1473ROYAL MEDICAL AND 0;1ilIRURGJiCAL SOCIETY.

Medical Societies.ROYAL MEDICAL AND CHIRURGICAL

SOCIETY.

Tlte Influence of Postllre on the Normal Cardioc 80ltnds andon the Normal Cardiae Ð1llness.-Injluenzal Endocarditis.A MEETING of this society was held on Nov. 14th, Dr.

THOMAS BUZZARD being in the chair.Dr. WILLIAM GORDON read a paper on the Influence of

posture on the Normal Cardiac Sounds and on the NormalCardiac Dulness. He said that the changes in cardiacmurmurs which occurred on change of posture were so

pronounced as to suggest the inquiry whether alteration ofposition also affected the normal heart sounds. Carefulobservation of normal hearts would soon convince anyone thatchange of position did affect the normal heart sounds, some-times slightly and sometimes markedly. The change producedwas a change in the character of both sounds. It would

generally be found that in the upright position the firstsound was sharper, whilst the second sound was duller, thanin the recumbent position, so that the two sounds were muchmore like each other in the upright position than theywere in the recumbent. Indeed, it might be fairly saidthat the "lub-dup" of the text-books was in mostcases a true description only of the sounds whenthe body was recumbent and that lup-Iup

" more

exactly described them when the body was erect. Hehad shown in a previous paper that the changes incardiac murmurs produced by change of position could beexplained partly by the action of gravity on the intracardiaccurrents and partly by the flattening of the chest whichoccurred when the patient lay on his back. As the changesnow referred to were changes in the character of the sounds,differences in the depth of the chest could not be held to Iaccount for them, and the question was, Could the actionof gravity account for the changes ? 1 If the position of the Ivalves of the heart in the upright and recumbent positionswere considered it became obvious that when the firstsound was produced a weight of blood was resting on themitral and tricuspid valves if the person examined wererecumbent, but that if the person was erect no such weightrested on these valves. Also, it was obvious that when thesecond sound was produced a weight of blood was restingon the aortic and pulmonary valves if the person were erect,but that if he were recumbent no such weight rested on thesevalves. Therefore the question resolved itself into this:Did a valvular sound vary according as a fluid weightdid or did not rest on the valves producing it ? 7 Dr.Gordon showed by experiments that the sound did so vary.The observed changes in the normal heart sounds producedby change of posture might therefore be reasonably explained,at least in part, by the different relations of the valves tothe weight of blood in contact with them in the differentpositions. Posture also affected the deep cardiac dulness.In the erect position the cardiac dulness dropped nearly a rib’sbreadth further from the clavicle than in the recumbentposition and became about three-quarters of an inch widerfrom side to side at the level of the fifth costal cartilage,the increase being greater to the right than to the left, thatto the left being about one-third of an inch. The change,however, in the width of dulness was strikingly constant.The following explanation was given. On assuming theerect position the heart tended to fall lower in the chestand owing to the forward slant of the anterior part of thediaphragm also to fall forward against the front wall of thebody. Thus the cardiac dulness should tend to sink some-what lower and to widen out when the upright position wasassumed, which was just what usually happened. In diseasewhere the weight of the heart was increased this drop onchange to the erect posture might be very marked, theapex being sometimes found to beat, when the patient stoodor sat, in a lower space than when he lay on his back.In a much smaller number of cases, however, the upperlimit of dulness actually rose instead of falling. If this wasdue to the heart being anatomically more firmly held upthin was usual and to its upper part coming forward into

1 Brit. Med. Jour., March 15th, 1902, Posture and Heart Murmurs.

contact with the chest wall when the person stood, itmight be reasonably expected that the dulness in those caseswould widen less than usual and this was actually found tobe the case.-Dr. G. NEWTON PiTT suggested that as the fluidpressure within the ventricle was equal in all directions itwas immaterial whether the valves of the heart were verticalor horizontal in position. What was of importance was thehead of blood above the valve.-Dr. T. J. HORDER said thatthe pressure of gravity as compared to the pressure withinthe ventricle was so small that it was a factor which mightalmost be neglected.-Dr. GORDON, in reply, said that theexplanation of the condition which he had described was oflittle importance ; the fact that change of posture alteredthe cardiac sounds and the cardiac dulness was of greatimportance.

