Amoebic dysentery is a somewhat prolonged disease, lasting from six to twelve weeks, and it is a dangerous affection. While some reports show that about twenty-five per cent. of the cases are fatal, the cases studied in this country, particularly in Baltimore, have resulted in a mortality of nearly ninety-five per cent.

The treatment is, of course, directed towards supporting the patient, for, whether the amoeba is alive in the intestines or not, the poisons produced by this organism cause marked depression, calling for stimulation and careful diet. Local measures are undertaken with the hope of destroying the parasite, and quinine in solution has been found of apparent benefit. Even a 1 to 5000 solution has proved sufficiently strong, and Osler has used enemata varying from this strength to 1 to 1000. Although these enemata destroy the organisms wherever they can be reached, it is manifest that they cannot reach the amoebae lying in the overhanging wall of the ulcer, or in the lymphatics, or in the hepatic abscesses. As these abscesses are most frequently in the right lobe of the liver, it is not unusual for the inflammation to extend through the diaphragm to the right pleura, and thence to the lung, where abscesses may be formed. The expectoration in these cases has been found to contain living amœbæ, and the immediate cause of death in this form of dysentery has sometimes been the pulmonary abscesses. Besides washing out the bowel for the sake of cleanliness, injections of starch-water and laudanum have been beneficial in lessening the number of evacuations.

In the present case the outlook is a very serious one. With hiccough and great prostration in spite of the fact that everything has been done to support his vitality, with the poisoning going on continually, and with the probability that abscesses have formed in other parts of the body, the lethal result is daily expected.

I am very glad to show you this case, for the disease, though more wide-spread than was believed a few years ago, is, in this section, still rare. But it is necessary for you to be able to recognize even the infrequent diseases, for your practice will not be limited to common affections. I am certain that I have seen a number of cases of amoebic dysentery, especially when physician to the penitentiary, where there were many prisoners from the South, and these cases passed unrecognized simply because I was unacquainted with the disease.

[Note.-This patient died three days after the delivery of the lecture. The changes in the colon and liver, as revealed by the autopsy, corresponded with the description above given.]

ENDOCARDITIS AND PERICARDITIS; EXOPHTHAL

MIC GOITRE; EMPYEMA; NERVOUS JAUNDICE.

CLINICAL LECTURE DELIVERED AT THE CHICAGO POLICLINIC.

BY JOSEPH M. PATTON, M.D.,

Professor of Clinical Medicine in the Chicago Policlinic, etc.

ENDOCARDITIS AND PERICARDITIS.

GENTLEMEN, This young lady is seventeen years of age. She had always been healthy, until about six weeks ago, when she was taken with manifestations of acute rheumatism, located in the joints, which, her physician tells me, pursued no unusual course. About a week after the commencement of the rheumatic attack I was called to see her in consultation because of the symptoms, which were attributed to her heart. Three or four days before I was called to see her she had developed a systolic murmur in the region of the aortic valve. The murmur had the usual characteristics of aortic stenosis. The heart was rapid and excitable, but there were no unusual manifestations until the time I saw her, a few days later. At that time, the physician in charge noticed that the previously strong, energetic beat of the heart had become less perceptible, and the motion more heaving and undulating in character. The heart seemed to work harder, and there was more dyspnoea. At the time that I saw her, the temperature was about 100.5°, the pulse was rapid and irregular, and there was considerable dyspnoea, but no cough.

Examination of the heart showed that the area of motion was increased, the apex-beat could not be distinctly located, the motion was rather heaving and undulating in character, and extended all over the cardiac area. The heart was evidently working hard and energetically, and yet the previous well-defined apex-beat was lacking. Percussion showed that the dulness extended from the second intercostal space to the sixth, and from one-quarter of an inch to the right of the sternum along the right parasternal line to about the left nipple-line. The dulness was wider below than above. Auscultation showed a blowing,

systolic murmur in the aortic area, which was transmitted into the vessels of the neck, and which was evidently an aortic stenosis caused by rheumatic inflammation about the aortic valve. The murmur was not nearly so distinct as it had been a few days previous. The first sound of the heart was muffled and indistinct, although the heart was laboring with considerable force. At the base of the heart there could be heard at times a harsh, rubbing double sound, which was evidently a pericardial friction-sound. A diagnosis was made of endo- and pericarditis, of a rheumatic nature. She was kept on anti-rheumatic treatment; a blister had been applied to the pericardial region, and it was allowed to remain until it had acted sufficiently. In the course of a week the area of dulness had decreased markedly. The heart was not laboring so strenuously, the friction-sound at the base was more apparent, and she was improving in every respect, and went on to recovery. I show her to you to-day because you may still hear the dry, rubbing friction-sound at the base of the heart, but not so clearly as it could be heard a week ago.

These cases of combined inflammation of the endocardium and pericardium in the same subject are somewhat rare. They are usually associated with rheumatism.

