ST. GEORGE'S HOSPITAL
Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborum et dissectionum historias, tum aliorum tum proprias collectas habere, et inter se comparare.—MORGAGNI De Sed. et Caus Morb., lib. iv., Proœmium. ST. GEORGE'S HOSPITAL. THE rarity of pulmonary incompetence and the peculiar character of the abnormality of the pulmonary valves in the following case render it one of unusual interest. The notes of the case were taken by the late Dr. E. Delafosse Bond, late house physician,
... house physician, and Dr. R. Salusbury Trevor, assistant curator of the museum. A man, aged 41 years, was first admitted into St. George's Hospital on Feb. 8th, 1900. He gave a history of having had for six years a winter cough which had latterly become almost continuous. For two years he had had oedema of the legs, ascites, and frequent streaky haemoptysis. He complained of cough and pain in the chest. On admission he was much cyanosed, with dilated venules on the face and pulsation of the jugular veins. He was very dyspnoeic and coughed up blood-tinged sputum. His lungs were emphysematous and full of rhonchi and sibili. The heart sounds and the position of the apex beat were normal but the right side of the heart was dilated to three fingers' breadth bevond the sternal margin. The liver was enlarged and extended two fingers' breadth below the costal margin. There was œdema of the loins and lower extremities. He improved and left the hospital. Another breakdown occurred one month later and he returned to the hospital until July, 1900. On Jan. 6th, 1901, he was re-admitted into the hospital with dyspnoea, intense cyanosis, constantly recurring cough, and much epigastric pain. Bales and rhonchi were heard all over the lungs ; there were signs of collapse at the bases. All the extremities, the legs especially, were very blue. Much ascites and oedema of the legs were present. The pulse was irregular and the urine was albuminous. The heart was in much the same condition as it had been before but the pulmonary emphysema and adventitious sounds present interfered with its examination. A soft systolic murmur at the apex was made out and the pulmonary second sound was accentuated. No murmurs were audible in the pulmonary area. On March llth, 1902 he was admitted under the care of Dr. Rolleston with the same symptoms, but they were worse than before. All the signs were exaggerated ; the cyanosis was more intense, venous pulsation and oedema were much increased, the lungs were more choked, and the liver now reached to the umbilicus. The size of the heart was estimated with difficulty owing to the emphysema, but much enlargement of the right side was thought to exist. The apex beat was neither visible nor palpable. The heart sounds were faint and distant. A soft systolic murmur was heard at the apex and in the pulmonary area ; while a definite diasolic murmur had now developed over a limited area in the third, fourth, and fifth spaces to the left of the sternum, not audible immediately along the border of the sternum but a little external to this. The aortic second sound was clear. A soft systolic murmur was heard occasionally over the tricuspid area just to the left and low down, but as a rule could not be heard. Orthopncea, ascites, and haemoptysis persisted in spite of treatment and a good deal of pain and tenderness in the abdomen were complained of. On April 14th the cough suddenly became much worse ; the cyanosis increased and deepened with each coughing attack. There was a rigor and the temperature rose to 104°F. with rapid pulse and respiration. Venesection was performed but gave only very temporary relief. The patient died on the same day. Neoropsy.-The body was examined 14 hours after death. It was well nourished. The lower extremities and penis were oedematous. On opening the chest each pleural cavity was found to contain half a pint of fluid. The lungs were covered with recent fibrin except at their bases and the lower part of their outer surfaces, where they were firmly adherent to the diaphragm and chest wall. Both lungs were bulky and heavy and emphysematous on their anterior ,ur. faces. The right lung weighed two pounds five ounces and the left lung one pound six ounces. Both were cedematous with the exception of the right lower lobe, which showed to. the naked eye and under the microscope early pneumonic. consolidation. The bronchial tubes in both lungs were thickened and filled with muco-purulent secretion. The branches of the pulmonary artery were markedly athero. matous. The pericardium contained a slight excess of fluid. The heart was large and weighed ZO ounces. The right ventricle was considerably dilated and hypertrophied. The tricuspid valve admitted five fingers' easily, the orifice being obviously dilated. The valve leaflets were healthy. Reproduction of drawing (semi-diagrammatic) of the pulmonary valve. A, Right anterior segment. B, fLeft anterior segment. C, Posterior segment. D, Additional segment ' The pulmonary orifice looked larger than normal and measured 3 13/16th inches in circumference. It was guarded by four cusps, all of which were delicate and thin. and fenestrated at their margins. The additional cusp (D in the Figure) was placed between the right and left anterior segments (A and B respectively) and was a little smaller than these although well formed. It was fenestrated on either side, the openings being, however, above the line of contact, as is usually the case when they are present. The fenestration on the right side of the cusp was the larger and was divided by fine septa. The right anterior segment was exceedingly thin and extensively fenestrated, the fenestrations on the side next the abnormal valve extending right down to its base below the line of contact. The left anterior segment was fenestrated on the side next the additional cusp and the posterior cusp was fenestrated on both sides. In both these, however, the fenestrations were above the line of contact. In the situation of the corpus Arantii in each segment was a large, irregular, projecting nodule, which was seen under the microscope to be composed of well-formed fibrous tissue. Each nodule had a glistening surface and was slightly bossed. The symmetrical situation of the nodule in each valve in the place of the corpus Arantii, the delicate flexible state of the cusps, and the absence of any other signs of endocarditis suggested the view that they were hypertrophied corpora Arantii. Unfortunately, the valve was not submitted to the water test. The right auricle was dilated and hypertrophied. The foramen ovale was closed. The left ventricle was a little hypertrophied. The mitral orifice admitted three fingers ; the valve segments were normal. The aortic orifice measured 3 3/32 inches in circumference and the cusps were healthy. The left auricle appeared to be of normal size. The heart muscle was good. The abdomen contained three pints of strawcoloured fluid. All the viscera showed chronic venous engorgement, the liver weighing 4 pounds 12 ounces, and extending to within three fingers' breadth of the right anterior superior spine.