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that is it produces essentially local lesions, and this combined
with the great resistance of the tissues makes it difficult to iso-
late the micrococcus from the exudations even if their presence



INTRODUCTION 9

be obvious in films. Then, again, it is a delicate micrococcus,
and living in the local lesions its isolation from the blood
is not to be as a rule expected, and the maintenance of the
virulence we have found difficult and have repeatedly directed
attention to the failure of peptone-agar and peptone-bouillon as
satisfactory media. The demonstration of the micro-organism
in the tissues is not easy for the reason given above and because
it is minute and not tenacious of Gram's stain. Over this
point we had many difficulties until experimental investi-
gation came to our assistance. In our papers we have re-
peatedly dwelt upon these difficulties which we have only
succeeded in overcoming by the closest attention to all details.

There was another initial difficulty not perhaps at first so
apparent, the necessity for obtaining some firm basis from
which to start. It is clear that the first step must be to
obtain some position or some guide which can be made reason-
ably safe and to which we can fall back for support and
assistance. The acute rheumatism of childhood was the
basis for this investigation, because it is frequent in its occur-
rence and also not uncommonly fatal, and thus clinical, patho-
logical and histological facts can be obtained. The greater
part of this book is concerned with the details of this disease,
and because it is our basis we have opposed with the utmost
determination any attempts to make us draw back from our
contention that it is a specific disease. If this point is yielded
we drop back once more into the chaos of those disorders
covered by the all-embracing term " rheumatism " and much
time will be lost then in disputing as to what is to be looked
upon as rheumatic.

Those who have not paid especial attention to rheumatic
affections may think that we have fallen into the trap of
believing that everything we met with showing the least
resemblance to acute rheumatism was in reality of that nature.
Such however is not the case : we certainly have ventured
from time to time from our basis to explore allied disorder



io INTRODUCTION

by the light of ascertained facts but we have always remem-
bered that these ventures were tentative. The establishment
of the cause of a most important disease among those classed
in general terms as " rheumatic " is, we believe, the first and
essential step in the study of the problem and then by com-
paratively easy stages the remainder of the group will be
eventually elucidated. It is not difficult to see how the
horizon widens as an outcome even of the results recorded
here. If there is a definite infective agent for some form
of "rheumatism" that agent must differ in virulence and
resistance in different cases, and in these possibilities lies a
large field for observation. The morbid anatomy resulting
from the toxines of this infection will serve as a basis for
comparison in the study of the allied disorders. Again, the
results of multiple infections can be more easily interpreted
when the results of the simple infection are understood.

This investigation we realise only touches upon the greater
problem of " rheumatism." We have not thrown light upon
the actual nature of the toxines, and many of the questions
as to the more chronic forms of arthritis have yet to be ex-
plained. The field is a very wide one and of the greatest
interest and importance in this country in which rheumatism
is so frequent.



PART I

PAPERS PUBLISHED BETWEEN 1898 AND 1900, PRE-
VIOUS TO THE DEMONSTRATION OF THE DIPLO-
COCCUS, WHICH WE LOOK UPON AS THE BACTERIAL
CAUSE OF ACUTE RHEUMATISM

I. ACUTE DILATATION OF THE HEART IN THE RHEUMA-
TISM AND CHOREA OF CHILDHOOD. By Dr. D. B. Lees
and Dr. F. J. Poynton

II. A CASE OF RHEUMATIC PERICARDITIS AND EXTREME
DILATATION OF THE HEART, WITH AN INVESTI-
GATION INTO THE MICROSCOPY OF RHEUMATIC
HEART DISEASE

III. A STUDY OF THE HEART-WALL IN DIPHTHERIA,

RHEUMATIC FEVER, AND CHOREA

IV. OBSERVATIONS UPON THE PATHOLOGY OF THE MYO-

CARDIUM

V. THE HISTOLOGY OF THE RHEUMATIC NODULE. By
Dr. F. J. Poynton and Dr. G. F. Still

VI. THREE FATAL CASES OF EXTENSIVE VENOUS THROM-
BOSIS ASSOCIATED WITH SEVERE RHEUMATIC CAR-
DITIS

VII. A CASE OF VIRULENT RHEUMATISM WITH EXTEN-
SIVE PURPURA



1 1



PAPER NO. I

ACUTE DILATATION OF THE HEART IN THE

RHEUMATISM AND CHOREA OF

CHILDHOOD.

By D. B. LEES, M.D. and F. J. POYNTON, M.D.

(From vol. lxxxi of the Medico-Chirurgical Transactions.)