Dr. THOMAS J. HORDER read an account of two cases inwhich the Influenz* Bacillus was Repeatedly Cultivated fromthe Blood of the Patients during Life. He said that in thestudy of influenza tardy convalescence and the existence of avariety of troublesome sequels had always attracted atten-tion. Of late, however, one of the most striking featuresin connexion with the disease had been the occurrence ofprolonged attacks of the fever, suggesting the continuedoperation of the causal organism in the tissues rather than amere delay in the recovery of these from an infection lastingonly a few days. In these prolonged attacks there wasoften no bacteriological evidence forthcoming to provewhat organ formed the nidus of the bacillus. But instill a third series of prolonged cases definite complica-tions were now known to be directly due to the actionof the organism : otitis media, pleurisy, pneumonia,pericarditis, meningitis, cerebral abscess, and arthritis-ineach of these the influenza bacillus had been isolatedfrom the seat of the lesion. It would now appear that atrue influenzal septicaemia might occur to add to the terrorsof the disease already known. The two cases described

appeared to be undoubted instances of influenzal septicaemia.Both were patients suffering from chronic endocarditis, thesepticasmia therefore being of the endocardial type. Theinfluenza bacillus was cultivated from the blood during lifein one case upon four different occasions and in the othercase upon two different occasions. In each cultivation theinfluenza bacillus was the only organism obtained. Both caseswere fatal. In the first the diagnosis was arrived at by meansof the blood culture so long a time as six weeks beforedeath ; in the second case the nature of the disease wasdiscovered in the same manner five weeks before death.At the necropsy the diagnosis was verified in both cases ; theendocardial vegetations gave a growth of influenza bacilli,and sections through the endocardium at the seat of thedisease showed this same organism invading the tissuesdeeply and in large masses. Neither in the culturesor in the sections nor in cover-glass specimens madedirectly from the vegetations could any other organismbe demonstrated. In the two cases described the organ-ism obtained ante and post mortem had all the charactersof the influenza bacillus as described by Pfeiffer. Thereseemed to be no doubt that in these two cases a con-

dition of influenzal septicsemia was present. They, there-fore, as already stated, formed a striking contrast tothe ordinary cases of influenza, in which, despite theearlier assertions of Canon, it was now agreed that thebacillus dd not invade the general blood stream. Thefocus of the disease was in both cases the endocardium.Henceforth, to the already rich flora of endocarditismust be added Pfeiffer’s influenza bacillus. The illnessof both patients began somewhat insidiously ; therewas no initial disease which bore any obvious resem-

blance to the common features of an influenzal attack. Inthis respect the cases were analogous to the more chroniccases of streptococcus endocarditis. Both cases ran a pro-longed course ; one lasted three months and the otherfour months. In both instances the influenzal infection was

grafted upon an endocardium which had been damagedby previous attacks of rheumatism. The clinical picturepresented by the patients differed in no essential pointsfrom that seen in the majority of cases of chronicmalignant endocarditis. The terminal symptoms were

in ’one case due to cerebral embolism and in the otherto nephritis. Both of these conditions were of commonoccurrence as terminal events in malignant endocarditis. Apoint of some considerable interest was the fact that in eachcase a well-marked leucocytosis was present. In one case(that of an adult) the highest count was 18,400 ; in the other

