The Diagnosis of Mitral Valvulitis, 
with a Report of Three Cases. 
CLINICAL LECTURE DELIVERED AT THE PHILADELPHIA HOSPITAL. 
BY JUDSON DALAND, M.D., 
Instructor in Clinical Medicine in the University of Pennsylvania; Assistant Physi- 
cian to the University Hospital; Physician to the Philadelphia Hospital 
and to the Rush Hospital for Consumptives. 
[Reprinted from International Clinics, Vol. IV., Third Series.] The Diagnosis of Mitral Valvulitis, 
with a Report of Three Cases. 
CLINICAL LECTURE DELIVERED AT THE PHILADELPHIA HOSPITAL. 
BY JUDSON DALAND, M.D., 
Instructor in Clinical Medicine in the University of Pennsylvania; Assistant Physi- 
cian to the University Hospital; Physician to the Philadelphia Hospital 
and to the Rush Hospital for Consumptives. 
[Reprinted from International Clinics, Vol. IV., Third Series.] THE DIAGNOSIS OF MITRAL VALVULITIS, WITH A 
REPORT OF THREE CASES. 
CLINICAL LECTURE DELIVERED AT THE PHILADELPHIA HOSPITAL. 
Instructor in Clinical Medicine in the University of Pennsylvania ; Assistant 
Physician to the University Hospital; Physician to the Philadelphia 
Hospital and to the Rush Hospital for Consumptives. 
BY JUDSON DALAND, M.D., 
Gentlemen,-This morning I shall call your attention to a series 
of cardiac cases, and point out to you the most interesting facts con- 
nected with each. 
The first is that of a man aged fifty-seven years, a worker in lead. 
His father died at the age of eighty, his mother from an injury, one 
sister from apoplexy, and another from a cause unknown. He has al- 
ways been strong and vigorous, having suffered from no diseases except 
those of childhood and one attack of inflammation of the bowels. He 
acknowledges the more or less habitual use of alcohol, but denies ever 
having had rheumatism. He began working in white lead seven 
months ago. He was admitted to the hospital about one month ago 
with severe paroxysmal attacks of painful muscular cramps in the 
abdomen and legs, most severe at night. He also complained of loss 
of energy, but at no time was there paralysis of the extensors of the 
arms. Frequent examinations of the urine failed to show any albumin 
or sugar. In searching for the characteristic blue line on the gums at 
the point of contact with the teeth, we observe that his teeth are few 
in number, many of them carious, and the gums acutely inflamed. A 
discoloration of the gums is visible, but not the typical blue line that 
is so frequently present in cases of lead-poisoning. The diagnosis of 
lead-poisoning was self-evident, and the ordinary treatment by sulphate 
of magnesium, given until frequent purgation was produced, conjoined 
with the free use of iodide of potassium, was advised, and he has re- 
covered very satisfactorily. 
Thus far in his history we have not elicited a single symptom of 
cardiac disease. At no time has he had dyspnoea, either objective, 
48 THE DIAGNOSIS OF MITRAL VALVULITIS. 
49 
subjective, or that produced by exertion, and at no time has palpitation 
of the heart or oedema been present. The symptoms up to the present 
time are as I have given them to you, and, but for the art of physical 
diagnosis, we should all imagine that he was a perfectly sound man. 
Now let us examine him together. 
As he stands before us, those who are near will notice that the 
thorax is not normal in shape, but is rachitic or pigeon-shaped. In 
build the man is quite tall and rather slender. We will now inspect 
the prsecordia. In this region there is a heaving pulsation which ex- 
tends over a considerable area. The normal apex-beat covers a circle 
having a diameter of one inch, but this man's apex-beat occupies three 
times this area. Palpation shows that the centre of this pulsation, 
where the apex comes in direct contact with the chest-wall, corresponds 
to the sixth interspace, in the nipple-line, so that there is considerable 
displacement of the heart downward and towards the left of its normal 
position. Percussion shows that the area of cardiac dulness is decreased. 
This would not coincide with the information already gathered from 
inspection and palpation, that this man had an unusually large heart. 
