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Un dea symbolea suivants apparattra sur la darniire image de chaque microfiche, selon le cas: le symbols —»• signifie "A SUIVRE", le symbols ▼ signifie TIN". Maps, plates, charts, etc., may be filmed ax different reduction ratios. Thoae too large to be entirely included in one expoaura are fit '«ied beginning in the upper left hand corner, left to right and top to bottom, aa many framea aa required. The following diagrams iiiuatrata the method: Lea cartaa. planchea. tableaux, etc., psuvent Atre filmte A dea taux de rMuction diff Artints. Lorsque le document est trop grand pour Atre reproduit en un saul clichA, 11 est film* A partir de Tangle sup^rieur gauche, de gauche A droite, et de haut an baa. en prenant le nombre d'imagea nteaasaira. Lea diagrammea suivants illustrent ia mAthode. t ,. 2 « 1 2 3 4 5 6 Pvx \~ wvOa-A>< . r" . G> ' PNEUMONIA, MALI6N4M ENDOCARDITIS OF TRICUSPID VALVE. BY F. G. FINLEY, :M.D., Assistant Professor of Medicine, and Associate Professor of Clinical Medicine, McGiil University ; Attending Physician, Montreal General Hospital. {Reprinted from the Montreal MedxcalJournal May, 1898.) T p. G. raiLEY, 1655. PNEUMONIA, MALIGNANT ENDOCARDITIS OF TRICUSPID VALVE.1 BY F. G. FiNLEY, M.D. Assistant Professor of Medicine, and Associate Professor of Clinical Medicine McGill University ; Attending Physician, Montreal General Hospital, Mrs. L., a)t 40, wiis admitted to the Montreal General Hospital on Marcli 2r)th, 1898, coinplainin<^ of pain in the left side and difficulty in lircathinijf. Two years a Read before the Montreal Medico-Chirurgical Society, April 27, 1898. stools. At ;i..j'» this aft«'nii)()ii sli" 'tiul a ri;^or, tlit* tfiiipiTiitiire rising to 104|°, lasting for live minutes, and followed by piofuse sweating. March HO. There was a slight rigor at midnight, severe headache, and followed l)y profuse sweating, the temperature ro.se to 104,^°, and the pulse to 144 at 4 a.m. ; ten minutes^ later the temperature fell to 102. She slept badly, had a dry cough, and the diarrhcea continues, being .somewhat controlled by starch and opium er.emata. A pleuritic to and fro friction is present at tlu; right base ; otherwise the physi- cal signs in the chest are unchanged. The .splenic dulness reaches the costal border, but the organ is not palpable. Api'il 2. Two I'igors occurred yesterday, the rectal temperatures reaching l()o;i° to lOGJ". Following ami preceding the rigors the temp(!rature fell to normal. During the high temperature, the pulse became very weak and rapid, IGO to IfiS, and the respiration very labored, increasing from 24 to 28 up to 40 or 44. The lungs as before, and the heart, which has l)een carefully ex- amined daily, presents no murmur. April 8. ])r. Uardner examined the fundi and reports them normal. A culture from the blood shows diplncocci and staphylococci. Pros- tration is very marked, the 2nd sound is feeble, the first accentuated. The pulse varies with the temperature from 104 to 170, and once fell to 80. The temperature is remitting, rising from 103i° to 106° in the latter part of the day, and falling as low as 99f° in the morning. The last rigor, there being five altogether, took place on the 3rd. A dry cough without expectoration continues, and there are from three to four stools daily. April 8. Lies propped up in bed owing to dyspncBa. Complains of severe pain at back of left knee ; nothing made out objectively. April 13. Breath extremely offensive for some day.s. Examination by Dr. Birkett shows atrophic catarrh and ozjena. April 16. Prostration during last few days has become extreme. Temperature 105° to 106° in the afternoon without rigors, the mini- mum temperatures being 102° to 103°. Yesterday and to-day tempera- ture 105° to 106°. The pulse rapid, 124 to 170, and weak. The mind has been clear throughout. The lungs when examined yesterday still showed the same evidence of consolidation. The heart, which has been daily examined, has been normal. Diarrhoea, 3 or 4 stools daily. Death took place at 2 a.m. on the l7th April, the temperature rising before death to 108". Autopsy by Dr. Wyatt Johnston, showed a very unusual condition of the heart, there being acute endocarditis confined to the tricuspid valve. This valve was covered with polypoid vegetations as large I 8 I as cherries, forming a cluster and having a general appearance analogouH to condyloumta round an orifice. The tricuspid orifice tiiough somewhat obstructed by these vegetations, was neither dilated nor stenoff^d, the other orifices were of normal size. The inHral valve was very slightly thickened, but free from vegetations. None of the heart cavities were dilated. The character of the vegetations was pecu- liar. They were white, rounded and very firmly attached to the valve and Imtl not led to destruction or perforation, their appearance being rather that of mural thrombi in the heart than usual vegetation. This made it appear as if the peculiar lesions in this case resulted from an antecedent riyht heart thrombosis. The auricular surface of the tri- cuspid was the part effected ; the auricle itself being free except for a snuill throuibosis the size of a pea about one-half inch above the ring. Microscopical examination showed large numbers of large laniret shaped diplococci staining by Grams' method about twice the size of the pneumococcus, also a number of short coccus chains of four elements staining by Gram. The diplococci grew on blood serum and gave an abundant greyish growth ; injections of the cultures into mice failed to kill them. It was suggested by Dr. Finley that they might be involution forms of the pneumococcus which had lost virulence during the chronic course of the case. The spleen and kidneys showed extreme cloudy swelling, but neither showed emboli. On the other hand in the small branches of the pulmonary artery of both lungs, there were several areas of necro- sis and softening surrounded by areas of pneumonia. In other parts of the lungs partly decolourised infarcts existed surrounded by pneu- monic areas. Near the root of the lung were firm areas of interstitial pneumonia, the lung process showing different dates or recurrences of infection. The cultures from the lungs sliowed pneumococci, staphy- lococci, auris and streptococci; The thrombi in the lung arteries had the same white rounded appearance as the cardiac vegetations. On the entry of the patient the case presented the typical picture of acute lobar pneumonia of a moderately severe type. It was not until the 11th day, when the rigor took place, that a complication was suspected, and after the second rigor I was strongly inclined to regard the condition as one of malignant endocarditis. This seemed to be the only explanation for the septic condition of the patient, and the preceding pneumonia also supported this supposition. The marked and early prostration was a striking feature and was a strong point in favour of this opinion. The spleen, which was of normal size on admission, was first noticed to be enlarged on the 30th and was in accord with a septic condition. The case lackeil tlio conclusive evidence of the development of cardiac niuniiurs and uf emboli. Although carefully (examined daily there were no murmurs, and this was fairly well explained liy the condition of tlie tricuspid valve which was competent, whilst the heart's action was doubtless too weak to generate a direct murmur, and beyond the evidence of cardiac weakness present in any severe septic state, there was no signs of any abnormality. The limitation of the endocarditis to the tricuspid valve explaine(| the absence of arterial emboli, which is such a marked feature of most cases of ulcerative endocarditis. I'l*