1474 MEDICAL SOCIETY OF LONDON.

case (that of a boy) the Ligbest count was 22,400. So that,whatever might obtain in ordinary attacks of influenza-andit seemed certain that these cases usually presented no leucc-cytosis-it would appear that influenzal septic semia ledto considerable increase in leucocytes. Turning to themorbid anatomy of the cases, it was noticeable thatthere was little or no tendency to destruction of tissuein the heart, as was often seen in endocarditis due to

pyogenic organisms, but rather to the formation of newmasses of material of considerable size, firm and rounded.In the heart first described the situation of the single largesessile mass on the wall of the left auricle suggested a directinfection of the endocardium at this spot by organismsarriving in the pulmonary blood stream. The presenceof a congenital valvular defect in one of the hearts-two aortic cusps-furnished an illustration of the specialtendency to infective endocarditis which this conditionconferred upon the subject of such malformation. In con-

sidering the question of the treatment of patients suffeiingfrom influenzal endocarditis they found themselves facedwith a problem of great difficulty. The various means

which were at their disposal of indirectly raising the patient’sresistance mut, of course, be employed here as in allother cases of septicaemia. But left to his own resourcesthe patient would seem to be doomed from the day onwhich the diagnosis of influenzal endocarditis was made.And yet the physician was at present helpless to battle withthe disease in any direct manner. Experience showed thatchemical antiseptics, whether given by the mouth, sub-

cutaneously or intravenously, were disappointing in thetreatment of septicasmia. Even the hopes that have beenso largely entertained in recent years with regard to the useof bactericidal sera in cases of pyogenic septicaemia must beabandoned here. For the causal microbe was so trict a

parasite that no certain pathogenic (-ffccts had yet beenobtained by animal inoculation. No actively immunisedserum could therefore be expected at present. Therapeuticshad not yet arrived at a stage which admitted the employ-ment of serum of human beings recently convalescent fromattacks of influenza.-Dr. H. S. FRENCH called attention tothe fact that marked leucocytosis was an unusual feature inmalignant endocarditis. He asked whether the path by whichinfection took place had been ascertained in the two casesrecorded, and questioned whether it was justifiable to take acase of influenza in the general ward of the hospital inwhich there were always cases of chronic endocarditis seeingthat these cases were especially liable to infection.-Dr.NEWTON PITT suggested that the reason why these caseswere so frequently overlooked was that the organism couldnot be found in the ordinary blood film but it was necessaryto take a considerable amount of blood and to cultivate it inbroth in the special method suggested by Dr. Horder.-Dr. HORDER, in reply, said that the probable mode ofinfection was through the lungs since the infection occurredin the left auricle.

MEDICAL SOCIETY OF LONDON.

Exhibition of Cases.A MEETING of this society was held on Nov. 13tb, Sir

LAUDER BRUNTON, the President, being in the chair.Dr. F. J. POYNTON exhibited a case of Congenital Mal-

formation of the Chest in an Infant aged 12 months. Theleft side of the chest was contracted and the deformity wasmost apparent over the horizontal line of the nipples. Theheart was situated on the right of the sternum. The first,second, third, fourth, and fifth costal cartilages when thechild was first seen were deficient and apparently the

upper four ribs were not attached at all to the sternum.A finger pressed into the region deficient in costal

cartilages could feel the heart pulsating. Three monthslater the condition had altered. The first and second

cartilages were now completed and there was a hori-zontal bar formed by the second costal cartilage whichbounded a space till deficient in cartilage. The rightboundary of this area formed by the sternal border wasclearly felt and there was a small projection from it corre-

sponding to the fourth costal cartilage. The heart was still

mainly upon the right side.-Mr. W. H. CLAYTON-GREENEremarked that the fase threw light on the develcpment ofthe sternum and supported Patterson’s theory that it wasaccomplished without supporting outshcots from the costalcartilages.

