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Mitral Stenosis: Mitral Narrowing
Source: Disturbances Of The Heart
This particular valvular defect occurs more frequently in women than
in men, and between the ages of 10 and 30, and is generally the
result of rheumatic endocarditis or chorea, perhaps 60 percent of
mitral stenosis having this origin. Other causes are various
infections or chronic disease, such as nephritis. Of course, like
any valvular lesion, it may be associated with other lesions, and
sooner or later in many instances, when the left ventricle becomes
dilated or weakened, mitral insufficiency also occurs.
It has sometimes seemed that high blood pressure has caused the left
ventricle to act with such force as to irritate this mitral valve,
and later develop from such irritation a sclerosis or narrowing, and
stenosis occurs. It has been suggested that, though lime may be of
advantage in heart weakness, as will be stated later, if the blood
is overfull of calcium ions the valvular irritations may more
readily have deposits of calcium, in other words, become calcareous,
and therefore cause more obstruction. It is quite likely, however,
that this sort of deposit is only a piece of the general
calcification of tissue in arteriosclerosis and old age, and could
not be caused by the administration of calcium to a younger patient,
and might then occur in older patients even if substances containing
much calcium were kept out of the dict. Calcium metabolisim in
arteriosclerosis and in softening of the bones is not well
Patients with this lesion are seriously handicapped when any
congestion of the lungs occurs, such as pneumonia, pleurisy, or even
bronchitis. Asthma is especially serious in these cases, and these
patients rarely live to old age.
The pulse is generally slow, unless broken compensation occurs;
dyspnea on exertion is a prominent symptom; the increased secretion
of mucus in the bronchial tubes and throat is often troublesome, and
there is liable to be considerable cough. If these patients have an
acute heart attack, a feeling of suffocation is their worst symptom
and the dyspnea may be great, although there may be no tachycardia,
these hearts often acting slowly even when there is serious
discomfort. When compensation fails, there is an occurrence of all
the usual symptoms, as previously described.
The distinctive diagnostic physical sign of this lesion is the
diastolic and perhaps presystolic murmur heard over the left
ventricle, accentuated at the apex and transmitted some distance to
the left of the heart. There is also an accentuated pulmonary
closure. To palpation this lesion often gives a characteristic
presystolic thrill at and around the apex.
The first symptoms of weakening of the compensation are irregularity
in the beat and venous congestion of the head and face, causing
bluing of the lips, often nosebleed, and sometimes hemoptysis and
insomnia. Later the usual series of disturbances from dilatation of
the right ventricle occurs. As previously stated, with the absence
of good coronary circulation and the consequent impaired nutrition,
the left ventricle may also dilate and the mitral valve may become
insufficient. Sudden death from heart failure may occur with this
lesion more frequently than with mitral insufficiency but less
frequently than with aortic insufficiency.
A particularly dangerous period for women with this lesion is when
the blood pressure rises after the menopause and the patients become
full-blooded and begin to put on weight. Also, these patients always
suffer more or less from cold extremities. In most cases they sleep
best and with least disturbance with the head higher than one
Besides the usual treatment for broken compensation in patients with
this lesion, digitalis is of the greatest value, and the slowing of
the heart by it, allowing the left ventricle to be more completely
filled with the blood coming through the narrowed mitral opening
during the diastole, is the object desired. This drug acts similarly
on both the right and left ventricles, and though there is no real
occasion for stimulation of the left ventricle, and it is the right
ventricle that is in trouble, dilated and failing, still a greater
force of left ventricle contraction helps the peripheral
circulation. The action on the right ventricle contributes greatly
to the relief of the patient by sending the blood through the lungs
and into the left auricle more forcibly. and the left ventricle
receives an increased amount of blood, the congestion in the lungs
is relieved, and the dyspnea improves. Perhaps there is no class of
cardiac diseases in which more frequent striking relief can be
obtained than in these cases of mitral stenosis.
If the congestion of the lungs is very great, and death seems
imminent from cardiac paralysis, if cyanosis is serious, and bloody.
frothy mucus is being expectorated, venesection and an intramuscular
injection of aseptic ergot may be indicated. Digitalis should also
be given, hypodermically perhaps, but its action would be too late
if it was not aided by other more quickly acting drugs. The
physician may often save life by such radical measures.
Next: Mitral Insufficiency: Mitral Regurgitation
Previous: Symptomatology And Treatment Of Chronic Valvular Lesions