Rheumatic Lesions Research Articles

Aschoff bodies in left auricular appendages of patients with mitral stenosis; clinicopathologic study, including postoperative follow-up.

IN RECENT years surgical valvulotomy for mitral stenosis has made it possible to examine microscopically the left auricular appendage and observe histologically the rheumatic process in a part of the heart during life. Since this is a phase in the natural history of rheumatic fever, it may be possible to correlate the incidence and degree of activity with the clinical events of rheumatic cardiac disease. Although the lesions of rheumatic fever have been described in the left auricle proper,* the auricular appendage has escaped more critical examination. Von Glahn, 8 in a study of rheumatic auricular endocarditis, concluded that the changes observed may extend into the first portion of the auricular appendage. He did not, however, record Aschoff bodies in this location. Similarly, Gross, 9 in an exhaustive review of rheumatic auricular lesions, made no reference to the auricular appendage. Unusual circumstances have on occasion prompted the making of sections of this

Correlation between active rheumatic lesions in the left auricular appendage and elsewhere in the heart.

Correlation between active rheumatic lesions in the left auricular appendage and elsewhere in the heart.

Left atrial calcification; report of eight cases verified at surgery for the relief of mitral stenosis.

In 1949, Epstein (1) reported 3 cases of left atrial calcification in rheumatic heart disease diagnosed roentgenologically during life and noted that only 2 other such cases appeared in the literature. Since that time numerous other reports have been published (2–6). Although somewhat less than half of the recorded cases have been accompanied by necropsy data (2, 3), stress has been laid upon the probable endocardial location of the calcium. Attention has been invited to the rheumatic endocardial lesion of MacCallum (7) as the probable calcium nidus (1). The frequency of the MacCallum lesion in rheumatic heart disease has also been noted, as well as the probable infrequency of calcific deposits within it (1, 8). As a basis for this report, x-ray film studies and the recorded fluoroscopic findings of 300 patients examined prior to mitral commissurotomy for the relief of mitral stenosis were reviewed. Eight cases of left atrial calcification were found. In all but 2 instances the tip of the atrial appendage...

Potassium deficiency as cause of the so-called rheumatic heart lesions of the adaptation syndrome.

IN THE course of experiments designed to study the relationship of diet and hypertension, various techniques of inducing hypertension in rats were used including Selye’s method which he describes in his communication on pathogenetical correlations between periarteritis nodosa, renal hypertension and rheumatic lesions (Selye and Pentz, 1943). This method consists of overdosage with desoxycorticosterone acetate (DCA) with or without high sodium chloride intake in unilaterally nephrectomized rats. Selye found that severe overdosage with DCA reproduces in the rat morphological lesions similar to those seen in periarteritis nodosa, malignant hypertension and rheumatic fever. He concludes that these diseases are, at least partly caused by an abnormal adaptive response of the adrenal cortex and represent diseases of adaptation. In the first series of our experiments when rats with an average weight of 168 grams were treated with DCA overdosage following unilateral nephrectomy, hypertension was only rarely produc...

Syphilitic cardiovascular disease combined with chronic endocardial lesions usually attributed to rheumatic fever

Forty-seven instances of syphilitic cardiovascular disease combined with chronic endocardial disease, probably rheumatic in origin, have been noted in the literature and are briefly reviewed. Among 398 autopsy specimens of syphilitic cardiovascular disease and 459 specimens showing rheumatic heart disease (acute and chronic) at this institution, there were eight specimens exhibiting combined syphilitic aortitis and chronic endocardial lesions judged to be of probable rheumatic origin. The clinical problem of the recognition of combined syphilitic and rheumatic lesions of the cardiovascular system is illustrated by the case report of a male patient showing clinical evidence of aortic dilatation, aortic insufficiency and a mitral diastolic murmur together with a history of syphilis. Necropsy showed a combination of diseases herein described. It is emphasized that the possibility of coexistent syphilitic rheumatic heart disease must be considered when overlapping evidence of either of the diseases is discovered clinically. In large autopsy series of either syphilitic or rheumatic hearts the incidence of such combined lesions varies from 1 to 10 per cent.

