No. 3666.

DECEMBER 2, 1893.

A Clinical LectureON

MITRAL STENOSIS.Delivered at the London, Hospital,

BY THE LATE SIR ANDREW CLARK, BART.,M.D. ABERD., F.R.S.

IN view of the recent removal from amongst us of one of’the leading clinical teachers of London, we have thought itwould be of interest to publish the following report of one ofSir Andrew Clark’s cliniques. It formed one of the series of

,demonstrations which, as consulting physician to the LondonHospital, he gave there two years ago. We have publishedprevious lectures given in this course on other subjectswhich had the advantage of the lamented physician’spersonal revision ; but that, alas, can no longer be obtained.On the occasion when this lecture was delivered the patient-.a young man, pale and thin-was seated on a chair in the newclinical theatre, then opened by Sir Andrew Clark. In replyto the question, "What do you feel wrong with you"? thepatient replied : " am troubled with shortness of breath, afeeling of exhaustion, a feeling of oppression at the pit of the.stomach, a sickish feeling, and have no appetite. "

Sir Andrew Clark, in the course of his examination, madethe following observations : He has five important sym-ptoms. Look at him. There is not much to be said aboutMs appearance. He is a spare man, and I fancy he isa little yellow. It is rather important to notice that.He complains of shortness of breath and he says thate has heart disease. We will go to his heart first.I shall look at the region of the heart in order tosee if there is anything wrong there. I shall want to:see that the heart is beating in the right place and if theimpulse which the heart makes in beating is of the rightsort. I have already told you, but I cannot tell you toooften, though you may get tired of my telling you, that thedirst thing you ought always to do when examining a chestis to see where the heart beats, because that will almost morethan anything else enable you to frame an accurate diagnosis.

. I find that in this case the heart is beating a little outside of’its usual place and that the area of impulse is larger than is’usual. The heart is beating irregularly ; sometimes it stops,and then it goes on again. Now, I have learned a good’deal about this case already. It is something to see the heartto the left of its usual position. It may be that theoheart itself is big, or it may be that something is pushingit on one side. I notice that the heart is larger thanusual because the area of impulse is larger than usual, and.-also because the general pr2ecordium, the region in front ofthe heart, has conveyed the movement of a larger heart’than usual.Now I willfeel the heart. I may discover something by doing

that. In placing my hand upon the heart I am expecting tofeel the lub-dub " which indicates the normal action of’the heart. I do not feel that in this case, but I feel a thrill-a peculiar thrill ; what that may mean I do not yet know.Now I will examine the area of cardiac dulness and see

whether it is extended or diminished. Sometimes the area"of cardiac dulness is very much increased--sometimes verymuch diminished. It may be increased by enlargement of’the heart or by pericardial effusion or diminished by-emphysematous lung encroaching in front of the heart.There is the upper limit-that is, the upper surface of thethird rib-and it merges below into the dulness of the liver.’It goes outwards about one inch or more beyond the nipple.It is apparently three and a half, nearly four, inches in depthfrom the upper line to the base and about three and a halfinches across. Therefore this superficial examination showsas that the cardiac dulness is greatly increased.

I will now listen to the heart, and I first place my stetho-scope over the mitral area in order to hear the sound of thecaitral valve. When I listen over the mitral area I expect’&Igrave;o hear - first sound, second sound, pause. But in this,case confusion meets my ear ; there is no distinct succession<of sounds. I do manage to catch occasionally the first sound,No. 36M

and occasionally the second sound, but they are confused,and through them I hear a murmur the exact time of which Iam not quite sure of. I will therefore listen again. On a morecritical examination I hear two first sounds. The heart is whatwe call reduplicated-some say the ventricles are not actingsynchronously. Secondly, I catch a slight murmur with thesecond sound ; and thirdly, during or before the first sound,I hear a rough, roaring murmur just antecedent to the con-traction of the ventricles and accompanying the contractionof the auricles.Now I will go to the aortic area in order to hear the second

