IMAGE EVALUATION TEST TARGET (MT-3) 1.0 I.I laiM 12.5 ISO ""^^ il^HI ta Ki& 12.2 ui liiK 2.0 US u IL25 iu I m . / Photographic Sciences Corporation 33 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 873-4503 ■^ CIHM/ICMH Microfiche Series. CIHM/ICIVIH Collection de microfiches. Cansdian Institute for Historical Microreproductions / Institut Canadian de microreproductions historiques . Tachnical and Bibliographic Notaa/Notas tachniquaa at bibiiographiquaa Tha Inatituta haa attamptad to obtain tha baat original copy availabia for filming. 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This itam is filmad at tha raduction ratio chackad balow/ Ca document aat fiimi au taux da reduction indiquA ci-daasous. 10X 14X 18X 22X 26X 30X 7 12X 16X 20X 24X 28X 32X "^«»w«»»i5p«T Th« copy flimad h«r« Hm bMn r«produo«d thanks to th« g«n«ro«ity of: MMiiMl Library McQill Univeriity Montraal Tho imagM appoaring haro ara tha baat quality poaaibia eonaidaring tha condition and iagibiiity of tha original copy and in icaaping with tha filming contract spaeificatlona. Original copiaa in printad papar covara ara filniad baginning with ttM front cover and anding on tha laat paga with a printad or illuatratad impraa- sion, or tha bacic eovar wlian appropriata. All otiiar original copiaa ara fllniad baginning on tha first paga with a printad or illuatratad impraa- aion. and anding on tlw laat paga with a printad or illuatratad impraaaion. Tha laat racordad frama on aaeh microflcha ahail contain tha aymboi •-•^ (moaning "CON- TINUED"), or tha aymboi y (maaning "END"), whiehavar appliaa. L'axamplaira fllm4 fut raproduK grica A la giniroaitA da: IMwIieii Library IMcGill Univtrtity - MontrMi Laa imagaa auhmntaa ont 4ti raproduitaa avac la plua grand aoln, compta tanu da la condition at da la nattatA da l'axamplaira filmA, at an oonformitA avac laa condltiona du contrat da filmaga. Laa axamplairaa originaux dont la couvartura w* papiar aat ImprimAa aont fllmia an commandant par la pramiar plat at an tarmlnant salt par la danrfAra paga qui comportr una amprainta dimpraaalon ou d1lluatrati«in. aoit par ia aacond plat, salon la caa. Toua laa autraa axamplairaa originaux aont filmAa an commandant par ia pramlAra paga qui comporta una amprainta dimpraaalon ou dllluatration at an tarminant par la damlAra paga qui comporta una teiia amprainta. Un daa symbdaa suivants apparattra sur ia damlAra imaga da chaqua microflcha, salon la caa: la symbola — ^ aignifia "A SUiVRE". ia symbols ▼ signifis "FIN". IMapa, plataa. charta, ate., may ba flimad at diffarant raduction ratioa. Thoaa too larga to ba antiraly included in ona axposura ara flimad baginning in tha uppar laft hand comar, laft to right and top to bottom, aa many framaa aa raquirad. Thia following diagrama lliustrata tha mathod: Laa cartaa, planchaa, tableaux, ate, pauvant Atra flImAa A daa taux da rAduction dlff Arants. Loraqua la document act trap grand pour Atre reproduit en un sstil ciichA. il set flImA A partir da I'angia aupArieur gauche, do gauche A droite, et do haut en bee. sn prsnant la nombre d'imegea nAcessaire. Las diagrammes suivanta illustrent la mAthode. 1 2 3 1 2 3 4 5 6 A CASE OF PYjEMIA. BY W. F. HAMILTON, M.D., Assistant Demonstrator of M<5dioine, McGill University ; Assistant Physician Royal Victoria Hospital. AND C. F. MAETIN, B.A., M.D., Demonstrator of Pathology, McGill University ; Assistant Physician Royal Victoria Hospital. Reprinttd from the Montreal Medical Journal, December, 1895. i / t ^ n Vf.- 3 * Wl . T ,T / / ■ K •' ' 'I. I a: / ■M IE k A CASE OF PYiEMIA.' WITH SUGGESTIONS AS TO POSSIBLE CAUSE FOR PRESENCE OF A PREn SYSTOLIC MURMUR WITBOUT STENOSIS OF THE MITRAL VALVE. By W. F. Hamilton, M.D. Assistant Demonstrator of Medicine, McOill University; Assistant Physician, Boyal Victoria HospitAl. and G. F. Martin, B,A., M.D. Demonstrator of Pathology, McGill University ; Assistant Physician Royal Victoria Hospital. The history of this case is of considerable interest owing to the following Conditions which were present : 1. The apparent insignificance of the seat of infection, and the extensive distribution of the secondary symptoms. 2. The presence of a high degree of suppurative myocarditis. 3. The absence of abscess formation in the lung. 4. The presence of a presystolic thrill and murmur without stenosis of the mitral valve. J. D., aged 21 years, employed as an assistant cook, was admitted to the medical department of ihe Royal Victoria Hospital on the 26th of July, 1895, complaining of general pains, extreme weakness, and vomiting. Though he had not been in good health during June and the greater part of July, yet he continued to do his regular work. On the 28rd of July he became acutely ill, the onset of the attack being charac- terized by chill, headache, pains in the back, nausea, and vomiting. The history of the patient showed him to be a subject of articular rheumatism as early as his seventh year, with subsequent and frequent attacks of sore throat, as well as recurrences of arthritic manifesta- tions. The last attack of rheumatism occurred in June, 1894. The convalescence therefrom was not satisfactory, as cardiac complications were already established. Shortly