THE MEDICAL GAZETTE

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in a State of ;n was slightly Tliere was no^ jndocarditi . The luiigs' Végétations ant. Therigli ly dis

a sudden gasping effort, though to push the motlier away aiid dîed without furtlier slniggle. At tlie postmortem examinalion made on the following day, intense congestion of the lîver was found, wilh enlargement and a deep purplish color. Tlie kidneys were also deeply congested, the secretîng cells of the tabules being " cloudy sweHing." The splt enlarged from engorgement, pleural or pericardîal effusioi were pale, retracted and crépi cavities of the heart tended. The auricle contained much soft, dark clotted blood. There was a firm wliiLe clôt enlangled in the triciispid leaflets, a"rid extending from there ïnto the right ventrîcle, where it was very tightly attached to the muscular trabeculre by délicate prolongations; was thence prolonged into the piilmonary artery, the calibre of wliich was to a great extent obstructed bya firm, white, ante-mortem dot, which was molded onto the leaflets and closely apposed to the walls. The left cavilies of the beart contained less blood, but hère also there was a large firm ante-mortem clôt, obstnicting the milral orifice, partly filling the left ventricle and prolonged into the aorta. The musciilar fibres of the heart were in advanced fatly degeneratîon, their transverse striation heing in places completely obliterated. The contents of the stomach were only ingesta. Its mucous membrane was for the most part not much congested, but at one spot near the mîddie of the gre; ature there was intense congestion wise the stomach was entirely normal. The occurrence of the heart dot is now known to be among the dangers in so many diseases that it demands carefui sludy, It must be understood, of course, Ihat I only refer to such dots as are formed in the heart some consideralde tîme before death. It is wellknown that whenever Ihe act of d/ing is protracted, heart dots are apt to formed. But snch heart dots hâve Utile, or no pathological significance. The true ante-mortem heart dot is distinguished by certain anatomical characters which are unusually well illustrated in thèse spécimens. Il is whilish, firm and tough, it is apt to be molded on tlie inequalitiesof Ihe inner surface of the heart. and maybe tightly altached by délicate prolongations passing arourd the muscular trabecul.-e. The circumslances which favor the formation of such dots are quite various. Attempts hâve been made to explain their production, but none of thèse théories hâve been fully substantiated, or can beapplied to ail cases. Among the conditions whidi prédispose may be mentîoned; — an excess of the fibrinous éléments of the blood, roughness, or végétations of the leaflets of the valves of the heart; obstruction of the circulation of the blood; failure, or momentary arrest of cardiac action, and the hitroductionof certain spécifie poisons into the blood. There are, doubtless, other conditions, but thèse are the

most prominent, and several of them are often associated in a single case. Thus, in diphtheria, there is a greater tendency to Ihe production of fibrinous exudatîons than in olher zymotic diseases, and the blood contains a larger proportion of fibrinous élément, There is also a marked tendency to the degeneralion of the cardiac muscular fibres, with great enfeeblingof its action; not rarely also, there will be found slight évidences of n Ihfi formof minute, bead-like rai leajet-î, The latter were not found in this case, but the degeneration of the muscular structure of the heart was marked. The tendency to heart dot in diphtheria is, accordingly, so very strong that

it raust never be forgol This accident may occu diseases and not rarely a place after convalescenc lished. I hâve also kno earlicr sta^re in doîng perfectly

ost sight of.

stage of the

rase, it takes

nce seems to be estab-

;novvn it to occur at an

whidi were apparenlly

ly spécial de.

ermining influence which I hâve suspected n such cases bas been an undue amount of muscular effort. This, thercfore, should be pulously avoided in ail cases of dîphlherîa for this as well as for olher reasons. Although usually followed by death, it is important to be able to delecl the occurrence of heart clôt, if possible. Thesymptoms which may be stated as indicative of this condition are anxiety and great dyspncei ; pallor of face, and coolnessof extremities ; small, fréquent puise ; and obscure, dull heart sounds with occasionallya blowing murmur, It will be seen that the symptoms in the présent case were unusually obscure. I am inclined to regard the violent vomiting as one of the first results of the heart dot. The ob-

to the entrance of blood into cavilies of the heart caused

ongestion of the liver and of

5 membrane of the stomach. This would readily account for the obstinate vomiting, and carefui examination of the stomach after death failed to reveal any other cause. It is true that there had been found a few days before, a trace of albumen in the urine, and that the early stage of kidney disease, with cloudy swelHng of the epithelîum existed ; but thèse do not suflîce to account for the sudden occurrence of such violent and uncontrollable vomiting, without any symptoms of aniemia. Considering the marked ante-mortem characters of the dots, it must be admitted that Ihey had existed for several days before death, yet until a half hour before death, no symptoms arose to call spécial attention to the Iieart. It is true that they may hâve been marked by the fréquent vomiting and the slight opiate effect which was mainlained. There was no extrême dyspnœa, however, and the puise was regular and not veryrapid. There was also nolhing spécial about the heart sounds, which were observed

:ly faint. It is important, Ihere-

fore, to note how însidïous may be the for-

of heart dot and how closely we

should be on our guard against it. When fina7/y the dots attained such size as to seriously obstruct the orifices of the heart, and prevent the closure of the valves, very characteristic symptoms appeared, and were rapidly followed by death. The prognosis in cases of heart dot is very grave. Still it cannot be doubted but that in a few instances the dot has gradually conlracted and finally become attached to some part of the heart's cavity, where it has not seriously interfered with the heart's action, and thus life has been saved. In other cases it is possible that a smalI dot may hâve undergone graduai molecular disîntegration, and hâve been distributed without the occurrence of any serious embolism, This very lortunate termination, however, cannot be hoped for in any giver» case, and death nearly always follows dose. The most important part of the trealment is prophylactic, as the marked tendency to the formation of heart clôt in diphtheria is probably connected with the spécial altération of the blood, and there is no remedy known which will avert this dreadful accident. But there is little doubt but that by Judiciously sustaining the tone of cardiac action, and by carefully guarding against ail muscular exertion, especially in the way of sitting up, or rising to the feet, a good deal may be donc to lessen the danger of its occurrence. Should it become évident that a heart clôt has formed, the only treatment to be recommended still îs active stimulation of the tone of the heart. The various remédies which hâve been advised, with the idea that the solution of the dot may be promoted, areuseless. Ammonia is valuable, not in this latter way, but sïmply as a stimulant to respiration and circulation. Ail alcoholic stimuli and concentrated nourishment must be'given as freely as seems called for by the prostration and the dépression of circulation, I should place more reliance upon digitalis, freely administered, than upon any other remedy. Absolule avoidance of muscular efforts must be insisted upon. Stiil, as before stated, it is only in very excepLîonal cases that death does not follow.