This paper upon dilatation of the heart, inspired and collaborated
in by Dr. D. B. Lees, gave us one of the chief clues as to the line of
subsequent investigation. For the demonstration of the clinical
importance of this dilatation in rheumatism suggested a resemblance
between the behaviour of the heart in this disease and in others of
undoubtedly infective origin. Further, the view was favoured that a
minute study of the myocardium in rheumatism would discover lesions,
which in their turn would support the theory that the process was of an
infective nature.

The paper itself was a sequel to one by Dr. D. B. Lees upon acute
dilatation of the heart in rheumatic fever read the same evening. The
methods of investigation that were employed in both of them were
identical, and their intention was to establish on a clinical basis the
reality of acute dilatation in the carditis of rheumatism, and also to
direct attention to the comparatively minor importance of pericardial
effusion as an explanation of the great increase in the area of precordial
dullness that may occur in severe carditis.

The extensive analysis of fatal cardiac rheumatism in Appendix C ,
is a useful reference Table for the study of the various lesions that may
occur.

This paper embodies the results of a joint investigation of
the subject of acute dilatation of the heart in rheumatism
and chorea made at the Hospital for Sick Children, and it
also includes an account of certain enquiries in further elucida-
tion of the subject. These enquiries comprise :

i. Observation on the size, strength, and sounds of the
heart in healthy children.

13



i 4 ACUTE DILATATION OF THE HEART

2. Observations on the condition of the heart in rheumatic
and choreic children under the care of physicians other than Dr.
Lees. We tender our thanks to Dr. Cheadle, Dr. Barlow,
Dr. Phillips, and Dr. Penrose, for kind permission to make
use of their case-.

3. An analysis of 150 fatal cases of rheumatic heart disease
in children under twelve years of age, taken from the records
of the Hospital for Sick Children and from those of St. Mary's
Hospital.

Before proceeding to discuss the condition of the heart in
rheumatic and choreic children we wish, in order to obtain
a standard of comparison, to draw attention to observations
on the size, strength, and sounds of the heart in children free
from rheumatism. These were carried out partly in the
surgical wards of the Hospital for Sick Children, in forty-five
cases under the care of Mr. Owen. Mr. Morgan, and Mr. Pitts,
who kindly allowed us to use their patients ; and partly at
Marlborough College, where the hearts of thirty-five healthy
boys of twelve and thirteen years were examined by the
permission and with the kind assistance of Dr. Penny,
medical officer to the College, to whom also we offer our
thanks.

All these observations were made with the child in the same
posture — on the back, with the left arm abducted. The
results are given in detail in Appendices A and B. We may
briefly summarise them as follows :

In children aged from seven to twelve years the area of
cardiac dullness (by which we mean the nearest approach to the
actual size of the heart that can be obtained by percussion)
extends upward to the third costal cartilage on the left side,
thence downward and to the left to the fourth space just
internal to the nipple, or even as far as the nipple-line. Crossing
the middle line above, it extends in the fourth right space three
quarters of an inch to the right of the median line, a bare
iingerbreadth to the right of the sternal margin. As it passes
downward it tends slightly inward before it reaches the
hepatic dullness, and then recrosses the middle line to reach
the apex.

In children under seven years of age the cardiac dullness
extends as far as the left nipple-line more frequently than is
the case in older children.



IN CHILDHOOD 15

In the boys between twelve and fourteen, the left limit
of the cardiac dullness was almost invariably distinctly internal
to the left nipple-line, on the average about three quarters
of an inch from it, and reached the fifth left rib or more fre-
quently the fifth space.

In healthy children the cardiac impulse is usually internal
to the left limit of the dullness, often markedly so. The
action of the heart is regular. At the apex, the first sound is
longer than the second. At the base, the second sound is
louder on the left side than on the right, though both have a
distinct relative sharpness. Soft blowing systolic murmurs
are sometimes heard, most frequently in the fourth space
internal to the impulse, sometimes at the base, more rarely
at the apex ; they may be modified by position. When these
murmurs occur, the area of the heart is often rather larger than
normal the general physique more feeble, and the child anaemic.

So far as regards the position of the cardiac impulse and its
relation to the nipple, in younger and in older children, our
results are in accord with those of Starck and of Dr. Archibald
Garrod quoted by the late Dr. Sturgess in the Lumleian lectures
in 1894. But in determining the " cardiac dullness " we have
rejected the " superficial dullness " and endeavoured to ascer-
tain the true outline of the heart.

We conclude this section of our paper by showing with
the lantern the area of cardiac dullness in a healthy boy of

Healthy boy, aged 12.
X*)H/pp/e




twelve, to serve as a standard of comparison for the tracings
taken from rheumatic and choreic children.

