1902 Journal of the American Medical Association  
8. There is but little tendency toward cicatricial contraction, and when recovery ensues, even in cases with ulceration, the integrity of the valve may be unimpaired and health completely restored. DISCUSSION. Dr. James B. Herrick, Chicago-I was particularly interested in that portion of Dr. Well's paper which dealt with the possibility of recovery in acute ulcerative endocarditis. Of course, we recognize that it is very difficult to draw any sharp dividing line between the simple form and the
more » ... imple form and the ulcerative. Yet, by the complex symptoms, chills, petechial spots, embolic phenomena, emaciation, bacteria in the blood, etc., we are justified in making a diagnosis of ulcerative endocarditis. That ulcerative endocarditis need not necessarily prove fatal may be argued on a priori grounds. Other cases of septicemia, e. g., streptococcic puerpural septicemia, may recover even though severe. Another argument that may be advanced for the possibility of recovery from this disease is the relating of such cases as reported by Dr. Wells. When one looks through the literature on this subject much surprise is expressed on finding how many cases have been reported. I have been particularly interested in the subject of late, and I have found some 30 or 40 cases of reported recovery from this form of the disease. While it is very easy to pick flaws in the , histories of these cases and to sa}' that they do not conclusively show that the disease was ulcerative endocarditis, yet each history has been carefully given by skilled observers whose judgment must be given some weight. Another line of argument is to be found in the study of autopsies on those cases dying from mechanical lesions induced by the valvular trouble. No more interesting work has been done than that of Harbitz. A few years ago, in a monograph on this subject, he divided endocarditis into two classes, toxic and infectious. This second class he again divided into two forms; (a) where the clinical manifestations were of the pyemic type, with chills, fever, sweat, etc., which run a fulminating course, terminating in death; in this class we find the staphylococci; (6) the clinical symptoms are less violent and at autopsy changes may be found which are ulcerative and, as a rule, the pneumococci or, more often, the streptococci, are to blame. In a certain number of cases, dying from the mechanical effects, there are found the same anatomic changes as are found in the second group of fatal cases, but the micro-organisms have lost their virulence. By inoculating experiments he found them degenerate and dead. He found sear tissue and calcification and other evidences at attempts at healing. So that, arguing along these three lines of a priori reasoning, clinical experience and postmortem observation, we may say that, in the small percentage of cases, particularly when the pneumococcus or streptococcus is the organism that produces the lesion, recovery is possible. If this is so it must modify the very unfavorable prognosis given in such cases and should encourage us in our efforts to cure. The prognosis need not be so grave as before. We should make more careful baeteriologic examinations of the blood and so determine the micro-organisms that are doing the damage. Db. Wells, in closing-I wish to say in a few words that which I consider to be very important concerning the endocarditis of rheumatism and of pneumonia. As is well known, rheumatic endocarditis attacks the tissues of the valves, producing thickening; contraction follows with consequent deformity of the valves. This contraction is progressive until its limits are attained, and many months are required before the full damage can be measured or estimated. I do not believe the same to be true in the endocarditis of pneumonia; there being but little tendency to subsequent cicatricial contraction of the tissues of the valve. If there should, perchance, be recovery from the initial lesion recovery with fair valvular action may ensue, unless the ulceration has been very extensive. Certainly in the endocarditis due to pneumonia the chances of recovery are infinitely less than in the endocarditis due to rheumatism, but if the patient recovers at all it is possible that recovery may be more complete. Another very important point which I wish to emphasize is that examinations of a very large number of postmortem reports show conclusively (hat it is difficult and often impossible to recognize the pres-ence of even large valvular vegetations during life, no matter how carefully or skilfully they may be searched for. In the case reported Dr Babcock could detect no murmur previous to ulceration, and I am sure none was present during this time when the patient was under the closest observation. The only change noticed in the cardiac movement was a tendency for six days to slight irregularity of rhythm. (Concluded from page 901.) Complications. Hemorrhage. The most serious and first complication encountered is hemorrhage. That from the external incision and bone, especially at the anterior angle, from the anterior branch of the middle meningeal artery, is profuse. William Perry had a case of meningeal hemorrhage from the flap and the patient died of meningitis on the fourth day. For this reason the bone is not divided in this position until the last act of the osteoplastic flap formation. If the artery is free on the surface, it may be ligated at this point, or if it be in a bony canal, as it was in 55 per cent, of the skulls examined by Dollinger,11 it can be compressed by plugging the opening, or, better, by indenting the bone with a blunt punch. A second source of hemorrhage is from the ven\l =ae\ Santorini, with the separation of the dura. The separation should be carried well into the anterior portion of the middle fossa, so that the second branch of the nerve is encountered at the foramen rotundum first. The dura should then be separated backwards until the third branch is reached, and for one-third to one-half an inch posterior to the foramen ovale. It is possible by this process to entirely avoid opening the middle meningeal artery or exposing theforamen spinosum, as Dollinger found in 59 per cent, of the skulls examined by him that the artery was situated at least this distance behind the foramen ovale. The hemorrhage from these veins can be controlled by a few minutes' gentle packing, and time is saved by patience at this point. When the packing is removed the hemorrhage is slight and the operation may be proceeded with. The venous hemorrhage in one of Dollinger's cases was so great that he had to abandon the operation, and in some of Keen's cases it was profuse. The third and most serious source of hemorrhage is from the middle meningeal artery at its point of exit from the foramen spinosum. In some of the cases of hemorrhage recorded the location is not definitely stated, but simply that it was severe and uncontrollable. Keen's experience was most trying, as in four out of eleven cases he had to abandon the operation temporarily in order to control the hemorrhage. In three of these cases it was of venous origin and in one from the middle meningeal at the foramen spinosum. In a fourth he controlled the hemorrhage by tamponing, but the patient died of coma and hemiplegia. In two other cases he had bleeding from the torn middle meningeal at the base, but did not have to postpone the operation. In one of Koenig's cases the hemorrhage was fatal. Czerny had two severe hemorrhages in three cases; one required, plugging of the foramen spinosum and the other was controlled by the cautery on the twelfth day. Finny 11. Cent. f\l=u"\rChir., 1900, p. 1089.
doi:10.1001/jama.1902.52480420033001h fatcat:pneqe3orojctvpmqttqjxxkfva