sound of the heart. What I expect to hear at this point inhealth is the sharp second sound. I do not hear it. Insteadof it I hear a short, obscure sound accompanied by amurmur, systolic in time ; and on listening very closely Ican hear doubtfully another murmur, diastolic in time. Ihave learned a good deal about the heart now. I know thatthe mitral valve is in some way imperfect and that the aorticvalve is in some way imperfect also.Now I want to look about and get fresh information as to

the state of the heart from the neighbouring parts. Ilook at the vessels of the neck. I learn nothing fromthem. I might have seen these vessels very much dis-tended, and I would then know that the circulation wasnot getting through the lung. I might have seen regurgi-tation through the vessels of the neck and then I wouldlearn that there was some reflux of blood into them.On examining the pulse I feel that it is very small, veryweak and irregular-tbere is no tension, as it is called, nostrength in ic. Now I have got pretty nearly all the factsthat I want I know that the heart is enlarged, the mitraland aortic valves are imperfect; and I know that somethinghas prevented the passage outwards of blood to the arteries.The volume of blood is very small, there is something some-how or other preventing the free passage of the blood into thearteries. What can it be ? 7

I must endeavour to see whether anything can be found inthe lungs that will explain the condition of the heart. Hetells us he has got dyspnoea and a bad cough. There is slightdulness of both bases ; harsh breathing, with occasional crepi-tation on his taking a deep breath. Now leaving the heart andlungs for a moment let us see what is the state of the systemin the presence of this disease. Then we will return to theheart, and try to see if by our diagnosis we can tell what isthe matter with this patient and unfold its relations with theother systems.Having examined the digestive track, the state of the urine,

and the condition of the nervous system, Sir Andrew Clarkcontinued : Thus you see we have been able to make out inthis rough clinical way-but yet sufficiently accurately for.our purpose-that, except what is connected with his heartand his lungs, there is nothing else wrong ; and the first thingwe have got to ask is, What is the matter with his heart ?The first thing is that it is enlarged and dilated. We knowthat by the extension of the cardiac area and by the extensionof the area of impulse. Secondly, the mitral valve is imperfect.How imperfect ? 7 We know that for two reasons-becausethere is a murmur in the mitral area. and that murmur is notaccompanying and consequent upon the first sound and is ofa roaring character. What is it ? 7 It is one of two things cer-tainly : either mitral regurgitation or mitral stenosis. It is notmitral regurgitation, because the murmur is not of the kind orin the time which accompanies a murmur of regurgitation.A mitral regurgitation murmur occurs during, or just imme-

di-ately after, the first sound. It is not of that kind. The

regurgitant murmur is a sighing murmur ; this is a roaringmurmur. Is it really, then, mitral stenosis which, as you mayknow, is a disease very uncommon in men ? 7 When Ilisten to the heart I have constantly in my mind whatis going on in the heart at the time that I am listening,and if I omit that I am always in peril of overlooking some-thing or of making a mistake. I put my ear to the chestand I hear the first sound, and I recall to my mind what isoccurring during the first sound-the contraction of theventricles, the closure of the auriculo-ventricular valves, therushing of the blood through the pulmonary orifice and theaorta, the entrance of blood through the pulmonary veins intothe auricles-these are the main things that are occurring,and it is necessary for me to have them in my mind at thetime. If I do not, and if there is anything new, I shall notknow how to explain it.

Secondly, we hear the second sound, and I ask myself,What is occurring all through the heart at the time of thissecond sound ? 7 Well, there is the flapping back of the aortic

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and pulmonary valves, the relaxing of the ventricles, theopening of the auriculo-ventricular valves, the filling of theventricles with blood. I have all these things in my mindwhen I am listening to the second sound of the heart.And, lastly, there comes the pause which follows the second

sound ; then the auricles are filling more and more, and theventricles are relaxing and taking in more and more blood.Suddenly, at the end of the pause, the auricles contractand force the blood into the ventricles.

