1922 Journal of the American Medical Association (JAMA)  
pericardial adhesions were present. The most interesting findings were in the heart and kidneys. The visceral and parietal layers of the pericardium were loosely adherent, and on being separated, left a rough, ragged hemorrhagic surface. There was no evidence of free or sacculated fluid. The mitral valve showed the typical fine, beadlike vegetations along the line of closure, and similar wartlike nodules were present on all the cusps of the aortic valve. The tricuspid and pulmonary valves were
more » ... monary valves were normal. None of the valves showed any evidence of an old valvulitis. There was no thickening, scarring or retraction of any of the leaflets. The heart muscle was very flabby, and was pale, brownish red. Microscopic examination of the myocardium revealed the pathognomonic histologic findings of this disease, namely, the submiliary nodule of Aschoff. This peculiar cellular response occurs only in cases of acute articular rheumatism, and in this case they were strikingly numerous and widely distributed. They are found especially along the smaller vessels and, as Aschoff originally pointed out, are closely related with the adventitia. The characteristic cell is a large, clear cell with a large, pale, vesicular nucleus, often multiple and containing a prominent nucleolus. In the neighborhood of these large cells, there are also many large and small mononuclear cells and a few polymorphonuclears. A few showed scattered eosinophils. The rest of the myocardium appeared normal. The vessels appeared patent throughout. The origin of these large cells constituting the Aschoff body is still a matter of controversy. Aschoff's original contention was that they were derived from the adventitial wandering cells. Others believed they arose from the intramuscular connective tissue cells. Recently, Whitman and Kastlake brought forth some evidence that in certain cases they result from the degeneration and proliferation of the nuclei of the muscle-cells, having observed the presence of striae at the periphery of the cell. They believe that the process may begin as a minute infarct, but this is quite unlikely in view of the absence of embolic disorder elsewhere. The Aschoff bodies are probably the forerunners of the scattered areas of scar tissue so frequently encountered in old rheumatic hearts. They have as yet not been reproduced experimentally, though similar lesions, so-called Bracht-Wachter bodies, consisting of a focalized collection of connective tissue cells with lymphocytes, have been noted (by Cecil, Thalheimer and Rothschild, and others) in the heart muscle of animals injected intravenously with Streptococcus viridans. Bracht and Wachter have produced such lesions in rabbits with intravenous injections of streptococci isolated from cases of acute articular rheumatism. Schloss and Foster have also produced such lesions in monkeys following injections of hemolytic streptococci. But in none of the experiments and also in none of the human cases of endocarditis, other than rheumatism, did the myocardium show cellular deposits which were histologically comparable to the Aschoff body, except in their focalized character. The alterations in the kidneys were also very striking. Except for slight fibrous thickening of the capsule, the glomeruli appeared normal. The changes were confined chiefly to the tubules and to the interstitial tissue, especially of the medullary portion. The lining epithelium of the tubules showed varying stages of disintegration, and the lumen was filled with red blood cells, casts and polymorphonuclears and lymphocytes. Scattered throughout the interstitial tissue, there were innumerable foci of lymphocytes and plasma cells, and in some places there was a considerable accumulation of polymorphonuclear cells. The lesion appears to be a combined acute tubular and interstitial nephritis, not unlike Delafield's acute exudative nephritis, or the type of renal lesion that Councilman has described in cases of scarlatina and other acute infectious diseases. This picture is entirely different from the renal lesion in cases of bacterial endocarditis in which the glomeruli are chiefly involved. Various writers have pointed out the not infrequent association of chronic cardiovalvular disease with chronic interstitial nephritis. Though in some cases this may be a mere coincidence, it is not unlikely that the renal lesion may represent repeated mild and possibly unrecognized attacks by the rheumatic virus, just as the old endocardial lesions are usually the end-result of one or more attacks of acute rheumatic endocarditis. SUMMARY The case reported is one of acute rheumatic fever terminating in death on the sixty-sixth day. The course of the disease was unusual. The onset suggested an acute abdominal condition and, though the constitutional symptoms were pronounced, and cardiac, pleural and renal involvement occurred, arthritic manifestations were slight. The clinical diagnosis was confirmed by the finding of Aschoff bodies in the myocardium. M. C., aged 15, a schoolboy, referred to me, Dec. 29, 1921, had jumped from a wall about 10 feet (3 meters) in height, about December 15, landing on his feet. He complained of severe pain in the lumbar spine at that time. This pain gradually disappeared. About December 22, after being active for a week, he again complained of severe pain in the lumbar region. At this time he was unable to move his legs or to pass urine. As well as I can make out from careful questioning, this paralysis came on very suddenly on about December 22. I had the patient removed to Mercy Hospital, December 29. Next day the patient was very restless and apprehensive as to his condition. His head was drawn back. The legs were resting on pillows. The slightest touch caused him to groan. The pupils reacted to light and accommodation. Other eye signs were negative. The throat, lungs and heart were normal. The abdomen was moderately distended and rigid. There was no tenderness, except for general hyperesthesia. All the reflexes in the lower extremity were absent. He was unable to move his legs or wriggle his toes. There was slight movement in the adductor group of muscles when he attempted to move his legs. Sensation of heat, cold arid touch were everywhere present. There was marked tenderness on pressure everywhere in the lumbar region. The patient could be moved from the supine position only with great difficulty because of pain in the back. The leukocyte count was 54,200. Examination of the urine revealed albumin, pus and bacteria. The patient had been catherized twice daily for a week. Lumbar puncture yielded fluid apparently not under pressure. Only 6 cc. was obtainable. The fluid was amber and clear. It coagulated to a solid jelly in about five minutes. No cells or bacteria could be found on microscopic examination. Roentgen-ray examination of the spine, December 31, revealed a faint, indefinite shadow extending along the spine on both sides. Nothing wrong with the vertebrae was detected. The roentgenogram was rather unsatisfactory because the intestine could not be thoroughly emptied. There was a gradual accumulation of feces in the intestine. The bowels moved somewhat after-cathartics and enemas, but the patient had no control over his bowels. The temperature from Dec. 29, 192129, , to Jan. 1, 1922 between 101 and 103; the pulse, from 96 to 122; respiration, from 22 to 36. January 2, the temperature began to go up. At 7 p. m. the axillary temperature was 105. The respiration rate was 44. The respiration then began to be labored. He died at 10:30 p. m. A partial necropsy was held, January 3. The body had been embalmed the night before. An incision was made in the back along the spines of the vertebrae. In the lumbar region pus began to appear before the vertebrae were reached. The lumbar muscles were infiltrated with pus. There was pus along the entire spine from the sacrum to the skull. The spine was opened and pus was found within the spine along its entire length. This pus was outside the meninges. Within the meninges was a small amount of clear fluid. The meninges and cord were not inflamed. The body of the first lumbar vertebra was necrotic. Pus also extended in front of the spine along its entire length. Microscopic examinations were not made, as we promised the boy's mother to remove nothing from the body. SUMMARY A slight injury to the spine due to a jump from a wall
doi:10.1001/jama.1922.26410580002011a fatcat:rjzfquthm5e2hn2lvro6jkpebe