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LIVERPOOL MEDICAL INSTITUTION.
1400 was with the left atrium through the atrio-ventricular orifice. The aorta originated from the right ventricle, commencing posteriorly and to the right of the pulmonary artery ; it was somewhat small in size, but with normal valves. The pulmonary artery was large and normal as regards its valves. The lungs were congested, and showed evidence of slight bronchitis ; the only other abnormality present was a complete mesenteric attachment to the whole of the large intestine. The blood from the systemic veins reached the right ventricle from the right atrium, its passage to the left atrium through the foramen ovale being prevented by the valvular formation of that opening. The right ventricle then drove the blood through the aorta and pulmonary artery to the systemic and pulmonary circulations. From the lungs the blood returned through the normal pulmonary veins to the left atrium, and thence by the foramen ovale to the right atrium, the left ventricle being merely an appendage of the left atrium and the left atrio-ventricular orifice functionless.
The schema of the circulation
was as
1-’ollows
:—
The heart was carefully examined for the presence of inter-ventricular foramina, but the inter-ventricular septum was complete and well developed. Evidence of the normal origin of the aorta was also sought for, and two or three shallow recesses were found in the left ventricle, in the region from which the aorta should have arisen ; there was, in addition, an ill-defined recess in the right ventricle leading from the base of the aorta, backwards and to the left, towards the small left ventricle ; these were, however, only cul-de-sacs. It is probable that the ductus arteriosus in this case was patent, since, the pressure in the aorta and pulmonary artery being equal, the lungs would have suffered greatly from the high pressure, and the small aorta would have proved insufficient for the needs of the systemic circulation, had not such a safety-valve been present.
Commentary. interesting points
Medical Societies. LIVERPOOL MEDICAL INSTITUTION.
I A
A PATHOLOGICAL meeting was held on Dec. 6th. number of specimens were shown and a short discussion followed. Prof. E. GLYNN, in association with Prof. J. HILL ABRAM, communicated a note on a case of Acute Miliary Tuberculosis Complicated by an Anaerobic Infection. The patient, a male aged 19, had suffered from " influenza " twice during the past year and pleurisy once. Weakness had been increasing for six weeks before admission and he died three days later, the temperature ranging from 103°-105° F. The lymph glands and spleen were enlarged, but there were no other signs except a systolic cardiac murmur at the apex. Blood cultures yielded Staphylococcus albus consistently. Red blood cells were 3,000,000 with a few megalo- and normo-blasts. The white cells were 12,000 per c.mm. with a preponderance of lymphocytes. At the post-mortem, 11 hours after death, the ileo-csecal glands formed a mass the size of a hen’s egg, were heemorrhagic, and swarming with tubercle bacilli. They also grew Staphylococcus albus. All other lymph-glands were somewhat enlarged. There were gas bubbles in the portal system and large numbers of Gram-positive bacilli in the liver, which proved to be of the B. aerogenes capsulatus type. The liver showed typical caseating tuberculous nodules as well, and it contained hsemosiderin. The lungs showed a patch of grey hepatisation in which great masses of organisms resembling pneumococci - were present. A similar case of miliary tuberculosis affecting mainly the mesenteric glands, but without B. aerogenes caps1Ûatus infection, was described. This patient had not the ansemia of the pernicious type found in the former case. Of the four organisms found at death, the anaerobe was the most likely to have caused this anaemia. Other cases suggesting blood infection with anaerobes during life were quoted to confirm the speaker’s opinion that in this case the anaerobe was present in the blood during life. Prof. HILL ABRAM and Mr. J. T. MORRISON believed the infection was probably terminal, the latter mentioning that the typical blood picture seen in aerogenes infection was not present.-Prof. J. M. BEATTIE thought that the multiplicity of organisms present might explain the rapid multiplication of tubercle bacilli. Mr. MORRISON read a short paper on the Differentiation of Human and Bovine Tubercle