These are the things that occur during the first andsecond sound and the pause, and these are the thingsthat you must have constantly in mind when you are listeningto the heart. Now I listen here, and just before the firstsound we hear a roaring murmur. What would happen if therewas any impediment at the mitral orifice, any fusion of thevalve-segments, offering an obstruction to the blood-flow? Theauricles would produce a noise just at this very time, justbefore the contraction of the ventricles. So, I suspect, hearingthe murmur just before the contraction, that there is somesort of contraction of the mitral orifice, which, having theblood forced through it by the contracting of the auricles,produces a presystolic murmur, as it is called. But that isnot all. Listening very carefully to the heart, we hear, inaddition to this roaring sound, another sound of an acutecharacter, and it is just after this sound. I suspect that thatis, and indeed must be, a little mitral regurgitation. Thereis nothing else it can be at the time. If I hear a soundof that character coincident with the contraction of theventricles it must be mitral regurgitation. I makeout here that there is a mitral stenosis and mitralregurgitation. How can I be sure of that? Are the factswhich I have mentioned quite conclusive ? They may not be.I will see if I can confirm them. If the auriculo-ventricularorifice is contracted, then the auricle, by repeated endeavoursto force the blood through it, will have become a little

enlarged, and I ascertained on previous examination that Ican feel the auricles, just obscurely, through the chest wall.That is the first collateral proof of the existence of stenosis.I can feel the auricles beating. Then if this is really stenosisthere will be congestion of the lungs, because if the blood-vessels of the lung cannot empty themselves freely there willbe a back tide of blood upon the lung, and we hearthat there are crepitations about the base of the lung, andwe suspect that he has more or less congestion of the lungs-otherwise we cannot account for his cough and shortnessof breath, nor for his bleeding occasionally. So hereis additional proof of a contracted mitral orifice. If itis true that an insufficient quantity of blood gets into theleft ventricle, then it must be true that a small quantityof blood must be sent through the arteries and thereshould be a small pulse. I told you that he had a very small

pulse. Last of all, if there is any contraction and roughnessof the mitral orifice, and if the auricles have difficulty inpushing the blood through, it is very likely that the auricleswill produce in their efforts to pass through a very narrowauriculo-ventricular orifice a murmur which will be feltas a thrill when the hand is laid upon it. And thereis a thrill here. So that there is in my own mind nowno doubt whatever that with an enlarged heart we havecontracted mitral disease and a little mitral regurgitation.I will ask now, What is the meaning ?-for a diagnosis to beof any use ought to cover all the facts of the case. Wehave a slight systolic murmur at the aortic orifice, whichmeans a little obstruction or constriction, or roughing of theaortic orifice ; but I said that I heard now and again alittle regurgitant diastolic murmur-tbat is not quite so sure,but I think so, and therefore we say an enlarged heart, amitral contraction, mitral regurgitation, and imperfect aorticvalve.Now, that is the whole story of the diagnosis.The next question we have to ask is, Is it sufficient to account

for all the symptoms of the patient ? Why is he yellow ? Hehas apparently a little bronchial catarrh and some congestion ofthe liver. He must have them more or less, and every personwith mitral constriction has these symptoms in some degree.The bloodvessels of the lung cannot empty themselves freelythrough the left ventricle. If that be so, the vena cava and itscontributories cannot empty themselves, and there may bea back tide of blood upon the liver or upon the stomach.The diagnosis covers that fact and declares to me that hemust have congestion and catarrh of his liver. Will it explainall the symptoms ? It has explained his cough, bleeding,shortness of breath, and I have just now said it explained hisicteroid hue. Does it explain his exhaustion ? Well, yes,

a because the blood is stagnating in the deep parts of the bodyand an inadequate supply is sent through the arteries, th

l nervous system is imperfectly nourished, and the muscular’system suffers because such a small quantity of blood is pass-

1 ing through the vessels. That is the diagnosis which I thinkyou, in seeing this patient for the first time, would probably