after admission with the complaints enumerated above, the following condition of the patient was noted (July 27, 1895)': He was delirious and irritable, skin dry and hot, face flushed with slight cyanosis about the ears and lips; lips and tongue dry and > Bead before tite Montreal Medito-Chimiitioal Society, Octolier 18, 1806. .'f ,>» brown ; the abdomen showed no signs of dbtension ; the spleen was not palpable; there was no increase of liver dulness. The skin over the face, trunk, and extremities, presented an emption, petechial, papular, and at some points pustular. On the ulnai: surface of the left forearm, near the lower third, was a raised, slightly reddened patch, 3 cm. in diameter, tender on pressure, somewhat boggy to the feel, and presenting about its centre a small area about the size of a pin-head, at which the skin appeared in the state of recent healing — a recently closed opening without scab-thickoning. This region on the forearm was said to be the seat of an injury received a few days before the onset of his illness- The right ankle showed on its anterior and inner aspect signs of a recent scald. It was partly healed and no signs of extending inflam- mation were seen. At the root of the nail of the right fore-finger there were signs of localized inflammation. The temperature at this examination was 103°, the pulse 120, respirations 30. On examination of the circulatory system the signs present led to a diagnosis of cardiac hypertrophy due to valvular disease. The mur- murs present indicated mitral incompetency with stenosis, as in .addition to the apical systolic murmur which was transmitted to the axilla, a presystolic thrill and murmur were detected. In addition, distinct evidence of aortic valvular disease was manifest, inasmuch as both collapsing pulse and a diastolic murmur were observed. The respiratory system showed, besides increase in the rate of respirations, diminished expansion over the upper half of the left side. There was no dulness on percussion. A few moist r&les with dimin- ished breath sounds were heard at the right base. The urine was passed involuntarily. Its reaction was acid. Albu* men was present The blood examination revealed the presence of a leucocytosis of the poly nuclear variety, five to fourteen white cells being visible in each field. On the 27th and 2Sth of July cultures were made with agar and also with broth, etich day giving the staphylococcus pyogenes aureus. Progress of the case. — This was rapidly worse. The delirium of the 27th deepened into coma on the evening of the 28th July. The pulse rate increased to 160, while the strength of the beat diminished. The cardiac area was observed to increase toward the left by about one- half an inch. The respirations, 24 on admission, ran as high as 60 pier minute on the 29th. The cyanosis became more marked. The tem- perature followed an irregular remittent curve, ranging from 100*6° to 105*8°. The signs in the lungs were those indicating oedema, with possibly an area of infiltration at the right base posteriorly. t f isi'iS'Si- ' t I I On the 27th and 28th the movements of the left ankle, left great toe, left shoulder, and of the right little Bnger were painful, and redness and swelling were present over the ball of the left great toe, as well as over the dorsal surface of the little finger of the right hand. There was no diarrhcea nor. vomiting during the progress of the case in the hospital. On the 29th of July, the seventh day of the disease in its acute manifestations, the patient's condition was much worse, and he died at 3.30 p.m. The question of diagnosis in this case needed not a little considera- tion to decide. Evidently we had to deal with an infection which was extremely active and virulent. Malignant endocarditis, typhoid fever, pneumonia, miliary tuberculosis, and pyaemia, at first, were all in the category of possibilities. It was known that the patient was a subject uf chronic endocar- ditis, a suitable condition for the ulcerative form to succeed, but what was the source, and where the entrance of the micro-organism ? Malignant endocarditis could not be excluded. Indeed it appeared to be, in all probability, a part of the case. The rapidity of the onset, the absence of abdominal signs, and the presence of leucocytosis, as well as the character of the eruption, were all against a diagno.sis of typhoid fever. For pneumonia, there were not physiieal signs sufficient to account for the condition of the patient. An exclusion of miliary tuberculosis wouid, doubtless, have been impossible had not positive evidence of another disease been observed* From the following features of this case, then, a diagnosis of acute pyaemia with, in all probability, multiple abscesses throughout the organs, was made: An Injury with evidences of v^rund of skin sur- rounded by an area of tenderness and swelling ; sud 'ien onset of the illness ; rapid advance of the case ; albuminuria ; hsemorrhagic erup- tion ; joint redness and swelling; leucocytosis of an inflammatory character, and the presence of the staphylococcus pyogenes aureus in ' the blood. . The following is an abstract from the report of the autopsy per- formed four hours after