The relative incidence of rheumatic valve disease in New York and Costa Rica and its bearing on the rheumatic origin of calcareous aortic stenosis

The incidence of rheumatic endocarditis of the mitral valve alone, and of the mitral and aortic valves together, in three independent series of autopsies is compared. Differences in the total incidence of valvular lesions were noted in each of the three series. These differences cannot be attributed to racial or geographical factors alone, since two of the series represent cases from essentially the same types of population in the New York area. However, the relative incidence of each type of valve lesion is constant in the three series. Mitral stenosis is more common in women than in men in each series. The incidence of calcareous deforming lesions, limited to the aortic valve, is also determined in the three autopsy series and is found to vary constantly with the incidence of rheumatic lesions in each of the three series. In males, lesions of the mitral valve alone, together with lesions of both mitral and aortic valves, are about two and one-half to three times as common in each series as are calcareous deforming lesions limited to the aortic valve. Lesions of the aortic valve only are more common in males and involve an older age group than do the other types of rheumatic lesions. The incidence of lesions of the aortic valve only, in the groups surviving longer than 50 years in each series, is relatively the same as for the entire age group in each series, however.

A NOTE ON THE INCIDENCE OF RHEUMATIC HEART DISEASE AMONG CRIMINAL PSYCHOPATHS

Rheumatic heart lesions were present in 0.60 per cent of a group of 662 criminal psychopaths as compared to an incidence of 1.49 per cent in a roughly comparable control group of 18 and 19 year old selective service registrants. Rheumatic encephalopathy must be a very infrequent etiologic factor in the criminal types of psychopathic personality.

Hyperinsulinism as an Etiologic Factor in Acute Rheumatic Fever

INTRODUCTION THAT DIABETICS are largely free of allergic diseases is well known (1) whereas allergic individuals are prone to hyperinsulinism (2, 3). Diabetics have far less than their expected quota of peptic ulcers (4) and experimental evidence supports the view that these lesions, too, are accompanied by hypoglycemia that suggests hyperinsulinism. Another disorder seldom seen in diabetics is rheumatic fever (Joslin, 5). This disorder, according to Levine (6), represents an allergic reaction to the products of the causative organisms. Levine's conclusion is supported by the fact that bacteria have not been isolated from accessible rheumatic lesions. The appearance of allergic symptoms requires, in addition to contact with the specific allergen—in the case of rheumatic fever, bacteria or their toxins—the presence of a non-specific constitutional factor. In other types of allergy, it has been shown that this constitutional factor is, in some way, connected with hyperinsulinism since that metabolic abnorma...

The incidence of rheumatic and congenital heart disease among school children of louisville, KY

1. 1. A study is presented of the incidence of rheumatic and congenital heart disease among 41,905 school children from 6 through 14 years of age who yearly attend the schools of Louisville, Ky. 2. 2. A total of 221, or 0.52 per cent, had rheumatic or congenital heart lesions; this included 0.54 per cent of the white and 0.45 per cent of the negro children. 3. 3. Rheumatic heart disease accounted for 69 per cent of the 221 cases. 4. 4. Rheumatic heart disease occurred in 0.33 per cent of the white and 0.35 per cent of the negro pupils. 5. 5. Congenital heart lesions were found in 0.18 per cent of the white and 0.05 per cent of the negro children. 6. 6. Rheumatic valve lesions were approximately equally common in both sexes of both races. No cases were encountered in siblings. 7. 7. Although the incidence was not higher in the slum clearance areas of the city, there was a greater incidence of rheumatic lesions in children from the “poorer” than from the “better” districts.

