Reprinted from the Colorado Medical Journal, January, 1898. 
AORTIC STENOSIS WITH MITRAL REGURGITATION. 
A CLINICAL LECTURE. * 
ByJ. N. HALL, M. D., 
Denver, Colo., 
Professor of Medicine in Gross Medical College; Visiting Physician to the Arapahoe County 
Hospital and to St. Anthony's Hospital. 
Gentlemen:-I wish to show you to-day an instance of the 
rarest of the valvular diseases of the left side of the heart, aortic 
stenosis, accompanied, in this case, with mitral insufficiency. After 
the close of the lecture the patient will pass around the room, that 
you may have an opportunity to examine him. 
M. D., 68 years of age, without family history of interest in 
this connection, has been a miner in this state for nearly forty 
years. He has experienced, at intervals of several years, several 
attacks of acute articular iheumatism. There is no history of 
syphilis or of alcoholism, but the patient has done much severe 
manual labor. 
He complains of dyspnoea, palpitation, faintness and dizziness, 
but almost solely after some sudden change of posture, notably 
from the recumbent one to the erect position, or upon exertion. 
Upon physical examination we find extensive atheroma in all 
of the accessible arteries,-a feature of some importance in making 
the diagnosis of aortic stenosis. We may briefly state that the ex- 
amination of organs other than those involved in carrying on the 
circulation has been negative. The impulse of the heart is found 
in the fifth space, somewhat outside of the mamillary line. The 
area of dullness is decidedly increased, as you may see by follow- 
ing the blue lines drawn upon the patient's chest, and which have 
been verified by some of those present. The increase in area is 
almost wholly in a transverse direction, extending from the right 
edge of the sternum to a line one inch to the left of the left nipple. 
Upon palpation we feel a marked systolic thrill over the sec- 
* Delivered at the Arapahoe County Hospital, Dec. 15, 1897. 2 
ond right interspace. The pulse is seventy to the minute, small, 
but of fair tension. There is no visible pulsation in the arteries of 
the neck. 
With the stethoscope we hear a loud, sawing, systolic murmur 
over the aortic area, but transmitted beyond the area of the thrill, 
for it is to be heard in the arteries of the neck and in the femoral 
and radial arteries as well. With the fingers holding the bell of 
the stethoscope one easily feels the thrill transmitted through the 
wall of the chest to the instrument. 
Over the apex we distinguish a second systolic murmur, which 
differs from the first in being musical, or, as one of your number 
has just described it, "cooing" in character. This murmur is trans- 
mitted to the axilla, and faintly into the back, and indicates, in 
connection with the increase in the transverse area of cardiac dul- 
ness, and the accentuation of the pulmonic second sound, which is 
fairly marked in this case, mitral insufficiency. Although these 
two murmurs are both systolic, we may be sure that they are dis- 
tinct, because their areas of greatest intensity are different; the di- 
rection of transmission of the murmur in each case is characteristic 
of that of the lesion described; between the areas of greatest in- 
tensity is a space where neither is heard with its normal distinct- 
ness; and, finally, the timbre of each murmur differs decidedly 
from that of the other. This second lesion doubtless accounts in 
part for the great lateral extension of the cardiac dullness, for the 
hypertrophy in pure aortic stenosis-simple rather than excentric- 
does not give rise to marked increase in cardiac area. 
The mitral murmur probably originates in this case from endo- 
carditic change in the mitral leaflets, and not from secondary 
changes brought about by the effects of the aortic lesion, as we 
might have inferred, possibly, had this latter lesion been that of in- 
sufficiency. We base this statement largely upon the history of re- 
peated attacks of rheum itism, which disease, you will remember, 
has an especial predilection for the mitral valve, in case the endo- 
cardium is involved. Musical murmurs, further, are found, in my 
experience, at least, rather in cases of regurgitation accompanying 
actual valvular disease than in those of relative insufficiency. Still 
further, we have no reason for looking for relative insufficiency in 
a case of pure aortic stenosis during the time of compensation, be- 
cause the stenotic lesion is not occompanied with dilatation of the 3 
left ventricle sufficient to interfere, in any manner, with a complete 
closure of the mitral leaflets, although such relative insufficiency 
may easily occur after myocardial degeneration begins. 