in this case were, The inter-ventricular septum was complete, showing no defects at all; the left ventricle communicated only with the left atrium, of which chamber it was merely a recess ; and the aorta and pulmonary artery both sprang from the conus arteriosus of the right ventricle. To attempt to explain these anomalies it would appear necessary to assume an almost complete failure of development of the proximal bulbar septum, with secondary closure of the resultant defect in the inter-ventricular septum, the two ventricles being thus completely separated. The patent condition of the foramen ovale is a less rare occurrence, but it, is interesting to note that in this case the blood passed through the aperture in the reverse direction to that of the normal foetal stream. Bacilli. There are a few cases on record which somewhat Alluding to the need for a reasoned consensus of resemble the one described above. Keith described opinion on this subject, he proceeded to sketch the a similar condition, but the infant only lived for two differences recognised between the two types, and days ; the cardiac malformations consisted of stenosis showed illustrative specimens of cultures and animal of the aorta, obliteration of the left atrio-ventricular inoculations. Attention was drawn to the variations orifice and left ventricle (traces only of this chamber in results even in animal inoculations. Dean and remaining), a small left atrium, a patent foramen Todd, and others too, had shown that Koch’s original ovale, dilated right ventricle, patent ductus arteriosus,2 statement that animals could not be infected with and partial transposition of the great vessels. DudZIIS2 human bacilli was not accurate. In the rabbit the collected records of a series of congenital cardiac results of inoculation were usually conclusive, but abnormalities, three of these in particular (those of variations were also suggested that the number of Jost, Theremin, and Spolverini) show a marked simi- organisms injected might materially influence the larity to the case recorded here. The condition I decision. With regard to the question of the stability have described is, according to Abbott in Osler and of types the findings of the Royal Commission on MeCrae’s " System of Medicine," one of the rare cases Tuberculosis were quoted, and the importance of the of true cor triloculare biatriatum, showing two fully exceptional cases pointed out, where by passage or developed atria, a patent foramen ovale, a single culture definite changes in type had been produced. functioning ventricle from which both great vessels These observations supported the view of Besson and spring, and a rudimentary left ventricle which is others that the two organisms were essentially one, to which view the author tended to adhere. At the merely a recess of the left atrium. I am greatly indebted to Dr. Nesta Perry for her same time in animal inoculation we had a means of permission to publish this case. determining with considerable accuracy the immediate source of the infecting bacillus, and on such con1 Keith, Sir A. : Jour. Anat. and Physiol., 1912, p. 211. 2 Dudzus, M. : Virchow’s Archiv f. Path. Anat. Berl., 1922, clusions it was justifiable to base public policy in ccxxxvii., 32. the campaign against tuberculosis. The most
therefore,
as
follows.
The schema of the circulation
was as
1-’ollows
:—
The heart was carefully examined for the presence of inter-ventricular foramina, but the inter-ventricular septum was complete and well developed. Evidence of the normal origin of the aorta was also sought for, and two or three shallow recesses were found in the left ventricle, in the region from which the aorta should have arisen ; there was, in addition, an ill-defined recess in the right ventricle leading from the base of the aorta, backwards and to the left, towards the small left ventricle ; these were, however, only cul-de-sacs. It is probable that the ductus arteriosus in this case was patent, since, the pressure in the aorta and pulmonary artery being equal, the lungs would have suffered greatly from the high pressure, and the small aorta would have proved insufficient for the needs of the systemic circulation, had not such a safety-valve been present.
Commentary. interesting points
Medical Societies. LIVERPOOL MEDICAL INSTITUTION.