We now proceed to show tracings taken from the hearts
of children suffering from rheumatism or from chorea, and
would premise that the several tracings in each case were always
taken without reference to previous tracings from the same case.

The varying severity of the cardiac affection makes it
desirable to arrange our observations in four groups.



i6



ACUTE DILATATION OF THE HEART



Group I. First attacks of mild subacute rheumatism, in which
there was no pericarditis, and either no murmur or only a
systolic murmur best heard internal to the nipple.

(ask i. E. S — -, aged 12, admitted into St. Mary's Hospital
under Dr. Cheadle October 9, 1897, lor moderate articular
rheumatism.



E. S — , aged 12. Rheumatic fever, first attack.





A

No. 2.
Oct. 26, 1897.



! accentuated pulmonary second sound.

X impulse.



systolic murmur.



October 10. First tracing. Temperature normal. Impulse
in the V.N.L. Area as shown. Short first sound. Accentuated
pulmonary second.

16th. A slight rise of temperature (to 99.8°), and a soft
systolic murmur heard internal to the impulse.

26th. Second tracing. Steady recovery had taken place.
Temperature normal. Impulse internal to V.N.L. Area as
shown. Systolic murmur very faint. It disappeared two
days afterwards.

Case 2. F. D — , aged n, admitted into St. Mary's under
Dr. Lees, April 6, 1897, with mild articular rheumatism.

F. D — , aged 11. Rheumatic fever, first attack.





A

No. 1. No. 2.

April 7, 1897. April 17. 1897.

! accentuated pulmonary second sound. * systolic murmur,
x impulse.



IN CHILDHOOD



17



April yth. First tracing. Temperature 102°. Impulse
diffuse, Area as shown. Soft systolic murmur internal to
impulse. Loud pulmonary second.

8th. Temperature fell to normal.

xyth. The boy well. Second tracing. Impulse more
definite, and internal to the nipple. Area diminished. No
murmur.



Case 3. E. D — , aged 9, admitted into the Hospital for
Sick Children under Dr. Lees, February 29, 1896, for articular
rheumatism.

E. D — , aged 9. Rheumatic fever, first attack.






A

No. 2. No. 3.

March 5, 1896. April 7, 1896.

! accentuated pulmonary second sound. * systolic murmur,
x X diffuse impulse.

March 1. First tracing. Temperature 101.2 . Impulse
diffused, and external to V.N.L. Faint systolic murmur
internal to the impulse. Loud pulmonary second.

$th. Second tracing. Increase in cardiac area. Salicylates
were now pushed, and the dilatation slowly subsided.

April 7. Third tracing. Impulse definite and internal to
V.N.L. Area diminished. Systolic murmur gone.

Group II. First attacks of chorea without history of previous
rheumatism.

The occasional occurrence of dilatation of the heart in
chorea has been noted both by Dr. Garrod and by Dr. Osier.
We find that it is common, even in cases in which there is no
indication of rheumatism other than the chorea and no history
of any previous rheumatic attack. In thirty-three cases
without history of previous rheumatism, and in many of them
without evidence of present rheumatism, we found that the
area of cardiac dullness extended to the left of the nipple-line
(usually about one finger-breadth) in no fewer than twenty-

2



i8



ACUTE DILATATION OF THE HEART



nine, and in sixteen of these the impulse also was external to
the nipple. On the other hand, in only three of them was
there evidence of increase of the cardiac dullness towards the
right. The auscultatory signs were noted in twenty-eight
cases ; in twenty-four of these the first sound was short, or
accompanied by a faint systolic murmur. Tracings were taken
in all the thirty-three cases, but a day was always allowed
to elapse after the child's admission into hospital before the
first determination of the cardiac outline was made. We now
show two examples illustrating the condition of the heart in
typical cases.

Case 4. \Y. A — , aged 12, admitted into St. Mary's Hospital,
October 19, 1897, under Dr. Lees, for chorea of moderate
severity.

W. A., aged 12. Chorea, first attack.






A

No. 1. No. 2. Xo. 3.

Oct. 20, 1897. Nov. 19, 1897. Jan. 3, 1898.

! accentuated pulmonary second sound. * systolic murmur.

x impulse.

October 20. First tracing. Temperature 100. 2°. Heart's
action irregular. Impulse external to nipple. Area as shown.
First sound remarkably short. Systolic murmur over pul-
monary artery ; loud pulmonary second.

During the early part of November there was some irregular
pyrexia, and a rheumatic erythema appeared.

November 19. Second tracing. The area had increased,
and a soft blowing murmur could be heard internal to the
nipple. After this there was gradual and slow recovery.

