DOI: 10.7925/drs1.ucdlib_280593
title: Endocarditis, permanent patency of aortic orifice

description: Watercolour medical illustration depicting endocarditis. It has the alternative reference number 1289 and P1B on the front. The Richmond Hospital Museum reference is C.e.32. The entry for this in P263/1 pg. 28 reads 'Endocarditis, permanent patency of aortic orifice. Dr Corrigan'. The artist's name is in the bottom right corner 'J. Connolly fec.t'. The handwritten note under the illustration reads 'Endocarditis permanent patency of Aortic orifice'. The handwritten and typescript notes on the back begin 'Dr Corrigan. Richmond, Whitworth and Hardwicke Hospitals. CLINICAL LECTURE by Dr Corrigan Physician in Ordinary to the Queen in Ireland &c, &c. Permanent Patency of Aorta, of several years' duration'.
description: Scope and content: The full handwritten and typescript notes on the back read 'Dr Corrigan. Richmond, Whitworth and Hardwicke Hospitals. CLINICAL LECTURE by Dr Corrigan Physician in Ordinary to the Queen in Ireland &c, &c. Permanent Patency of Aorta, of several years' duration – Recent endocarditis supervening on it – Treatment, rules of – Importance of rest. We have a case before us to-day full of interest. The patient, J.H., a young man, aged 24, died suddenly last night, in a fit of angina. I will first draw your attention to the post-mortem appearances, and then make such observations as the case appears to suggest. The lungs are healthy, or somewhat oedematous, but quite free from any appearance of pneumonia or pulmonary apoplexy. The heart is of immense size – at least four times the healthy bulk; the left ventricle greatly enlarged; its parietes healthy in texture, and of at least double their natural thickness. The pericardium contained some serous fluid, but no lymph, or sign of pericarditis. As the case had been marked during life as permanent patency, the first examination was directed to this point; and the heart having been removed from its attachments, the aorta was passed up on the nozzle of the water-cock in the dead-room, and while held securely there, water was turned on. The water flowed freely downwards through the aortic orifice into the ventricle, and passed, through the incision made in the ventricle, into the basin beneath, showing that the aortic valves did not perform their function. The action of these valves, being purely mechanical, is perfect after death, if they are sound. The diagnosis being verified, the ventricle was then opened by a longitudinal incision extending from apex of ventricle, and carried between two of the aortic valves into the ascending aorta and its arch; and the following are the appearances: - The aortic valves are thickened on their edges and fringed with red lymph; and immediately under one of the valves is a small aneurismal pouch, about the size of a very small hazelnut, evidently of old standing. The triangular spaces which should exist between the valves are no longer apparent, but are filled up with a tough ligamentous deposit, extending across from valve to valve, which has evidently been lymph of old standing, and which has been undergoing a process of contraction, for the valves are dragged together by this contracting tissue, so that two valves look like one; and I have seen, in some cases of very old duration, the common point of attachment of two of the valves give way, and this ligamentous deposit continuing to hold the edges united, after the point of attachment to the aorta has ceased to exist. The two valves then seem, at first sight, to be only one, and might lead to the supposition that there had been only two aortic valves. It is quite evident from its appearance, paleness, toughness and firmness, that this ligamentous tissue tying together the aortic valves, and impeding their functions, has been of long duration, and that the other morbid appearances which next come under our observation are of quite a different and of recent date. I have already noticed the fringe of red lymph on the old thickened edges of the aortic valves. In addition to this there is an extensive deposit of lymph on the inner membrane of the ventricle, constituting one of the best specimens of recent endocarditis I have seen for a long time. The patch of lymph covers the whole anterior surface of the mitral valve, from the attachment of the cordie tendineae, extending upwards along the lining membrane of the ventricle, until it reaches the roots of the aortic valves. This patch is fully an inch square, consisting of tolerably firm lymph, of a deep pinkish-red colour, pulpy on its surface, and irregular, looking somewhat like the pile of very coarse velvet. It is firmly adherent to the adjacent serous membrane, but still can be detached from it with the nail. The lining membrane of the ascending aorta, you observe, is deep red through nearly its whole extent, with two or three small ecchymoses near the valves, a few patches only of the internal membrane of the vessel retaining its healthy pale colour. We have here, then, before us two pathological formations, evidently of very different dates – one of old standing, the other of recent occurrence; and we have data which enable us to fix their dates, and to give us other very useful information. J.H., aged 24, a labourer, of well-built frame and strong muscular development, was admitted into hospital on the 16th November. About two months before he had been under rain the whole day, and, a few days after, began to suffer from cough, and occasional palpitations with repeated rigours, against which, however, he bore up until the evening of the 14th, when he was attacked with angina, or, as he describes it "sudden suffocation in his breathing". This left great debility behind it; he was obliged to give up work, and came into hospital, as already noticed, on the 16th – next day but one. Seven years ago he had an attack of rheumatic fever, and in the course of it was cupped and blistered over the region of the heart, the marks which are still to be seen; but from that period up to this present illness he continued at labouring work, without suffering any inconvenience. Debility and fits of angina were his prominent symptoms while in hospital, requiring frequent does of stimulants and brandy to revive him; the