CASE HISTORY

Patient was admitted complaining of breathlessness of about 18 months' duration. He was an old naval man who had been working as a butler for 16 years. Eighteen months before admission he found that he was unable to climb stairs owing to breathlessness. He became a porter in a block of flats, but even the decreased exertion left him breathless until, at the time of admission, he was unable to mount stairs at all without severe breathlessness. During the 3 months before admission he had also suffered from attacks of dyspnoea, which woke him up in the night and compelled him to stand up. He also had a little cough. He was found to be thin, pale, orthopnoeic, with well marked venous congestion, the veins of his neck being distended and pulsating on lying down, and still full on sitting up. Apex beat diffuse and heaving. Heart enlarged. Rhythm regular. There is an aortic diastolic murmur, and also a mid-diastolic which was diagnosed as an Austin Flint murmur. Pulse 120, regular, of Corrigan's type. B.P. 160/60. Chest showed impaired not at both bases. Abdomen shows a markedly enlarged tender liver. No oedema of ankles. Urine contains albumin and shows hyaline and granular casts.

PATHOLOGY

Heart 210mmx180mmx100mm. The left ventricle has been opened along the anterior surface to expose both mitral and aortic valves. The aorta shows a number of puckered, radiating syphilitic scars. In addition there is a severe degree of atheroma overlying and tending to obscure the syphilitic lesions. The aortic valves are thickened, particularly at their free margin. They also show considerable widening of the commissures. On testing with water, they were grossly incompetent. The left ventricle shows hypertrophy, the wall being about fifty per cent thicker than normal. In addition, the cavity of the ventricle is dilated. The mitral valve is healthy. The pericardium shows some old fibrous thickening.