death. The body was that of a well-nourished and well-bai]t young man, presenting the usual signs of death. On the outer side of the fifth finger of the right hand there was a slightly red- dened swelling, which on section presented a small drop of pus lying about the sheath of the extensor tendon. No abrasion appeared externally. Upon the ulnar surface of the left forearm was seen a bluish-purple swelling 3 cm. in diameter, the centre of which showed externally a point of recent healing. Incision into this allowed the exit of greyish-green pus, situated amid much disin- * ■ ; tf- i. disintegration of tissue out of all proportion to that elsewhere found ; further, the inflammatory thickening of the overlying subcutaneous tissue, and the absence of any other visible seat of entry would in all probability warrant such an opinion. Without such an origin it would be almost impossible to do otherwise than regard the case in the light of the somewhat dubious cryptogenetio or so-called idiopathic pyeemias. As possible objections to our view it may be urged that in the forearm we have merely an additional secondary focus, similar to all the others ; yet not only is the condition apparently one of greater duration than the other affections, but further, the wound having had at one time definite connection with the outer air would hardly suggest a secondary focus. That no thrombo-phlebitis was found in the proxi< mal vessels is indeed unusual, yet that the affection may occur without such a coincident event seems to us quite possible. Nor is the case one of primary malignant endocarrlitis, for the valvular lesion is of the most acute type, one eminently recent and apparently contemporaneous with the other secondary events of the disease — the old valve lesions rendering this site a locvM minoria reaiatentioe. , Additional features of interest exist in the facts that three different sets of valves were affected, and that although the liver presented ample evidence of infection, the luugs, so commonly involved, showed here no signs of abscess formation. There is another point of no little interest to the clinician, in that the signs ol)served in the heart and the subsequently found pathological condition fail to correspond, and another example of the difficulty in exact diagnosis of cardiac conditions is afforded. As described above, among the physical signs present on examina- tion of the heart was a rough murmur, presystolic in rhythm, and well localized to the apex I'^gion — in other words, a combination of symp- toms very suggestive of mitral stenosis. Yet at the autopsy the auriculo-ventricular ori^ce of the left side was of normal size, so that it would seem necessary to find some cause other than a mjtral lesion to explain the presence of so typical a presystolic murmur. Within a recent date not a little discussion has arisen lipon the origin of such conditions as those found in this case, and since Hunt' offered the classical suggestion that an aortic regui^itation may in- duce presystolic murmurs by bringing about an abnormal vibra- tion of the mitral valves, further opinions have been elicited. Thus, 1 Hunt (Austin), Amer. Jour. Med. Science, 1880. Vol. I, p. 27. ^ t- ■''^ k' ... '* ■;■.. ',■" w '7': Theodore Fisher* has died more fhan a doien oases in which an adherent pericardium seemed a possible etiological factor, while Osier' and Graham Steele* hara Rimilar cases on record. A very recent thesis by Phear* hao volnnieered f^ another explanation, that a thickening of the tendinous cord* ai^ dilatation of the ventricle may cause the two cusps of ih* niitral valve to be abnormally approximated and thus induce a faJbetional stenosis. In one of Professor Adami's' ca^ with dilated heart and enlarged mitral orifice there had been obsarved clinically a presystolic thrill and muniiur. Although in '>ur own cose there had been present both adherent pericardium and nurtic incompetence, it would seem that still another suggestion might be subiaitted. The heart being enlarged to nearly twice its normal size and \,he chambers presenting extreme dilatation, the quantity oi blood contained by them is correspondingly increased. Under such circumstances there would be a very much greater amount of blood endeavouring to fooce its way through the mitral orifice, especially with the great hypei*trophy seen in the auricle. Hence with a normal sized left auriculo- ventricular opening we have an excessive amount of blood seeking passage through it — in other words, the proportion of blood to the siae of the passage makes a relative stenosis of the orifice. It may be further mentioned that in the majority of cases which present a similar set of conditions, very great dilatation has been present, and it would seem that according to the degree of dilatation, that is the amount of blood within the chambers, so there would be a presystolic murmur or not, this sign presenting only when the amount of blood is extreme. 1 Frsber, B. M. J., April 28, 1894. » Osier, Trana. Aaa. Amer. Phya., 1888. V«4. lit. p. 138. » Steell (Graham), Practitioner, April, 1804. * Phear, Lancet, September 21, 1806. * Adaml, Mont. Med. Journal, April, 1806, p. 780. 1- -'a m i ■