A CLINICAL LECTURE — ON DISEASE OF THE HEART AND LUNGS, WITH SPECIAL REFERENCE TO PHYSICAL DIAGNOSIS. By STEPHEN S. BURT, M.D., PROFESSOR OF PHYSICAL DIAGNOSIS IN THE NEW YORK POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL. FROM THE NEW YORK MEDICAL JOURNAL, September 26th, 1885. A CLINICAL LECTURE ON DISEASES OF THE HEART AND LUNGS, With Special Reference to Physical Diagnosis. BY STEPHEN S. BURT, M.D., Professor of Physical Diagnosis in the New York Post-Graduate Medical School and Hospital. While directing our attention more especially to the physical diagnosis of disease of the heart and lungs, we are constantly reminded of the intimate relations that exist between them and the remaining organs of the body. A study of these relations forces upon us the conviction that only by thorough knowledge of disease in general may we hope to arrive at anything like pre- cision in the diagnosis of special subjects. He is indeed a poor practitioner who allows himself to be so carried away by some absorbing specialty as to lose his interest in the general health of the body. But what shall we say, on the other hand, of the physician who believes physical exploration unnecessary, and goes his way, having prescribed for only ? To the general practitioner an understanding of the methods of physical diagnosis has now become a neces- sity, and one that is well recognized. It is expected by his patient and demanded by the profession, so univer- sally, indeed, that some are forced to go through a sort of mummery for its moral effect upon the patient, when in reality there is little if any true perception of what the examination reveals. Fortunately, however, this class is in the minority. There is a desire prevalent in the profession, as shown by the increasing numbers at our clinical schools, to grasp the subject of physical 2 diagnosis, and ere long no doctor will think of prescrib- ing for a cough until he has discovered the cause there- of. No practitioner will mistake a functional for an or- ganic disease of the heart; nor will he make life miser- able to a patient just because an organic murmur has been found. He will be capable of explaining that life may continue in comparative comfort so long as compen- satory hypertrophy lasts. Furthermore, he will be able not only to recognize failing compensation, but also to ward off its fatal effects, maybe for years, by judicious treatment, and finally he will be less likely to interfere when nature does not call for aid —an achievement per- haps one of the greatest in medicine. Now, let us turn to the study of diseases of the chest as they are presented, not in books, but at the clinic. It is one thing to learn the symptoms and phys- ical signs of disease, and quite another to recognize them in the patient. Here lies the difference in medical men. Book knowledge is important, but some never get beyond it. The first patient that it is our privilege to examine gives a good family history. She is thirty years of age, has not had rheumatism, nor any severe illness. She complains chiefly of loss of appetite, headache, and flat- ulence. Upon exertion and on exposure to cold she has a slight cough. You observe that it is not until the lead- ing question has been asked that she tells of any short- ness of breath on exertion. Her symptoms are mainly those of dyspepsia. But these disorders of the digestive tract that receive the name of dyspepsia are not always so innocent as they might seem Not infrequently a grave kidney lesion may be found lurking in the back- ground, and then again the heart may be at fault. A careful examination has excluded the probability of a 3 kidney complication in this case. We will now investi- gate the heart. Upon inspection, it is seen that the ap- ical impulse is somewhat to the left and below its normal position. The impulse, on palpation, is found to be slightly increased in force. Percussion does not give a marked increase in the cardiac area. Auscultation, however, reveals a soft, blowing systolic murmur, ex- tending to the left, with point of maximum intensity in the mitral area. Mitral insufficiency is the lesion, and for it the heart muscles fairly compensate. There is neither oedema nor cyanosis. This is a very instructive case, illustrating as i,t does one of the secondary symptoms of heart disease— namely, flatulent dyspepsia. Long before serious en- gorgement becomes apparent there is this slight altera- tion in the circulation which results in defective diges- tion. And, too, a little unusual exertion or some slight exposure of the neck and shoulders produces a dry cough. Besides, if you closely watch these patients you will see that there is dyspnoea, not upon ordinary exer- tion, so long as it is confined to a plain surface, but dur- ing an ascent of a very slight elevation, or on any