action of the heart being so weak, notwithstanding its enormous size and thick parietes, as to be unable to propel the blood into the radial arteries when the arms were held up, the pulse at the wrists then ceasing. Slight oedema of the legs occasionally appeared, but no symptoms of congestion ever showed themselves; and on 3rd December he died in a fit of angina, having been seventeen days in hospital. The symptoms of permanent patency were well marked, and I need only briefly recall them to you. They were, extensive dullness on percussion over the precordial region, corresponding with the increased size of the heart; double bruit over the middle and lower sternal region; single bruit in carotid and subclavians, with well-marked fremissement in these vessels in both sides of the neck, best felt by laying the thumb longitudinally in the supra-clavicular space over the subclavian arteries, where visible pulsation was also most strongly marked. The first instructive point in the case is, that we are able precisely to mark the dates of the two pathological states in the heart. The older deposit of ligamentous tissue in connexion with the valves, we can have no doubt, took place seven years ago, in the attack of rheumatic fever; and we learn from it how little may mere mechanical alteration, when not of great degree, interfere with the action of the heart, and even long-continued bodily exertion. In this case, for seven years, the man followed the occupation of a labourer, and his able muscular development fully bore out his own statement, that during that long period he had suffered no inconvenience. I recollect an instance of this disease, in which the person labouring under it was the medical officer of an extensive country dispensary, the laborious duties of which he continued to discharge for fifteen years, with very little inconvenience, and eventually died from another cause. When the endocarditis, however, in our patient's case, which had been hanging over him, probably, from the period of his wetting, set in with full intensity on the 14th inst., then came with it an attack of angina, and suddenly weakened action of the heart; and under these repeated attacks, with a continuing weakened action of the heart, he at length sank, and died after seventeen days. We thus from this case learn this important lesson – that in the sudden exacerbations that will sometimes occur in valvular diseases, we have to deal with some vital derangement, rather than with the mere mechanical defect. The mere valvular defect in the case before us had undergone no change; but on endocarditis setting in, arising partly from the wetting, but excited also by the previously-existing morbid deposit, this vital derangement, added to the prior mechanical defect, was sufficient to cause the [?]ming symptoms under which the patient sank. Endocarditis is at all times a most dangerous and suddenly depressing disease, but the more so when engrafted on previously diseased tissue. It may be asked, why did the action of the heart become suddenly so weak, and remain so notwithstanding all the stimulants exhibited, although its muscular tissue seemed healthy as usual. This phenomenon appears to me to be in accordance with what we observe of muscular tissue in analogous instances. When the pleaura costalis is acutely inflamed, the intercostal muscles will not act. When the peritonaeum is inflamed, in most cases the muscular fibres of the intestines will not propel their contents; and when a joint is inflamed, the muscles in connexion with it will obstinately refuse to act, no matter with what efforts the patient may attempt to command them. Thus it is, I believe, where the lining membrane of the aorta or of the left ventricle is acutely inflamed. The muscular fibres of the left ventricle will not act with their accustomed force; and if the inflammation be sudden and acute, and over a great surface, as in this case, involving aorta and lining membrane of ventricle together, the action will become so weak as to cause syncope and death. What are the lessons to the treatment that we learn here? 1st. That no matter what may be our opinion of the extent of endocarditis, we must meet the depression with stimulants and opium, and particularly with a full anodyne at night; and next, that if we can obtain a rally, we shall, as soon as possible, superadd local bleeding, blistering, and the use of mercury, to check the effusion of lymph, and to promote the absorption of what has been poured out. In connexion with the treatment of pericarditis and endocarditis in the sub-acute stage. I have now a few observations to make on one of the most important agents in their cure – namely, rest and abstinence from stimulants. If a joint has been inflamed, a patient is quite satisfied, because he sees the inflamed joint before him, and because the part is endowed with animal sensibility, to keep it at rest for weeks or months. He understands perfectly that if he not, deformity, and perhaps disorganisation, will be the result; but the necessity of the same rule does not often come sufficiently forcibly to either patient or physician in convalescence from endocarditis or pericarditis, because the part effected is out of sight, and is not endowed with animal sensibility; and thus, after, perhaps a short time, patient and physician both become impatient, and instead of rest and mild nutrition, tonics, wine, strong food, and exercise are had to recourse to, and with the naturally to be expected bad results. Remember how long it will take to bring round an inflamed joint even when we can give it perfect rest. Remember that we can in no case give the heart perfect rest, and that is the more necessary, on that account, to give it as much as we can. Let your patient lie for weeks on a sofa or bed, in convalescence for pericarditis or endocarditis. Always bear in mind that you have, as it were, an inflamed joint within to deal with. Abstain from stimulants, or give them most sparingly. Keep the action of the heart as quiet as you can during the day, and give an anodyne every night, and you will see recoveries that will occasionally surprise you. See Dublin Hospital Gazette. N.S. Vol. 5 page 1. January 1. 1858'.
description: Numbering/sequence: Original reference number: 1289.