Two cases of acute endocarditis / by John Cowan [and others].

Date:
[1910]
Catalogue details

Licence: In copyright

Credit: Two cases of acute endocarditis / by John Cowan [and others]. Source: Wellcome Collection.

Provider: This material has been provided by The University of Glasgow Library. The original may be consulted at The University of Glasgow Library.

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    soft^ replacing and running out of the first sound; the second sound was not audible here. The respirations were difficult and cyclic, but without any full apnoea. The upper part of the right chest was dull on percussion, and the respiratory murmur here was deficient, with prolongation of expiration. In the left lower axilla friction sounds were audible ; the stools contained a little mucus. The urine was concentrated and dark in colour, and contained a trace of albumin. For a few days his general condition improved slightly. The coupled rhythm ceased on the 16th, and he rested fairly well at night. The sphincter ani was flaccid, and he had no control over the bowels, though micturition was normal. On the 17th movement was more free in the left leg, but the palsy below the right knee persisted. Anaesthesia was still present, but did not extend so far up on the left leg, being apparently normal above the knee. The left plantar reflex and knee-jerk had reappeared, but the right were still absent. About midnight on the 18th he was noticed to be restless, and was found to be semi-conscious and unable to say moi'e than 'yes', and there was a well- marked full right hemiplegia. He gradually became weaker and more comatose, and the respirations and pulse became more frequent. Rales appeared all over the lungs, and he died with cardiac failure on July 27, 1909. The pulse remained ' single' until the day of death, when it was noticed to be ' coupled ' again for a short time. Post-mortem examination revealed an acute ulcerative endocai-ditis of the mitral valve, engrafted on a lesion of old standing. The upper and middle lobes of the right lung were solid from a somewhat chronic pneumonia, and there were numerous infarcts in the spleen and kidneys. The left middle cerebral artery was occluded by a large pale embolus which resembled the vegetations on the mitral valve, and was associated with a very extensive softening which involved the lenticular and caudate nuclei, most of the internal capsule, the island of Reil, and a large portion of the central convolutions; the rest of the brain and the spinal cord seemed normal. Microscopic examination of the cord showed no evidences of local damage (J. H. T.). Streptococci were isolated on culture from the spleen. No blood cultures were made during life. The mitral valve was stenosed, the cusps being notably shortened, the chordae tendineae short and thick, and the tips of the papillary muscles fibrous. There was well-marked evidence of fibrosis spreading upwards from the bases of the cusps in the direction of the central fibrous body of the heart. Enormous soft recent vegetations almost occluded the valve, and there was in addition extensive ulceration and perforation of the anterior mitral cusp. There was no evidence of any acute mural endocarditis ; but the endocardium of the left auricle was thick and opaque, with a special area of thickening about as large as a shilling on the contra-fossal wall just above the valve. A block of tissue containing the auriculo-ventricular bundle and the node was embedded in paraffin, and cut in serial sections on a plane at right angles to the longitudinal axis of the heart (A. M. K.). Microscopic examination revealed considerable congestion of the tissues generally. The node was the site of a profound inflammatory disturbance, many focal collections of round cells being present, as well as, in places, a diffuse infiltration. The bulk of the cells were lymphocytes, but a few large mononuclear cells, both round and spindle-shaped, were also present. The fibres of the a.-v. node were probably normal, and there was no evidence of old-standing fibrosis. The walls of a microscopic artery (Plate 3, Fig. 2) were infiltrated with round cells, though the lumen was patent; the other vessels seemed normal. The intensity of the lesions varied at different levels, but the whole of the node was more or less affected. The bundle, on the