unusual exercise. As a result also of this, the bright-red color of the lips is seen to change to a much darker hue. I have had just such an instance under observation for the past four years. The patient was treated for simple dyspep- sia, with very indifferent results, her heart lesion being unrecognized. But when the real cause of her trouble became known she made rapid improvement. A pill containing a grain each of digitalis, iron, and quinine, in addition to the stomach mixture, with, now and then, medicine for the intestines, comprised most of the treat- ment. The slight cough, which is provoked by a simi- lar condition in the pulmonary circulation, is prevented 4 by taking only moderate exercise and by keeping the superficial circulation active with sufficient clothing. There is still another very interesting example of venous congestion resulting from heart disease that occurs to me. A patient who was completely pros trated each month by menorrhagia came for treatment, but her errand was as fruitless as it had been elsewhere until 1 discovered that she had a stenosis of the mitral orifice. No lesion could be found as a local cause. Concluding, therefore, that the excessive haemorrhage was due to venous stasis, I put her upon large doses of the infusion of digitalis during that period, and the treat- ment proved most efficacious. On the other hand, it is a matter of frequent remark, the number of patients that come firmly convinced they are suffering from an organic disease of the heart, be- cause of the pain and palpitation that often attends dys- pepsia. A physical examination enables the physician to dispel all these fears, while properly directed reme- dies will remove the cause, quiet the heart, and quell the pain. Here we have exemplified the interdependence of viscera, and, at the same time, the importance of not at- tending to one at the neglect of another part of the body. We now have a patient on whom the ravages of time and disease have set their stamp. It is seen, by pitting on pressure, that his ankles are both oedematous. His face, marked with fine red streaks, is pale, and his lips are slightly cyanotic. The pulse is irregular and small. He tells us that exertion produces shortness of breath, and that upon two occasions he has had haemoptysis. Hence there is evidence of an increased venous and a diminished arterial pressure. By palpitation we find the 5 apex of the heart a little to the left of its normal posi- tion, with its impulse fairly strong, while epigastric pul- sation is forcible. Upon auscultation there is accentua- tion of the pulmonary second sound, and just over the apex can be heard a systolic murmur. This murmur is not heard in the back; neither is it carried to the left nor to the right. It is the indication of mitral regurgi- tation, but there is probably very little regurgitation as compared with the amouut of obstruction at this orifice. Delafield says: “The same lesion frequently pro- duces both stenosis and insufficiency of a valve.” And here we have the physical signs that most commonly proclaim this condition. Such a murmur is much oftener present than the au- ricular systolic, or so-called mitral presystolic, murmur with this lesion. A feeble mitral systolic murmur, due to a weak ventricle, is also confined to the area of the apex, but that is not the case in hand. Exceptionally, a systo ic murmur of the kind we have here gives place temporarily to a presystolic murmur. Obstruction of the mitral orifice produces an accentuation of the pul- monary second sound. This is brought about in two ways—first, by pulmonary engorgement and consequent hypertrophy of the right ventricle, and, second, by the diminution of the aortic second sound from decreased arterial pressure in the general circulation. When hypertrophy of the left auricle is sufficiently in excess of dilatation to follow up the at first passive flow of blood by a firm contraction, in completion of auricular systole, we may observe the so-called mitral presystolic murmur. But under other conditions of stenosis, unless the valve is closed during ventricular systole, such a systolic murmur will be produced as we find here. The case is of further interest in that we are 6 able to restore the arterial circulation, sufficiently at least to do away with the dropsy. In order to accom- plish this we must increase the quality of his blood by food, rest, and tonic medicines. By the addition of dig- italis, compensation will be re-established, and thus na- ture assisted by a timely and not unintelligent interfer- ence. The history and symptoms of patient number three are of a cough, attended at onetime by white frothy sputa, at another by muco-purulent expectoration. This began with an hemoptysis early in the spring. She has night sweats, and believes she is losing flesh and