severe mitral stenosis are improved by valvotomy, surgical treatment is but an incident in the relentless progress of rheumatic heart disease, whether from activity of the rheumatic process or from the progressive fibrosis which follows activity.