But when you remember that he is fifty-seven years of age, and has 
been engaged in hard manual labor all his life, the possibility of pul- 
monary emphysema should at once occur to you, from its frequency 
under these circumstances. An emphysematous lung may extend be- 
tween the heart and the chest-wall, and so encroach upon the area of 
cardiac dulness as greatly to diminish or even to obliterate it; and this 
is true when the heart is normal in size or enlarged from hypertrophy 
or dilatation. In this case there is so much emphysema of the thin 
border of lung covering the heart as to render it impossible to draw 
any conclusion as to its size from percussion. Although percussion 
has failed to give us the information so much needed, we may still 
turn to auscultation as the part of physical diagnosis that reveals the 
most satisfactory and decisive signs of morbid changes in the heart. 
When the stethoscope is placed over the apex, the first sound is very 
loud and muscular. This heaving muscular first sound indicates that 
we have here an excess of muscular tissue in the heart. We notice an 
additional sound; it is rather short in duration, blowing in quality, 
occurs with each contraction or systole of the heart, and is transmitted 
to the left as far as the axilla. This murmur terminates at the mid- 
axillary line, and cannot be heard at the angle of the left scapula. 
There is an accentuation of the pulmonic second sound, but no murmur 
is audible in this region nor over the aortic or tricuspid areas. It is 
evident, therefore, that this man has had, at some time in the past, 
Vol. IV. Ser. 3.-4 50 
INTERNATIONAL CLINICS. 
an acute mitral valvulitis, in all probability due to rheumatism, and, 
further, that this acute inflammation of the mitral valve did not cause 
sufficient constitutional disturbance to induce him to take to his bed : 
consequently we have no definite information as to when the primary 
acute endocarditis occurred. 
When we bear in mind how small is the reduplication of endocar- 
dium that constitutes the mitral valves, and how conceivable it is that 
inflammation may be entirely confined to this small area, we can readily 
understand that these processes may take place without the production 
of constitutional symptoms, and may be detected only by an alteration 
in the frequency of the heart's action, so that a patient, such as the one 
before you, may readily continue his ordinary occupation, and not be 
aware of the precise time when this process began. On more than one 
occasion I have had an opportunity of observing patients develop most 
serious rheumatic endocarditis with only a slight elevation of tempera- 
ture, and a moderate increase in the frequency of the pulse, with or 
without irregularity: this rheumatic affection may be evidenced only 
by severe pains in the sciatic or other regions of the body, which may 
last but a few hours, and on one occasion no other rheumatic phenomena 
presented themselves subsequently. In the present case we know that 
the mitral valve is thickened and shortened, not only from the history 
and from the absence of the causes of dilatation, but also because the 
fact that the systolic murmur is heard best at the apex-beat, and trans- 
mitted into the left axilla, proves that there is a regurgitation of blood 
with each contraction of the heart from the left ventricular cavity into 
the left auricle. Our diagnosis is not complete until we have deter- 
mined the condition of the heart-muscle and its cavities. From the 
displacement of the apex-beat downward and into the left axilla, and 
from the enlarged area of pulsation and its increased force, we know 
that the left ventricle is hypertrophied, and, if these conditions exist 
for years, pathology teaches us that the pulmonary circulation is 
under increased pressure, as is clinically evidenced by the accentuation 
of the second sound heard at the pulmonary cartilage, and this, in 
its turn, produces moderate hypertrophy of the right ventricle. Our 
patient tells us that he has no dyspnoea and no palpitation, that he 
performs muscular exertion without difficulty, and that at no time has 
oedema occurred. The absence of these symptoms clearly demonstrates 
that the hypertrophy of the left ventricle is sufficient to overcome the 
obstruction to the circulation caused by the regurgitation of blood into 
the left auricle during each systole of the heart, and therefore there is 
no reason for believing that the left ventricular cavity is dilated to any THE DIAGNOSIS OF MITRAL VALVULITIS. 
51 
considerable extent. The increase in force is so nicely adjusted to the 
increased work required of the heart that it exactly balances the diffi- 
culty, and we have before us a perfect example of what is known 
as "complete compensation." Without the aid of physical diagnosis 
it would be impossible to detect the existing lesion, and, from the 
patient's stand-point, he is entirely free from disease. The hypertrophy 
which is present is absolutely essential to his well-being. If it were 
possible to remove this hypertrophy so as to restore the left ventricle to 
its former condition, he would show the physical and rational signs of 
cardiac weakness. If, on the other hand, attempts were made to increase 
the force of his heart, he would probably complain of throbbing and 
beating in the cardiac region, headache, flushing of the face, vertigo, 
visible pulsation in the arteries, and perhaps praecordial distress or pain. 