strentli. A brother and a sister died of consumption. We are led naturally to suspect incipient phthisis; but the diagnosis of the early part of the first stage, by physical signs, is not always an easy matter; and it is quite beyond the reach of one who has not given some special attention to the subject. We know that fremitus is more marked at the right apex in health than at the left, that the pitch is higher on percussion, that expiration is higher in pitch and longer in duration upon auscultation, and also that vocal resonance is exaggerated. With these signs at the left apex we should be almost certain of phthisis. How, then, are we to determine whether there is phthisis upon the right side ? In the first place, the disparity seems to be greater than is found ordinarily in health ; and, secondly, there is evidence of circum- scribed bronchitis, shown by the localized subcrepitant rales. Besides, there are a few crackling and crepitant rales, indicating some slight co-existing pleurisy and pneumonia. These adventitious signs are confirmatory evidence, and, taken in connection with an elevation of tempera- ture, complete the diagnosis. 7 The advantage of detecting the presence of phthisis at an early stage is very great, for that is the time in which judicious treatment is productive of the best re- sults. While, unfortunately, the greater number do not, still it is a well-established fact that patients do re- cover from phthisis. We find this demonstrated in au- topsies, when death has taken place from other causes, by the presence of cicatrices or encapsulated cretaceous remains of old phthisis. It is also within the experience of many of us to have watched the progress toward re- covery. Localized pneumonia undergoes resolution, circumscribed bronchitis disappears, and with them all decisive evidence of pulmonary phthisis. The next patient comes with history of a cough which has lasted nearly two years, associated with night sweats, loss of flesh and strength, but no haemoptysis. His father and a brother died of what he thinks was consumption. Upon inspection, we see that he is much emaciated, especially about the chest. Under both clavicles there is depression, the retraction being more marked upon the right side. On palpitation, we find fremitus exaggerated upon the right side, and his respi- rations are twenty-four a minute. Light percussion shows dullness in the upper part of the right infra-clav- ular region and over the upper half of the left side of the chest, while forcible percussion brings out cracked-pot resonance from the left infra-clavicular region. Auscul- tation reveals bronchial breathing and bronchophony over the right, with amphoric respiration and whispering pectoriloquy in front upon the left side, while behind on the left side are large and small bubbling rales. Thus we have an example of the beginning of pulmonary phthisis at the same time with one approaching its end. It is but ill-conceived advice that sends a patient with 8 lungs in this advanced stage of destruction from home and friends, to find discomfort and finally death among strangers in a strange land; and it would seem that a knowledge of the physical signs of disease should enable physicians to avoid doing this thing. There are a few cases, to be sure, where phthisis ad- vances to the stage of excavation and, remains station- ary, the patient practically recovering, but this is rather exceptional. If the physician can decide that the phthisis is non-progressive, and finds the pulse good and the general condition of his patient fair, he may give a guarded favorable prognosis, and possibly allow him to try a change of scene and climate. lo return, then, to our opening proposition, we see in all these cases that a comprehensive knowledge of disease is quite indispensable to a specific understanding of the malady under which each patient labors. And without physical exploration there is no certainty, for different diseases have so many symptoms in common that dependence upon symptoms alone is often mislead- ing. By a thorough examination of each case the phy- sician exhausts all possible causes of any given com plaint. He begins to know definitely the matter in hand. He knows what is not as well as what is before him. He can direct his remedies to the true seat of the disorder, and he is not under the necessity of trying what may prove an ill-judged experiment, while without this examination his diagnosis is more or less guess- work. He may be right, for a guess has always one chance of being right; but he will often be wrong, and wrong, too, from avoidable causes. I cannot, therefore, urge upon the student too forci- bly the importance of a thorough familiarity with phys- ical diagnosis. He will not fail to be convinced of its supreme value in all cases of thoracic disease.