. make. -

t Now one of the first questions which the friends wiDask you in reference to a case of this kind is, What

l is to be the termination of a case of this kind ? Youi must be ready to answer it. The prognosis of a case

of this kind is exceedingly grave. The prognosis of many; cases of heart disease is quite the contrary ; it may be! exceedingly good, and in order to put as a foil to the: prognosis of this case I will mention a prognosis of another! case which occurred in this hospital. It is a well-known-, case. There was once a house-governor of this hospital,.

a clergyman, who was about to be married. His intended,! father-in-law came to him and said, "You see you have no,, money, sir ; you must go and get your life insured." At the

end of the medical examination the physicians said to him,"We cannot accept you."-"Why?" said the astonished’house governor.-" Oh, we would rather not say. "-"But,"he said, "I have never been ill in my life," (and, indeed,.he was a sturdy fellow).-"Well," said the physicians,."if you will have it, you have got heart disease."-’’ Heart disease. How long shall I live ? Shall I livefor six months?"-"Oh, yes," replied the medical men,"you may do that." He went home and the match wa&

broken off. He wrote to the committee, saying that as hehad a mortal disease of the heart and could not live for six.months he withdrew his application for rooms wherein to-dwell with his wife. On the receipt of this letter the coi-w-i-mittee deliberated, and said, ’’ We must superannuate him,poor fellow ; and, as he has but six months to live, we will’let him have his full pay." Accordingly he was super-annuated upon his full pay, and upon this superannuity andfull pay be lived for more than fifty years. About fifty years-afterwards I was summoned to a case. The patient wassuffering from cough and an attack of bronchitis. I felt-his heart first of all. I felt that it was outside theordinary place of beating, and when I listened I heard’the most awful roaring mitral that I have ever heard in’

my life. He suddenly said to me, "Don’t you bother-your head about that mitral murmur, I wish to ask you aboutthe bronchitis. That mitral has been there any time these fiftyyears." I finished my examination and went in with mycolleague to consult, and I expressed my surprise at the.character of the man whom I had just seen. I did not know-him and was surprised at his familiarity with medical terms." Well," he said, "he was the house governor of the LondonHospital many years ago. He was declared to have amortal disease of the heart and was superannuated on full"pay, and he has taken his pay ever since." He was a bad:bargain for the hospital. He got better from his bronchitis,and continued to earn his pension for some time longer, andI think he died at ninety-two years of age, having received’his pension-I am afraid to say the exact number of yearsduring which he was declared to be dying h-om a mortal.disease of the heart.That is the other side of the story, and I hope I shall be-

able to show you some one or other of these hearts as a con-tradistinction to this one, and to point to you the conditions-.upon which you may predict that with a fair obedience tothe laws of health mitral regurgitation and some other mitral’troubles may not seriously interfere with the duration of life-or its ordinary duties.But that is not the case to-day, and I merely mention.

this by way of contrast in the other instance. Those-of you who have such a case to pronounce upon as theone before us will say, "This is an anxious case ; thepatient has a grave and serious disease of the heart." Hehas a disease of both valves of the heart, and it is of a.

kind that lays him open to perpetual dangers. For-think.of it-but a small quantity of blood gets through his arteries,and if he had a very bad cold and the lungs got more con--gested there would be embarrassment, and the difficultyof passing the blood from the left ventricle would begreatly increased and the patient would die. He hasother perils to general health. Indiscretions of diet willgive rise to fresh troubles in his chest, and he will becomeweaker and weaker. The possibilities of the future are so-many and so near at hand that in speaking to the friendsyou may say these two things : " It is a very anxious and

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uncertain case, but with great care-that is, with the carefulmanagement of diet and freedom from exertion-his life maybe indefinkely prolonged."How are you going to treat a case of this kind ? The best

thing beloye you begin to treat such a case is to considerthe object you have in view. You need not have the objectin view of removing the imperfections of this heart. Youmust compensate them, if you can, and make the best of theconditions. The first thing is to keep up the strength and tohelp the heart as much as you can. There are two ways of

helping the heart-by diet and by drugs. To-day we willtake the hygienic method of helping the heart.