Dr. F. PARKES WEBER exhibited a case of ChronicSymmetrical (Edema of both Forearms, apparently due toNelli itis ofthe Upler Extremities. The patient, a woman, aged64 years, began to suffer from swelling of the forearms aboutthe middle of May of this year. She had enjoyed fairly goodhealth and had not indulged in excess of alcohol. The left armbegan to swell about two weeks before the right arm. The

swelling in both arms gradually increased and involved thehands (especially the backs of the hands), the forearms, andthe neighbourhood of the elbows. The swelling was at firstassociated with much pain. For 11 weeks the pain was sosevere that she could hardly sleep at night. Then the painsbecame less troublesome, improvement commenced, and theoedema gradually diminished. At the present time there wasonly moderate residual swelling. During the illness themovements in the joints of the hands, elbows, and shouldershad all become limited, evidently from the formation of peri-articular adhesions. In some of the muscles the response toelectrical stimulation was very deficient and the muscles of theforearms were wasted. The feet and legs were normal.-ThePRESIDENT suggested that the case resembled beri-beri insome respects.-Dr. J. S. RISIEN RUSSELL had seen a some-what similar case in which there was no doubt about theexistence of peripheral neuritis. The patient had never

recovered completely. The lower limbs had been affectedin that case.-In reply to the PRESIDENT, Dr. WEBER saidthat he had not tried thyroid gland.

Dr. W. ESSEX WYNTER exhibited a case of " Poker Back"(Osteo-arthritis of the Spine) in a woman, aged S6 years.She had suffered since 1898 from recurrent attacks ofmucous colitis. Pain in the interscapular region with sometender swelling had commenced in July last and had since ex-tended over the dorsal region; it was increased by movement.During the last few weeks the patient had been unable tobend her back in any direction without suffering acute painin the spine and was compelled to stoop in walking. Shehad a cachectic appearance and was only free from pain inthe supine position. The spine appeared quite rigid exceptin the cervical region ; the movements of the head were un-affected. There was marked limitation of movement inthe costo-vertebral joints and this permitted very lightthoracic expansion. Skiagrams of the spine showed nocalcareous or bony outgrowths. The other joints wereunaffected. Dr. Wynter did not agree with the viewthat all such cases were due to osteo-arthritis.-Dr.C. W. BUCKLEY (Buxton) also did not think that thesecases could be regarded as osteo-arthritis. He had observedseveral such cases in which the arthritic changes were

limited to the spine and adjacent bones.-Dr. OTTO J.KAUFFMANN (Birmingham) was very interested in theantecedent history of colitis. The arthritic condition was

’nteresting owing to the limitation of the disease to the spine.It was probably not curable.-Dr. POYNTON asked how osteo-arthritis was to be defined. Nothing seemed certain aboutthis clinical condition. He had seen ODe similar case improveunder iodide of potassium.-Dr. A. F. VoELCKER remarkedthat ossification of the anterior common ligament took placein some of these cases and asked whether it was present inthe case shown.

Mr. C. GORDON WATSON exhibited a case of Ichthyosisassociated with Papilloma of the Tongue of Unusual Size ina man, aged 50 years. 28 years ago he had had syphilis.Six months before being seen after smoking a clay pipe henoticed a small hard swelling on the left side of the tonguewhich had since grown ral idly and become a large mushroom-shaped papilloma with a broad base occupying the middletwc-thirds of the left half of the tongue. On Jan. 13th, aftera preliminary laryngotomy, the left half of the tongue hadbeen removed. The microscope showed no evidence ofmalignancy. The ichthyosis on the right side of the tongue,which before the operation was slight, had increased veryrapidly since.

Mr. EDRED M. CORNER brought forward two cases 15 and27 months after operation for Tuberculous Glands in theUpper Part of the Mesentery. The first case was a boy,aged 12 years, who was admitted to the Hospital for SickChildren, Great Ormond-treet, in August, 1904. For eightor nine months the patient had been anaemic and losingflesh. About three months before he had had sharp attacksof pain in the middle of the lower part of the abdomenwhich lasted usually less than half an hour and were notaccompanied by vomiting or sweating. For some months hehad occasionally had a few streaks of blood in his motions.Previously to this illness his health was very good. There was