January 3, 1898. Third tracing. Area diminished. Chorea
and murmur gone.



Case 5. M. M — , aged 10, admitted into the Hospital for



IN CHILDHOOD 19

Sick Children, March 17, 1896, under Dr. Penrose. Chorea
distinct, and of five weeks 'duration.



M. M— ,


aged 10. Chorea,


first attack.


O


O


O


No. 1.


No. 2.


No. 3.


March 18, 1896.


April 4, 1896.


April 9, 1896.


X x diffuse impulse.


x impulse.


. systolic murmur.



March 18. First tracing. Temperature 99 . Impulse just
internal to V.N.L. Area as shown. Basic systolic pulmonary
murmur ; accentuated second sound.

April 4. Second tracing. Chorea nearly well. Area of
dullness much diminished.

gth. Third tracing. The child had been getting up, but
on the 8th had a little pyrexia, and a relapse of chorea. She
was sent back to bed. This tracing shows an increase in the
area.

She subsequently entirely recovered.

It is clear, therefore, that in first attacks of rheumatism
and in first attacks of chorea there is often a definite increase
in the cardiac area, appearing and disappearing under observa-
tion ; there is also an outward movement of the impulse, and
an accentuation of the pulmonary second sound ; sometimes
there is development of a soft systolic murmur internal to the
nipple ; occasionally there is irregularity. Evidence of active
rheumatism may be present also ; such as arthritis, or erythema
or there may be pyrexia alone. It is in such a combination
of signs, more or less developed, that such hearts differ from
the normal standard ; it is a difference which is distinct, and
the earliest appreciable in the history of rheumatic heart-
disease. It cannot be explained by pyrexia, for it may be
present when the temperature is normal ; nor by the effect
of salicylates, for it is present before treatment has been com-
menced ; nor in cases of chorea by the movements, for its
amount bears no constant relation to the severity of these.
It is not merely a part of the debility caused by an illness, for it



20



ACUTE DILATATION OF THE HEART



is often much more distinct in very mild attacks of rheumatism
than in more severe diseases. It is evidently in some way a
special result of the rheumatic process. The evidence already
given appears to prove that it is independent of pericarditis.
It is more difficult to prove the absence of endocarditis, but
if any valvulitis at all was present in the above cases it must
have been extremely slight, and quite incapable of producing
so definite an enlargement of the heart, or one capable of such
easy recovery. It seems impossible to avoid the conclusion
that in rheumatism there is some toxic action exerted on the
cardiac muscle, enfeebling it and causing it to give way before
the normal blood-pressure. This explains why the first
sound becomes short, the area of dullness increased, and the
impulse diffused. The feebler diastolic rebound, causing a
weaker suction action in diastole, explains why the pulmonary
tension rises, and the pulmonary second becomes accentuated.
Before passing to the more severe rheumatic cases, which we
have placed in the third group, we wish to give an example
of acute dilatation in a first attack of chorea, which was followed
by definite valvulitis.

Case 6. L. H — , aged n, admitted into hospital August 19,
1897, under Dr. Lees, for moderate chorea of two weeks'
standing.

L. H., aged 11. Chorea, first attack.





No. 1. No. 2.

Aug. 20, 1897. Aug. 30, 1897.

! accentuated pulmonary second sound. * systolic murmur.
— ► systolic murmur conducted to axilla. x x diffuse
impulse.

August 20. First tracing. Temperature 99 . Impulse
external to nipple. Area as shown. First sound short.
Sounds spaced. A very faint soft murmur heard internal to the
impulse.

This condition continued unchanged for ten days. On the
29th the temperature rose from normal to 99. 8°, and a definite
musical blowing murmur appeared,



IN CHILDHOOD



21



30th. Second tracing. Area as shown. The murmur could
be traced to the axilla, and all who examined the case agreed
that there was now definite valvulitis. When the patient left
the hospital a month later, the murmur was still present and
audible in the axilla.

Group III. Severe cases of acute rheumatic heart disease, with
definite valvulitis and frequently pericarditis.

We give tracings from two cases as types of these severe
attacks.

Case 7. E. C — , aged 11, admitted into the Hospital for
Sick Children, February 20, 1896, under Dr. Penrose, for a
severe first attack of chorea. In the out-patient department
in the morning no murmur was heard, but later in the day a
soft apical murmur appeared.

E. C — , aged 1 1 . Chorea and rheumatic fever, first attack.




No. 1.
Feb. 21, 1896.



&




8



No. 3.
March 10, 189^
* diastolic murmur




A

No. 4.
I. April 22, 1896.