I might lay down the laws of health ; but that is not

enough-they must be somewhat modified for him. The

healthy man need not be very much afraid as to the amountof fluids that he takes. He may drink two or three pints aday with perfect impunity-nay, sometimes with advantage.The first thing you have to do in settling a proper dietary forthis patient is to limit the amount of his fluid. And why ?For this reason. Fluids, as you know, are at once absorbedinto the vascular system. They distend the vascular systemand increase the bulk without increasing the nutritivecharacter of the blood within the vessels. But, if you thinkof this man’s state, there is already difficulty in passingthrough the heart the comparatively small amount of bloodthat is circulating in his vascular system, and if youincrease the amount of fluid more than is physio-logically necessary you will do most serious damage,and one of the ways in which cases of this kindare lost is by the wholesale giving to the patientthings that will increase his thirst, and by gratifyingthat thirst the vessels get overfilled and render the difficultyof circulation insuperable. Diminish the amount of liquid.There is another reason why this should be done. Thecontinual fear that one has for this man is that his heartshall fail in power ; if anything were to enfeeble his heartvery much, such as a big dose of ipecacuanha given fora cold, you may make his heart strike work at once. Muchliquid will enfeeble the heart. If he drinks one or twotumblerfuls of water unnecessarily, from one to two pints, Ithe work of the enfeebled heart is correspondingly increased.See how these little things tell upon the management of acase. What am I to do with his diet ? I am going to puthim on three rather dry meals a day. I am going to order-and I presume that he is a patient who can get the food thatis necessary to do the best for him - I shall first see

that he is warmly clad in order to protect him from colds,and he is not to use cold water for his ablutions. He is tohave three good meals a day as dry as he can make themcompatible with the small amount of fluid which I shallorder. For breakfast he is to have cold chicken, breadand butter, fish, cold meat -he requires to be well fed-and he is to drink towards the close of his meal--he isto sip not more than half a pint of liquid -half a pintof cafi au lait, half a pint of cocoatina, or half a pintof tea (black China tea which has not been infused formore than five minutes at the outside). Which of the threedoes best must be determined by the idiosyncrasy ofthe patient. He is not to touch anything whatsoeveruntil dinner, the ordinary English dinner-meat, bread,potato, green vegetables, milk pudding, and cold fruit,-but if the patient is rheumatic keep out the fruit; and he isto drink water, or if the heart is likely to fag use waterwith from half to one ounce of any good spirit put into it-not beer, not wines, not sparkling wines particularly. The

partially fermented wines are liable to create fermentationin the stomach, to distend the organ, and to press againstthe heart, thereby producing serious evils. Then not lessthan five hours after the dinner he is to have high tea-toastand butter, a cutlet, game, and another half-pint of liquid ofwhatsoever sort he might prefer, and he had much better, ifhe could, do without anything more. One pint and a halfof liquid is a hard allowance for a man and tries some peoplevery much ; and therefore if he cannot very well get on withthis pint and a half, and if it does seem to you that a littlealcohol is helpful to him, a little alcohol at night, with orwithout a biscuit, might be allowed.What are you going to do about exercise ? 7 He is unfit for

labour, but he might be a timekeeper, or a check-taker, oranything of that sort. But if he is in the better ranks of lifeyou will say that, whatever he has to do, he is to be exceed-ingly moderate in exercise. It is not one of the forms ofheart disease in which exercise is ever tolerated well. But,on the other hand, you need not wholly deprive him of exer-

cise. Tell him also to avoid all hurry and worry, and scurry,and strain, and lifting; but so f.ar as business life is con-cerned he should live a quiet, regular, occupied, tranquil life,go to bed early, and be as much occupied as he can be withoutphysical exertion or strain.Then you must come in here with your medicaments. You