Therefore any attempt to interfere with the present conditions would 
injure our patient, and for this reason the administration of a cardiac 
stimulant, such as digitalis, may be followed by the symptoms nar- 
rated. 
The prognosis is good, provided he omits the over-use of alcohol, 
and leads a proper, hygienic life, with the especial avoidance of pro- 
longed or excessive muscular exertion. Such a patient should live 
to a good old age without discomfort. The treatment consists in the 
giving of this advice, making clear its necessity, and the avoidance 
of medication. 
Our second patient is a man aged thirty-six, a native of Italy, and 
in consequence we have not been able to secure a very accurate or full 
history. So far as we can learn, his mother died of phthisis. He 
tells us that he has always been healthy, though much exposed from 
his occupation as a laborer. He uses alcoholic beverages moderately; 
denies syphilitic infection, and states that he has never had rheuma- 
tism. One year ago his feet, ankles, and abdomen began to swell, and 
he suffered from dyspnoea, which was increased by exertion and asso- 
ciated with cough. He also complained of severe pains in the left 
chest and lumbar region. He entered the Reading Hospital, where 
he remained for some time, and then resumed his work as a laborer. 
He soon found that it was impossible for him to work, and he was 
admitted to the Philadelphia Hospital, where he has been under our 
observation for four months. The history, though brief, points to the 
heart as the probable cause of the oedema of the feet, the ascites, the 
dyspnoea increased or induced by exertion, and the prsecordial pain. 
Palpitation, one of the most frequent symptoms of heart-disease, is 
absent. 52 
INTERNATIONAL CLINICS. 
Here is a strong and vigorous man who is compelled to go to a 
hospital, where he remains for some time. Feeling much improved, 
he returns to work, which he is compelled to abandon at once, because 
of the prompt return of his former symptoms, so that he is forced to 
seek relief in the wards of this hospital. Men belonging to the labor- 
ing class do not give us such a history unless they are suffering from 
serious and often organic disease. At no time, with but one brief 
exception, has the temperature risen above the normal, and upon sev- 
eral occasions it has descended to 98° or 97° F. There has been no 
palpitation of the heart, but his pulse-rate has varied between 96 and 
56 per minute. The occasional occurrence of bradycardia was due to 
the administration of full doses of digitalis. As the time is so short, 
and we wish to devote ourselves more especially to a study of the 
heart, I may state that the pulmonary and abdominal viscera were ex- 
amined and revealed no changes of importance. Upon inspection the 
heart-beat seems unusually forcible, and may be described as heaving 
in character, as though the heart was bumping up against the entire 
side of the chest. I have outlined this impulse roughly with a blue 
pencil; and you can see that it extends from the apex-beat as high as 
the third rib, and then passes over to the right of the sternum, thence to 
the ensiform cartilage, and the epigastrium pulsates strongly. Carry- 
ing our inspection to the left, we find that it goes into the axillary 
region, so that this outline of pulsation includes all that part of the 
chest between the third and seventh ribsand from the anterior axillary 
line to the right border of the sternum. You must not mistake the 
movement of respiration for that of pulsation. From this outline 
alone it is but fair to conclude that a heart that is able to produce such 
a wide-spread pulsation must be larger than normal. The application 
of the hand to this region reveals a rather slowly acting heart, and, 
although the pulsations are visible over so large an area, they are weak. 
It is equal in force to a normal apex-beat, but does not correspond in 
force to the pulsation that you would expect from so large a heart. 
You can faintly feel the up-stroke of the apex during the contraction 
of the heart, and it is extremely difficult to determine precisely as to 
which part of this area of pulsation we shall decide upon as represent- 
ing the apex-beat. In searching for the apex-beat by palpation one 
should endeavor to find where the pulsation is stronger than at other 
places, and it is to be remembered that this region is the place of 
strongest impulse. That point corresponds to the sixth interspace, 
where it is crossed by a vertical line drawn one and a half inches to 
the left of the nipple-line. Therefore this apex-beat is displaced down- THE DIAGNOSIS OF MITRAL VALVULITIS. 
53 
ward two inches, and to the left three inches,-a truly extraordinary 
dislocation of the apex-beat. 