You will recall that I exhibited to you, a few weeks ago, a pa- 
tient with a double aortic murmur, and mitral regurgitation, with 
the statement that both aortic and mitral valves were insufficient, 
as indicated by the respective murmurs and associated signs; you 
were told, however, that the aortic direct murmur did not probably 
indicate stenosis. You will recall, further, that the statements 
made were all verified two weeks ago, when you examined the 
heart after the autopsy. Why should we expect to find stenosis at 
autopsy in our present case, and not in the one just quoted? 
The aortic systolic murmur may depend upon stenosis of the 
orifice, as we assume to be the case in this patient; upon roughen- 
ing of the intima of the aorta, from atheroma, as was the case in 
the patient mentioned, upon whom we held the autopsy; or upon 
the changes in the blood in anemia. Pressure from without may 
cause systolic murmur, and possibly other causes, but the three 
mentioned are the ones of immediate interest to us. 
The most common cause of the murmur is anemia. If we find 
a systolic murmur, especially if it be soft in quality, in a patient 
with pale complexion, associated with venous hum in the neck, and 
without enlargement of the heart, without atheroma and without 
thrill, we feel no hesitancy in attributing the abnormal sound to 
changes in the blood. In the case of the woman just quoted, we 
had no symptoms pointing to a failure of the blood-supply to the 
brain, and, on the other hand, we had a very notable pulsation in 
the carotid and other arteries, visible even at a distance of several 
yards. The latter feature, especially, is incompatible with mate- 
rial narrowing of the aortic orifice. There was, further, absence of 
thrill, of the "sawing" character of the murmur often found in sten- 
osis, and of transmission to the large arteries. The presence of 
notable atheroma, although this is found likewise in real stenosis, 
permitted us, especially in view of the syphilitic history, to assume 
that an endarteritis existed, sufficient to give rise to the murmur- 
an aortic direct but non-stenotic murmur. 
The diagnosis of stenosis is probable only in those cases, then, 
in which there are evidences of extensive atheroma, rough murmur 
transmitted to the neck and elsewhere, and vibratory thrill, in con- 
I 4 
nection with the symptoms noted in the history of this patient. 
Such a combination of signs and symptoms is most commonly seen 
in old men, and is decidedly rare in young patients of either sex. 
This patient, in spite of his two valvular lesions, presents no 
signs of serious disturbance of his circulation. He has no edema, 
no cough, no pain, no pulmonary hemorrhage, no irregularity of 
the pulse. The palpitation occurs only upon exertion, and does 
not interfere with moderate exercise, nor with sleep. The dizziness 
and faintness do not disturb him excepting upon the sudden as- 
sumption of the erect posture. In other words, his compensation 
is still quite perfect, the heart being sufficiently hypertrophied to 
enable it to perform the increased amount of work demanded by 
the aortic narrowing and the mitral leakage without showing any 
notable signs of failure of power. With the moderation in life 
natural to a man nearly seventy years of age, the patient may look 
forward pretty confidently to some years of fairly comfortable life, 
and to serving, for future medical students, as he has to your pred- 
ecessors for two or three years, as an excellent example of a dis- 
ease which is diagnosed clinically much more often than it is found 
post mortem. I feel, however, in this case, that I should face the 
pathologist with reasonable confidence. 
The patient receives at present no medicine, excepting as 
symptoms calling for treatment arise. It is chiefly important that 
his general health should be kept at its highest level, in order that 
his cardiac compensation may be maintained, With failing nu- 
trition of his myocardium, we may expect to see the signs and 
symptoms of the latter stages of mitral regurgitation which we 
have just mentioned as being conspicuous in this case by their ab- 
sence, for the mitral valve is the one, in such patients as this, most 
likely to give rise first to serious trouble.