have to remember that he has got loaded in the bases ofhis lungs. You can see from his countenance that his liveris embarrassed and his bowels are apt to become costive,and one of the perils of cases of this kind is fatal congestion,and another is hsemoptysis. To relieve the lungs, give some-thing to relieve the bowels. Sulphate of soda and phosphateof soda given in equal mixture, two or three teaspoonfuls inthe morning, relieve the portal system and so relieve theright side of the heart and lungs. Or if he is a poor manone teaspoonful of Epsom salts in half a tumblerful of warmwater will do the thing as well, though not so agreeably.

I have said that one of the things to be careful about isthe strength of the heart. You must look to the heart to seethat it is beating with strength, and, if possible, with regu-larity. If it seems fluttering it is one of the cases in whichyou should come in with strophanthus or digitalis. If he issickish, strophanthus will be the best-five drops three timesa day-and you will do well to conjoin with it ten drops oftincture of nux vomica every second or third day, with asaline aperient every other morning ; add iron ii his liver iscleared.

Occasionally in a case like this he will suddenly beginto cough up large quantities of blood. What are youto do in such circumstances ? I have seen one or two

patients killed by the administration of large quantities ofgallic acid to stop the bleeding. What are you to do ?Wait upon the hasmoptysis if you have the faith and the-courage. It is a mechanical haemoptysis. The auriculo-ventricular valve being narrowed the blood cannot getthrough and is mechanically accumulating in the lung andfilling it up. We, instead of stopping the bleeding-unlessit is of such an extent as to be immediately perilous to life-are right to hail it as a means of relieving the patient. Whenthe patient is very ill-and sometimes these patients do getvery ill and distressed by difficulty of breathing-and theheart is labouring and the pulse becomes small and feeh7e, bothat the chances of life are diminished, there is one remedythat will immediately and greatly relieve him-thatis bleeding.But nature will sometimes bleed the patient for you. I’Taydo not rush at nature. Administer some placebo unless theebleeding is of such extent and of a kind to immediateJyjeopardise life, when you must stop it.

ROYAL MICROSCOPICAL SOCIETY.-At the I228F7’:;of this Society, on the 15th ult., Mr. Curteis exhibited anddescribed a microscope by Leitz on the English mode3, andMr. A. W. Bennett gave a resume of l4lr. W. lVest’s paper c,nNew Fresh-water A)gse. Professor Jeffrey Bell then read apaper written by Mr. Sandeman on a Parasitic Disease inFlounders, in which were described certain round swellings,having the appearance of eggs under the skin, in some ofthese fish found on the coasts. On microscopic examinationthese tumours were seen to present all the characteristics cfeggs, but the cause and habits of the parasite were veryobscure. Mr. C. Beck raised a discussion on the possibilityof obtaining a standard tube length, and Dr. Dallinger thoughtthat a committee should be appointed to discuss the question.PROPOSED FEVER HOSPITAL AT NORWOOD.-

On the 22nd ult. Mr. Hedley and Dr. Downes, of the LocalGovernment Board, resumed their inquiry at Croydon intothe proposal of the Metropolitan Asylums Board to purchasethe Grangewood estate at Upper Norwood in order to

establish a fever hospital. The evidence of several witnesseswas given to show that the project would be adverse to thewellbeing of the district. Mr. Kimber, M.P., addressed theinspectors on behalf of the Crystal Palace Company, whoseinterests, he said, would be seriously jeopardised by theestablishment of an infectious diseases hospital in its irnme-diate vicinity. On behalf of the Brighton Railway Company,Mr. Laing gave evidence to the effect that the company bhdexpended large sums of money in the district and the sbare-holders naturally looked forward to the development of thelocality, the prosperity of which would necessarily be im-perilled by the presence of the proposed hospital. Mr. liyonreplied on the whole case, and the inspectors promised toreport the result of the inquiry to the Local GovernmentBoard.