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Source: Disturbances Of The Heart
The part of the heart most affected is the part which has the most
work to do--the left side of the heart--and of this side the left
ventricle and therefore the mitral and aortic valves; the most
frequent valve to be inflamed and to stiffer permanent disability is
the a mitral valve, the valve which in its inflamed condition is
subjected to the greatest amount of pressure and therefore
irritation. Not infrequently soft systolic murmurs are heard at the
pulmonary and tricuspid valves during acute endocarditis. It is
rare, however, that these valves are so affected during childhood or
adult life as to be permanently disabled.
Whether a diminished alkalinity of the blood in rheumatism has
anything to do with the cause of the frequent complication of
endocarditis has not been determined. Whether the administration of
alkalies to the point of increasing the alkalinity of the blood is
any protection against the complication of endocarditis has also not
been positively demonstrated, although clinically such treatment is
believed by a large number of practitioners to be wise.
A chronic endocarditis with permanent lesions of the valves may
become an acute inflammation with an infectious provocation.
It has been shown that even in a few hours after endocarditis has
started, little vegetations composed of fibrin, with white blood
cells, red blood pigment and platelets, may develop. Practically in
all instances such vegetations develop, and later become more or
less organized into connective tissue. These little vegetations,
generally minute, perhaps not exceeding 4 mm. in height, are
irregular in contour like a wart. Some of these may have small
pedicles, and as such, of course, are more likely to become loosened
and fly off into the blood stream. It is of interest to note that
these little vegetations are more likely to be on the left side of
the heart than the right; on the valves than any other part, and on
the mitral valve than on the aortic. The consequence is a more
frequent permanent disability of the valves of the left side of the
heart, and of these more frequently the mitral. Although these
little vegetations and excrescences sooner or later become mostly
connective tissue, still fibrin and white blood cells may form thin
layers over them, more or less permanent. In this fibrin are
frequently found bacteria, even when there has been no recent acute
inflammation. The deeper layers of the endocardium during acute
inflammation may become infiltrated with young cells, with resultant
softening and destruction of the intercellular substance. This
softening and some swelling of the lower layers of the endocardium
allow the pushing up of these extravasated blood cells which, being
covered with fibrin, makes the little vegetations above described;
and as just stated, the fibrin may form a more or less permanent
cap. If this cap is disintegrated or lost and the cells under it
washed away in the blood stream, ulceration takes place, which may
be more or less serious, even to the perforation of a valve or
actual erosion of one of its cusps, and the parts of the valves most
seriously affected are the parts which strike against each other on
closure; as previously stated, the parts subjected to the greatest
strain and the greatest amount of friction during the inflammation
are the parts most seriously affected afterward.
If a perforation has occurred, it may make a permanent leak. If an
erosion of the edge of the valve has occurred, it may make permanent
insufficient closure. If the valve has become thickened and
stiffened during the cicatricial healing, it may not only be
incompetent, but may not open perfectly, and a narrowed orifice may
be the consequence. During the healing of these granulating ulcers
there may be thickening of the part or shrinking of the tissue, and
the valve may become shortened by adhesion to the wall, or the cusps
of the valve may adhere together so that the valve becomes
permanently unable to open properly or to close properly, or to do
Not infrequently and probably more frequently than we recognize,
recovery without any of the pathologic lesions just described
follows mild endocarditis. The occurrence of simple endocarditis is
undoubtedly frequent during acute disease, and is unrecognized
because there are no lesions of the heart at the time or
subsequently; but valvular lesions only too frequently follow the
endocarditis which occurs with rheumatism. Occasionally the
ulcerations become serious, and ulcerative endocarditis or malignant
endocarditis develops on the mild inflammation. In this form the
little vegetations are liable to become loosened, fly off into the
blood stream, and cause emboli in different parts of the body.
Recently Fraenkel [Footnote: Fraenkel: Beitr. z. path. Anat. u. z.
allg. Path., 1912, iii, 597.] concluded that the microscopic nodules
which occur in endocarditis in the myocardium, and which consist of
the several varieties of white blood corpuscles first referred to by
Aschoff in 1904, are characteristic only of acute rheumatism.
Fraenkel found these nodules in the myocardium in a case of chorea,
showing the close relationship between it and rheumatism.
While repeated careful examination of the heart during acute
infections will generally show signs of endocarditis if it is
present, even if there are no subjective symptoms, the disease may
be so insidious as not to be noted until a valvular lesion occurs.
Often, however, during the course of the disease, especially in
rheumatism, there is a slight increase in fever and there is a
discomfort complained of in the region of the heart, frequently
accompanied by slight dyspnea. Real pain is seldom present unless
the pericardium is affected. If the myocardium is much inflamed at
the same time, the heart becomes more rapid and the blood tension
lowered, and the apex beat diminished in intensity and perhaps not
palpable. If there is pain, with or without pericarditis, it is
often referred to the epigastrium, especially in children. The
patient is often nervous, restless and sleepless. In simple
endocarditis emboli rarely occur. If they do, of course the signs
will be in the part in which the infarct occurs. Besides the
diminished intensity of the apex beat and its greater diffusion, the
valve sounds may be muffled, and sooner or later there may be
systolic murmurs over the different orifices. Of course systolic
murmurs may be due to a disturbed condition of the blood, but if
they occur with the above-mentioned symptoms and signs, endocarditis
should be diagnosed. If the heart becomes seriously weak and the
patient suffers much dyspnea, myocarditis should be known to be
present with the endocarditis. If there is a diastolic murmur, there
can be no question of serious endocarditis having occurred.
Unexplainable palpation during acute illness liar been thought to be
a distinct symptom of endocarditis.
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