8 to-and-fro mitral murmur,
x impulse.



February 21. First tracing. Temperature 10 1°. Impulse
external to nipple. Area as shown. A to-and-fro murmur
audible external to the nipple. Loud pulmonary second.

23rd. Erythema.

2jth. Arthritis.

29th. Second tracing. Temperature 99 . Area slightly
diminished. For some days the aortic second had been short.



22



AC I'll-: DILATATION OF THE HEART



March 10. Third tracing. Area no larger than before,
though a well-marked aortic diastolic murmur had developed.
The rheumatism had quieted down.

April 22. Fourth tracing. After decided improvement
there were now fresh pyrexia and joint pains. Area decidedly
increased. Signs of aortic disease less marked.

Eventually the boy recovered sufficiently to leave the
hospital, but with marked aortic and mitral regurgitation.

In this case there was no evidence of pericarditis. The
increase in the cardiac dullness was most marked when the
rheumatism was most active, and it diminished when the
rheumatism subsided. With the fresh outburst the area
again became enlarged. If the dilatation had been due
to the valvular lesions, it would not have varied in this way.
but would have steadily and gradually increased until checked
by compensatory hypertrophy.



Case 8. E. B— , aged 8, admitted under Dr. Penrose April
ii, 1896, for general pericarditis and chorea.



E. 13 — , aged 8. Chorea and rheumatic fever, first attack.






A

No. 1. Xo. 2. No. 3.

April 12, 1896. April iS, 1896. April J9, 1896.

£ pericardial friction. x x diffuse impulse.

8 to-and-fro mitral murmur.



April 12. First tracing. Temperature 99 . Xo definite
impulse ; area as shown ; loud general friction. Very ill.

ijt/i. Sharp rales over front of left lung.

i8//z. Second tracing. Area diminished ; less friction ;
a double murmur at the apex.

29^/7. Third tracing. Remarkable improvement ; chorea
almost gone". Area still further diminished. No friction ;
double murmur plainly heard.

June 8. Discharged ; only a loud systolic murmur remains ;
area stiii further diminished.



IN CHILDHOOD 23

In this case, when the area of cardiac dullness was most
extensive, the pericardial friction was loudest and most
general. This suggests that there was probably no great
excess of fluid in the pericardial cavity. The suggestion is
supported by the post-mortem records of fatal cases of rheu-
matic heart disease. In only 12 out of 150 cases (see Appendix
C) is it definitely stated that more than two ounces of fluid
were found in the pericardial cavity. By actual experiment
on the cadaver we have ascertained that this quantity will
not produce anything like the enlargement of the cardiac area
often observed during life. Dr. Sibson found that six ounces
of fluid were required to distend the pericardium in a boy of
nine. If to these facts we add the clinical observation that
the area of pulsation, in these cases, is usually extensive and the
cardiac sounds fairly loud, we are driven to the conclusion
that in the great majority of cases of rheumatic pericarditis
the increase in the area of cardiac dullness is mainly due to
dilatation. At first sight it might seem that the dilatation
is secondary to the pericarditis, but it is much less marked
in suppurative than in rheumatic pericarditis, and it is often
marked in rheumatism in which no pericarditis exists. We
conclude, therefore, that^the enfeeblement of the cardiac wall
is mainly due to a direct toxic action of the rheumatic poison.
However brought about, the dilatation is a most serious addition
to the valvulitis or the pericarditis which may accompany it,
and takes a very large share in the production of the dangerous
symptoms usually attributed to them.

Group IV. The more chronic forms of chorea and rheumatism.

Careful observation of the clinical course of these more chronic
cases, and comparison with the results revealed by post-mortem
examination, prove that in them also dilatation of the heart
is one of the most important factors. A moderate valve lesion
in a child is easily and effectually compensated if no fresh
incidence of rheumatism occurs. On the other hand, grave
symptoms of cardiac failure in a rheumatic child are almost
always accompanied by fresh rheumatic manifestations. In
100 such cases ending fatally (Appendix C) there was evidence
(apart from endocarditis) of fresh rheumatism in 86. We lay
special stress on this fact, for it indicates that in children the



24



ACUTE DILATATION OF THE HEART



fatal issue of rheumatic heart disease is not often the mechanical
result of damaged valves, as is frequently the case in adults,
and that some other explanation of the acute cardiac failure is
required. And this is confirmed by the fact that the amount
of change in the valves in such cases is usually moderate or
slight. The chief cause of the fatal issue is indicated by the



Online LibraryF. J. (Frederic John) PoyntonResearches on rheumatism → online text (page 2 of 42)