As these large areas of pulsation are produced by the striking of the 
heart against the chest, it would be more accurate to substitute the word 
heart-beat for apex-beat. There is no thrill. The area of cardiac 
dulness falls somewhat within that of the visible and palpable pulsa- 
tions already described. Upon placing the stethoscope over the apex- 
beat the first sound is weak, especially the muscular element, and in 
addition a murmur is heard, which is of the same duration as the first 
sound. This bruit is rather harsh and blowing in quality. The first 
sound seems unusually long, and in consequence the thought may occur 
that perhaps this increase in length is not all due to the contraction 
of the heart-muscle and closure of the valves. When the fingers are 
placed upon the carotid and the apex-beat, a murmur is heard that 
precedes the carotid and heart-beat, and in addition a second murmur, 
which is synchronous with the systole or contraction of the heart. 
We are, therefore, able to state that he has a pre-systolic and a systolic 
murmur. These murmurs, together with the inspection, palpation, and 
percussion signs already elicited, are usually associatefl with chronic 
mitral valvulitis, which has produced thickening and shortening of 
these valves, preventing them from closing during each systole, and 
thus accounting for the systolic murmur which is produced as the 
blood rushes from the ventricle to the auricle during each contraction 
of the left heart. The pre-systolic murmur is produced as the blood 
passes from the left auricle into the left ventricle, passing these stiff 
and greatly thickened valves, which project into the lumen of the 
mitral orifice, thus causing obstruction and stenosis. 
We next turn our attention to the heart-muscle and its cavities. 
From the character of the first sound of the heart, the displacement, 
the enlargement, and the disproportion between the size of the heart 
and the force of the impulse, together with the symptoms of failing 
cardiac power, we are justified in the opinion that the enlargement is 
chiefly dilatation and only partly hypertrophy. The best possible con- 
dition for this patient would be one of cardiac hypertrophy, with as 
little dilatation as possible. In the first case we had considerable 
hypertrophy, with little or no dilatation. From the fact that dilata- 
tion is so extreme, that two failures of compensation have occurred 
within a few months, and that, too, despite four months of careful 
treatment, it is evident that the prognosis is unfavorable. 
The indications for treatment are extremely simple. He must 
maintain a horizontal position, which is best secured by rest in bed; 54 
INTERNATIONAL CLINICS. 
and his general circulation is to be maintained by faradization and 
massage of the muscles, combined with daily inunctions with olive oil. 
This patient will be still further benefited by the use of a good digitalis 
preparation, as that of the tincture, beginning with ten and increasing 
to twenty or thirty drops at four-hour intervals, the dose being so ar- 
ranged that a positive physiological effect will be secured, decreasing the 
heart rate to 68 beats per minute, and this effect should be maintained 
for some weeks. Sulphate of strychnine in doses of from one-thirtieth 
to one-twentieth of a grain, four times daily, should also be administered. 
His food should be highly nutritious and easily digested, and it may 
become necessary to add pepsin and hydrochloric acid to aid digestion. 
The bowels should be moved daily, and he should be encouraged to 
drink freely of pure water between meals. This treatment shall be 
followed faithfully for one month, and the results reported to you. 
If these efforts are successful in securing sufficient hypertrophy of 
the heart, this man may again return to active life. 
Our third case is that of an unmarried woman, aged twenty-four, 
whose father was always delicate, dying of dropsy at the age of forty- 
six. Her mother is living, and has attacks of asthma. One sister 
and one brother are living, and are healthy. Another brother died 
of typhoid fever. Her paternal uncle and aunt died of heart-disease, 
and four maternal uncles and one aunt have died from the same cause. 
This case is interesting from several points of view. She has always 
been delicate and nervous, and was never able to attend school, or to 
work, for any protracted period, on account of her poor health. Seven 
years ago she had malaria, and as a child she had whooping-cough, 
measles, and scarlet fever. Four years ago she had typhoid fever, 
which was of moderate severity, though she reports that it confined 
her to bed for four months, and two years ago she had influenza. For 
four years she has been unable to do practically any work. Previous 
to that time her day was occupied in a weaving-mill, but only at inter- 
vals was she able to perform work. This history means that our patient 
was born with impaired vitality. If a normal individual be compared 
to a clock that is constructed to go for seventy years, this woman would 
run down in about thirty years. For some years it has been a con- 
stant struggle for her to keep alive. Consider for a moment the attack 
of typhoid fever, including the period of convalescence, lasting for four 
months, whereas an ordinary person would have recovered within six 
or seven weeks. Then, too, the death of five uncles and two aunts of 
heart-disease would suggest that she has inherited a special vulnera- 
bility of the heart and blood-vessels. Six years ago she complained of THE DIAGNOSIS OF MITRAL VALVULITIS. 