STAPHYLOCOCCIC ENDOCARDITIS SUPERIMPOSED ON SYPHILITIC AORTIC ENDOCARDITIS

Bacterial infection superimposed on syphilitic endocarditis is of interest because of the paucity of proved cases reported in the literature and the rarity of the infections occurring simultaneously, although each is common as a separate entity. Kastner1in 1918, Briggs2in 1922, Pineles3in 1926, and Craven4in 1932 have each reported one case proved by autopsy. Other cases have been reported which have not been proved by autopsy but which presented aortic insufficiency, blood cultures positive for Streptococcus viridans and positive Wassermann reactions of the blood. Cotton,5in a study of fifty cases of aortic insufficiency, agrees with other authors that prior to the age of 40 rheumatic lesions predominate, whereas after 40 the lesions are almost entirely syphilitic or atherosclerotic. He corroborates the well known fact that bacterial endocarditis occurs as a rule in youth or young adulthood. Bayne-Jones6has emphasized the increased vascularity of

II. THE CHANGES IN CHILDREN'S ELECTROCARDIOGRAMS PRODUCED BY RHEUMATIC AND CONGENITAL HEART DISEASE

RHEUMATIC HEART DISEASE Many of the first electrocardiographic studies that were carried out (Butterfield, 1 White 2 and Emanuel 3 ) emphasized the disturbance in conduction which appeared during the course of rheumatic fever. In addition to defects in conduction, Cohn and Swift 4 pointed out the changes in the ventricular complex produced by rheumatic fever. They followed the course of the disease closely, taking 2,591 electrocardiograms in 37 cases. Shortly afterwards White and Burwell 5 pointed out the incidence of predominance of the right ventricle and prominent P waves with rheumatic mitral stenosis. In 1926 Bain and Hamilton 6 studied 50 children, aged from 4½ to 14, some of whom showed only rheumatic carditis and others valvular lesions in addition. Their paper does not give a true idea of either the frequency or the extent of defects in conduction with these conditions in children because they neglected to give the

The significance of rheumatic fever in the etiology of coronary artery disease and thrombosis

Coronary thrombosis is relatively rare in patients with rheumatic valvular disease. At necropsy the coronary arteries of young patients with rheumatic heart disease showed strikingly little arteriosclerotic change. The age period of our series corresponds to that of ordinary cases of coronary sclerosis. In this material the degenerative changes of the coronary arteries corresponded roughly to the ages of the patients. A rheumatic subject without aortic insufficiency or active carditis who develops anginal pain may have an independent coronary arteriosclerosis. On the other hand, a patient with arteriosclerotic heart disease who shows enlargement of the right heart or the left auricle out of proportion to congestive failure may have an associated rheumatic lesion of the mitral valve. We believe that the most significant reason for the infrequent association of rheumatic and arteriosclerotic heart disease is that rheumatic fever runs its course before the degenerative period of heart disease. Those who survive middle life, especially if they develop hypertension or diabetes mellitus, may develop arteriosclerotic heart disease. Rheumatic fever per se does not, however, appear to predispose to coronary arteriosclerosis.

An outline of studies relating to vitamin C deficiency in rheumatic fever.

Abstract The concept that rheumatic fever may be due to the combined influence of vitamin C deficiency and infection, rests upon a broad experimental basis. In guinea pigs, under this dual influence, lesions comparable to those of rheumatic fever may develop in the heart and joints. The not infrequent occurrence of subcutaneous nodules appears to complete the pathologic similarity. It is of interest that in the experimental work no sharp line can be drawn between a disease picture resembling rheumatic fever and one characterized by a chronic joint disability with pathologic similarities to atrophic (rheumatoid) arthritis. There is much evidence indicating a relationship between the two diseases as seen in man. Epidemiologic data seem to support the thesis advanced. Particular significance is attached to the abnormally high incidence of rheumatic fever in the poor. Clinical studies in progress have afforded encouraging data, but are too few, and the period of observation too short to afford a basis for judgment. Rheumatic fever is a disease fundamentally characterized by widespread injury to collagen. Based upon the experimental studies and pathologic anatomy of rheumatic fever, a theory of mechanism of the development of the rheumatic lesion is advanced. Our knowledge of the metabolism of vitamin C is in the process of development. Capacity to store the vitamin is limited. Fatigue and certain infections may deplete the organic reserve. Factors which might inhibit absorption or utilization of vitamin C are not known. Urinary excretion studies may serve as an index of the immediate saturation level but are not a gauge of preexisting deficiency. The possible influence of infection in modifying the storage and excretion or utilization of vitamin C is not known. For these reasons, data based upon urinary excretion must be interpreted with care. The question of what we may reasonably expect from vitamin C therapy in rheumatic fever is considered in the light of the fundamental pathology of the disease. Even though vitamin C deficiency may contribute to the development of the rheumatic lesion, it is only one factor. Some influence of infection also operates. In view of this, and the frequently severe injury accompanying the disease, judgment of the preventive or therapeutic effectiveness of vitamin C administration in rheumatic fever can be based only on prolonged clinical study.