The diagnosis is usually not very difficult, especially when you get the signs of effusion as clearly as they were obtained in this case; but where the two conditions are associated, it may be difficult to distinguish between an endocardial and a pericardial murmur. Endocardial murmurs are softer, and are either systolic or diastolic. Pericardial murmurs are harsher, more apt to be rubbing, and are usually double. They are not transmitted, and they are apt to disappear sooner than endocardial murmurs. Small amounts of fluid in the pericardial sac may be difficult to recognize; large amounts, sufficient to distend the sac, will increase the area of dulness in a direction unlike that given by enlargement of the heart itself. The dulness may extend as high as the first rib and as low as the sixth, and from an inch to the right of the sternum to the left of the nipple, but usually the limits are much more circumscribed than this. The dulness is more or less pyramidal in shape, being wider at the bottom. There may be some change in the lines of dulness when the patient changes position. Dulness in the fifth intercostal space to the right of the sternum is stated by Rotch to be diagnostic of even very small effusions, and to be a valuable diagnostic sign. Roberts also states that this sign is of value where aspiration of the pericardium may be demanded.

Effusion into the pericardial sac may be confounded with pleural

effusion, but the dulness of pleural effusion will extend lower, and farther around to the side and back. The respiratory sounds in the infra-scapular region in the back are very seldom interfered with, except in very large pericardial effusion; whereas in pleurisy they will be modified by small effusion. The valuable point in diagnosing between these two conditions would be the displacement of the apexbeat, which nearly always occurs with pleural effusions, even if they be small in quantity and circumscribed.

The diagnosis between these two conditions, of course, would be between effusion in the left pleura and effusion in the pericardium; and therefore this displacement of the apex-beat in pleural effusions is a decidedly valuable sign.

The question of aspiration of the pericardium will occasionally present itself in these cases, and in deciding the necessity of such a procedure you must bear in mind that rheumatic effusions into the pericardial sac tend to get well of themselves, and usually the fluid disappears about as rapidly as it came; therefore they are to be treated conservatively, and not interfered with unless the danger to the heart is imminent. If the pressure of the fluid on the heart so interferes with the action of that organ as to produce great dyspnoea and failing circulation, the sac should be aspirated. This is best done by an ordinary aspirator, or by a small one, where the current can be reversed. The needle should be entered from half an inch to an inch to the left of the sternum, in the fifth intercostal space, in a direction backward and upward. As soon as the needle enters the tissues, the vacuum should be turned on, and the needle then advanced in search of the effusion. Sometimes the fluid can be reached by inserting a needle at the apex of the notch between the xiphoid appendix and the cartilages on the left side. It is possible that some cases may be aspirated immediately to the right of the sternum, but this must be the exception.

nose.

An interesting prognostic question in regard to these cases is the liability to permanent adhesion between the two surfaces of the pericardium. This is a condition which we are practically unable to diagThere are no positive signs of its occurrence. Some writers have designated signs for the recognition of its occurrence, but they are more or less unreliable. Hope has stated that an irregular, jogging, trembling motion, very abrupt in its character, is distinctive of adhesions between the two surfaces of the pericardium. Aran has claimed that in this condition there is a loss of the second sound. We often see cases where both of these conditions are present and yet adhesion has not taken place. Perhaps the most reliable sign is that

given by Skoda, where there is systolic retraction of the intercostal spaces, and perhaps, also, some depression of the lower end of the sternum. There is apt to be arhythmia associated with adhesion of the pericardial surfaces, but it is not in any way distinctive, and I have seen cases where this condition has obtained, yet in which none of these signs were present during the life of the patient. Where the pericardium has become adherent to the sternum this adherent condition has been termed indurated mediastinal pericarditis. Bands from these lesions may compress the aorta, and resulting from these conditions Kussmaul has described the pulsus paradoxus,-a pulse which disappears with full inspiration. Traube has noticed this sign in cases where the mediastinum was not involved.

This young lady, while the pericardial friction-sound can yet be heard, is rapidly improving: the sound is growing weaker. The endocardial murmur still remains, and in all probability the aortic valve has been permanently affected. How much the blister had to do with the improvement in her case it is difficult to say. Blisters are objected to by some writers for this disease, and very often we see them entirely fail. We will continue her for some time on antirheumatic remedies, such as sodium salicylate and potassium iodide, with iron, arsenic, and strychnine as general tonics.

EXOPHTHALMIC GOITRE.

This young lady is twenty-one years of age. She has never suffered from any special illness previous to the present one, although her menstruation developed early and was never very regular. She has been suffering from some dysmenorrhoea, with, at times, a little menorrhagia, but not enough to demand any treatment for either of these conditions. She says that about four months ago she began to notice some palpitation of the heart. This troubled her at intervals,-more when under excitement or mental strain than on exertion. About a month after this she began to notice some prominence of the eyes, and about the same time her attention was called to some enlargement of her throat. While these two symptoms developed about the same time, she thinks that the prominence of the eyes was present before the enlargement of the throat. The latter symptom, she tells us, was first noticed after some unusual mental excitement, and developed within the space of two or three days to the size which we see presented now. The thyroid, you notice, is quite large,—somewhat larger on the left than on the right side. It is not very firm. There is no murmur present in the gland. Examination of her heart shows it to be