I A
A PATHOLOGICAL meeting was held on Dec. 6th. number of specimens were shown and a short discussion followed. Prof. E. GLYNN, in association with Prof. J. HILL ABRAM, communicated a note on a case of Acute Miliary Tuberculosis Complicated by an Anaerobic Infection. The patient, a male aged 19, had suffered from " influenza " twice during the past year and pleurisy once. Weakness had been increasing for six weeks before admission and he died three days later, the temperature ranging from 103°-105° F. The lymph glands and spleen were enlarged, but there were no other signs except a systolic cardiac murmur at the apex. Blood cultures yielded Staphylococcus albus consistently. Red blood cells were 3,000,000 with a few megalo- and normo-blasts. The white cells were 12,000 per c.mm. with a preponderance of lymphocytes. At the post-mortem, 11 hours after death, the ileo-csecal glands formed a mass the size of a hen’s egg, were heemorrhagic, and swarming with tubercle bacilli. They also grew Staphylococcus albus. All other lymph-glands were somewhat enlarged. There were gas bubbles in the portal system and large numbers of Gram-positive bacilli in the liver, which proved to be of the B. aerogenes capsulatus type. The liver showed typical caseating tuberculous nodules as well, and it contained hsemosiderin. The lungs showed a patch of grey hepatisation in which great masses of organisms resembling pneumococci - were present. A similar case of miliary tuberculosis affecting mainly the mesenteric glands, but without B. aerogenes caps1Ûatus infection, was described. This patient had not the ansemia of the pernicious type found in the former case. Of the four organisms found at death, the anaerobe was the most likely to have caused this anaemia. Other cases suggesting blood infection with anaerobes during life were quoted to confirm the speaker’s opinion that in this case the anaerobe was present in the blood during life. Prof. HILL ABRAM and Mr. J. T. MORRISON believed the infection was probably terminal, the latter mentioning that the typical blood picture seen in aerogenes infection was not present.-Prof. J. M. BEATTIE thought that the multiplicity of organisms present might explain the rapid multiplication of tubercle bacilli. Mr. MORRISON read a short paper on the Differentiation of Human and Bovine Tubercle
in this case were, The inter-ventricular septum was complete, showing no defects at all; the left ventricle communicated only with the left atrium, of which chamber it was merely a recess ; and the aorta and pulmonary artery both sprang from the conus arteriosus of the right ventricle. To attempt to explain these anomalies it would appear necessary to assume an almost complete failure of development of the proximal bulbar septum, with secondary closure of the resultant defect in the inter-ventricular septum, the two ventricles being thus completely separated. The patent condition of the foramen ovale is a less rare occurrence, but it, is interesting to note that in this case the blood passed through the aperture in the reverse direction to that of the normal foetal stream. Bacilli. There are a few cases on record which somewhat Alluding to the need for a reasoned consensus of resemble the one described above. Keith described opinion on this subject, he proceeded to sketch the a similar condition, but the infant only lived for two differences recognised between the two types, and days ; the cardiac malformations consisted of stenosis showed illustrative specimens of cultures and animal of the aorta, obliteration of the left atrio-ventricular inoculations. Attention was drawn to the variations orifice and left ventricle (traces only of this chamber in results even in animal inoculations. Dean and remaining), a small left atrium, a patent foramen Todd, and others too, had shown that Koch’s original ovale, dilated right ventricle, patent ductus arteriosus,2 statement that animals could not be infected with and partial transposition of the great vessels. DudZIIS2 human bacilli was not accurate. In the rabbit the collected records of a series of congenital cardiac results of inoculation were usually conclusive, but abnormalities, three of these in particular (those of variations were also suggested that the number of Jost, Theremin, and Spolverini) show a marked simi- organisms injected might materially influence the larity to the case recorded here. The condition I decision. With regard to the question of the stability have described is, according to Abbott in Osler and of types the findings of the Royal Commission on MeCrae’s " System of Medicine," one of the rare cases Tuberculosis were quoted, and the importance of the of true cor triloculare biatriatum, showing two fully exceptional cases pointed out, where by passage or developed atria, a patent foramen ovale, a single culture definite changes in type had been produced. functioning ventricle from which both great vessels These observations supported the view of Besson and spring, and a rudimentary left ventricle which is others that the two organisms were essentially one, to which view the author tended to adhere. At the merely a recess of the left atrium. I am greatly indebted to Dr. Nesta Perry for her same time in animal inoculation we had a means of permission to publish this case. determining with considerable accuracy the immediate source of the infecting bacillus, and on such con1 Keith, Sir A. : Jour. Anat. and Physiol., 1912, p. 211. 2 Dudzus, M. : Virchow’s Archiv f. Path. Anat. Berl., 1922, clusions it was justifiable to base public policy in ccxxxvii., 32. the campaign against tuberculosis. The most
therefore,
as
follows.