The precordial lead of the electrocardiogram (Lead IV) as and aid in the recognition of active carditis in rheumatic fever

1. 1. In rheumatic fever, if successive electrocardiograms are taken, Lead IV may furnish evidence of active carditis when changes indicating active myocardial involvement are not observed in the standard three leads. 2. 2. Frequently, gross variations in the contour of Lead IV indicate the significance of minor alterations in the three standard leads which might otherwise be regarded as of doubtful importance. This statement applies particularly to slight changes in the T-wave in Lead III. 3. 3. On occasion, changes denoting rheumatic lesions in the heart muscle are present in the first three leads when no change is apparent in Lead IV. 4. 4. In ambulatory patients with rheumatic heart disease, a single electrocardiogram may reveal evidence of myocardial damage in Lead IV only. On the basis of a single record, however, it is clearly not possible to establish the presence of rheumatic activity in the heart. 5. 5. Changes in the electrocardiogram characteristic of myocardial involvement were found in five patients whose hearts at autopsy showed lesions of active rheumatism. In two patients, in whom active rheumatic carditis was suspected during life but was not found at autopsy, the electrocardiograms were normal. 6. 6. In rheumatic fever the use of Lead IV is of clinical value as an aid in the recognition of active myocardial involvement and in following its course.

Lead IV of the Electrocardiogram in Rheumatic Fever

SummaryIn acute rheumatic fever, lead IV of the electrocardiogram sometimes furnishes evidence of active carditis, when changes indicating myocardial involvement are not observed in the standard 3 leads. Frequently definite changes in lead IV render significant minor alterations in the first 3 leads which might otherwise be regarded as of doubtful importance. On occasion, changes denoting rheumatic lesions in the heart muscle may appear in the first 3 leads without change being present in lead IV. In ambulatory patients with rheumatic heart disease a single electrocardiogram may reveal evidence of myocardial damage in lead IV only. Obviously, a single record does not establish the presence of rheumatic activity in the heart.Changes in the electrocardiogram characteristic of myocardial involvement were found in 5 patients whose hearts, at autopsy, showed the lesions of active rheumatism. In 2 cases in which active rheumatic carditis was suspected during life, but was not found at autopsy, the electrocardio...

RELATIONSHIP OF THE RHEUMATIC PROCESS TO THE DEVELOPMENT OF ALTERATIONS IN TISSUES

<h3>I. CHARACTER OF TISSUE CHANGES ASSOCIATED WITH ACTIVITY OF THE RHEUMATIC PROCESS</h3> In 1904 Aschoff¹emphasized the association of the myocardial nodule with rheumatic fever. This marked the first recognition of histologic changes specific for rheumatic disease. During recent years the conception of the anatomic distribution of rheumatic lesions has been explained largely through the careful histologic studies of the pathologists. Vascular structures other than the cardiac muscle and valves have been found to be involved by the rheumatic process. Lesions specific in their histologic appearance have been described in the aorta by Klotz,²in the auricles by MacCallum,³in the blood vessels, aorta and auricles by Pappenheimer and VonGlahn⁴and in many other organs by Graff,⁵Paul⁶and Shaw.⁷That these lesions are extremely widespread in rheumatic fever has been demonstrated by the recent observations of Klinge,⁸who in detailed histologic

Experimental rheumatic lesions in dogs and in rabbits: Moon, V. H., and Stewart, H. L.: Arch. Path. 11: 190, 1931