55 
palpitation of the heart and dyspnoea, and we may consider that this 
was the beginning of the present trouble, although the endocarditis may 
have begun at the time of her attack of scarlet fever. A nervous girl 
frequently complains of palpitation of the heart, but when this symp- 
tom is associated with dyspnoea, and both are increased by exertion, 
the probability of organic disease is greatly increased. These attacks 
becoming more and more violent, she was frequently confined to her 
bed for a week or more. Soon she noticed that her face was becoming 
swollen in the morning, but as the day wore on the swelling would dis- 
appear, and the ankles would become swollen. Next morning the 
ankles would be normal, but the face would again be oedematous. 
This is the ordinary behavior of beginning oedema from kidney 
rather than cardiac disease, and the way in which this symptom de- 
velops is quite important diagnostically. At the same time dyspnoea 
increased, so that our patient preferred to sit up in bed. She com- 
plained of cold extremities and of shooting pains in the prsecordial 
region, with occasional vomiting. Her temperature remains about 
normal, ranging between 98.6° and 99.6° F., and her pulse between 
100 and 120, at times descending to 90. She has a continuous accelera- 
tion of the pulse-rate. 
Now let us determine the present condition of the heart. I exam- 
ined this patient yesterday, and, in order to save time, I have marked 
here in red, which I now replace by blue, this cross, indicating the 
point of the apex-beat. Let us examine the thorax. In physical 
diagnosis much importance is attached to the position of the signs of 
disease, such as pulsation, thrills, murmurs, etc., and in determining 
their precise position we are naturally led to consider anatomical land- 
marks ; when these are changed we easily fall into error. Our 
patient's chest is deformed, and you observe a prominence which 
corresponds more or less to the lower sternal and pnecordial region. 
At the base the thorax is contracted, considerably diminishing 
its antero-posterior diameter; it may be described as a modified 
chicken-breast. The apex-beat is visible over a larger area than 
normal, but is not forcible, and corresponds to the fourth and fifth 
interspaces. When we attempt to secure the outline of cardiac dulness 
by percussion, we find that our results are vitiated by this misshapen 
chest, while in the first case percussion was interfered with by emphy- 
sema. We have a rapidly-acting heart-beat, which is rather weak, and 
most careful palpation reveals no thrill. The results of auscultation 
corroborate palpation, insomuch as we find the heart is acting rapidly 
and irregularly, averaging 100 beats per minute. When we auscult 56 
INTERNATIONAL CLINICS. 
over the apex-beat the first sound is feeble, and the second sound is 
accentuated. A blowing systolic murmur is heard, which extends to 
the region of the left border of the sternum, and may also be heard one 
inch to the left of the apex-beat. The pulmonic and aortic second 
sounds are distant, rather weak, but no murmur is audible. Here we 
meet a condition of the mitral valve similar to that in our former cases, 
-i.e., mitral valvulitis with regurgitation. You may remember that 
in the first patient with mitral disease the prognosis was so favorable 
that it was not impossible for him to die of old age. In the second 
case the prognosis was not so good, but under the treatment suggested, 
especially if carried out thoroughly and minutely, we may secure resto- 
ration of his broken compensation; but if the patient does not im- 
prove, his prognosis is serious, and the probabilities are that he will 
not live long. The prognosis in this case is even worse. Here is a 
patient who, at the time when the mitral disease developed, was com- 
pelled literally to struggle for existence. After spending weeks in 
bed she has improved but little, while the improvement secured was 
quickly lost, with a return of all the old symptoms of failing compen- 
sation, and this has been frequently repeated. This patient may live 
for a number of months, but there is little hope of her ever walking 
about freely, or of returning to the ordinary duties of life, while, on 
the other hand, she may die any moment from sudden cardiac failure. 
The treatment should be conducted upon the same broad lines as indi- 
cated in Case II.