Experimental rheumatic lesions in dogs and in rabbits: Moon, V. H., and Stewart, H. L.: Arch. Path. 11: 190, 1931

THE VALUE OF SALICYLATES IN PREVENTION OF RHEUMATIC MANIFESTATIONS

Statistical evidence in regard to the value of the salicylates as a preventive of the recurrence of rheumatic disorders is meager. It has been the custom in some clinics to give to patients with inactive rheumatic heart disease rations of salicylates in the hope that such a procedure might prove beneficial in the prevention of recurrences and exacerbations. In the autumn of 1928, certain patients attending the cardiac clinic in the Harriet Lane Home of the Johns Hopkins Hospital were selected for the purpose of a study of the effect of constant salicylate ingestion. Patients with inactive rheumatic heart lesions were divided into two groups, one of which received salicylates daily for a period of six months; the other group received no salicylates and acted as a control. Similarly, children with potential heart disease, that is, children who had had one or more attacks of chorea or rheumatic fever but

IMPAIRED AURICULOVENTRICULAR CONDUCTION IN RHEUMATIC FEVER

It is now well known that auriculoventricular conduction is frequently impaired in the course of rheumatic fever and that this disturbance affords valuable evidence of myocardial involvement. 1 In a number of instances of partial or complete heart block 2 and in one case showing only prolonged auriculoventricular conduction, 3 postmortem examination of the heart has disclosed characteristic rheumatic lesions involving the auriculoventricular node or bundle. Such lesions have consisted of cellular infiltration and edema during the acute stages of the disease, or of scar tissue after healing has taken place. The transitory nature of conduction disturbances in many cases indicates that the inflammatory process may subside without graphic evidence of permanent damage to the heart muscle. In following a series of cases of rheumatic fever in which frequent electrocardiograms were made, the diagnostic importance of disturbances in auriculoventricular conduction became apparent. The present study covers a period of nine years. Most of

The treatment of rheumatic carditis by roentgen irradiation of the heart

1. 1. Thirty patients with rheumatic heart disease were given 249 roentgen irradiations over the cardiac area. The machine setting was calculated to yield about 10 per cent of the erythma dose distributed throughout the heart muscle. In addition to noting changes in clinical condition, frequent electrocardiograms and numerous teleroentgenograms were made. 2. 2. Following irradiation, changes in the form of the electrocardiogram were observed in 17 of the 30 cases. It is believed that these changes were due to the effect of irradiation on the myocardium, with modification of the rheumatic lesions. 3. 3. Of the 30 cases, 21 (70 per cent) showed clinical improvement at the end of the follow-up period. Three improved temporarily, '1 was unimproved, and 5 died. Those cases terminating fatally were all instances of continuously active rheumatism, with advanced lesions and progressive cardiac failure. 4. 4. In 5 of 7 patients with paroxysms of severe heart pain, relief from this symptom followed roentgenotherapy. 5. 5. Early cases, in the first attack of rheumatic fever, offer the best chance for success in therapy. In a number of cases with low-grade infection, predominantly cardiac, it appeared that the infection subsided following roentgenotherapy. It seems likely that at least one series of four treatments is necessary to initiate improvement. More prolonged therapy is probably desirable. 6. 6. No changes were observed in the teleroentgenograms which could be ascribed to the effects of irradiation. 7. 7. Unpleasant symptoms were noted in 14 cases. These were due, for the most part, to radiation reactions. In no instance was there evidence of injury to the heart or an unfavorable effect on the course of the disease. 8. 8. In 4 cases of subacute bacterial endocarditis due to nonhemolytic streptococcus, roentgen irradiation of the heart caused no change in the form of the electrocardiogram, nor did it arrest the fatal progress of the disease. 9. 9. It is suggested that in rheumatic fever, roentgen irradiation of the heart may serve to desensitize the tissues of the heart to an allergizing substance, thereby favoring the subsidence of existing lesions and preventing further cardiac damage. 10. 10. In patients having their first attack of rheumatism, irradiation may be useful in minimizing the danger of damage to the heart.