PRIMARY TUBERCULOUS ENDOCARDITIS DIAGNOSED DURING LIFE.

551 *’ charity organisation" proceeds are capable of beingswollen. On the 20th there were cough, muco-purulent followed in the administration of the Poor-law. People are expectoration, and large subcrepitant rales. On the 7 the patient had a"stitch"in the right side and apt to overlook the fact that the ends are different in the two26th cases. Something, of course, the two methods have inat the right base there were numerous fine subcrepitant common and, in so far as Poor-law officers fall short of ther6.les and slight dulness. Then the case took a new aspect. high standard which on rather insufficient grounds Sir W.The temperature, which had gradually fallen since Feb. 15th, Chance describes the societies, as attaining, this is due to the remained permanently below 100’ 4° after March 5th, while much larger number of cases with which guardians and their at the same time the frequency of the pulse increased until officers have to deal. But a parting of the ways is soon it reached from 120 to 140. The quantity of urine fell to reached, owing to the fact that whereas a private cor- from one-half to three-quarters of a litre in the 24 hours poration may, if it so please, treat as’’undeserving"" and there was much albumin in it. On the 12th cedema any particular section of the community a board of of the legs began. The liver extended below the ribs and guardians would not be fulfilling the duties which the law the apex of the heart was displaced downwards and outhas allotted to it if it attempted to disregard on sentimental wards. There was dyspnoea but of a different kind to that grounds the demands of even the most unworthy. Offenders previously described. The respirations were from 30 to 40 ; against conventional morality cannot be left to starve, if inspiration was deep and difficult, all the inspiratory muscles only for the simple reason that the starving are a stand- being contracted to the maximum. There were nocturnal ing menace to the community that includes them. It is attacks of suffocation. All over the chest large subcrepitant because voluntary charity did not suffice to meet the needs of râles were heard and were accompanied by slight dulness. the position that we have a Poor-law system, and this system The dyspnœa became so extreme that the patient passed is a political rather than a charitable one. The poor-rate is the days and nights seated in a chair, his face cyanosed Death occurred an instrument of intra-national defence on a par with the and covered with cold perspiration. military and naval estimates, upon which depend inter- on March 30th. The diagnosis was very difficult. Tubernational safety. Until we employ the lethal chamber for the culosis and typhoid fever were suggested ; the latter was disposal of such of the unfit as are not sufficiently excluded by the evolution of the attack as well as picturesque to excite popular sympathy we must have funds by the serum reaction. Blood obtained by puncture provided by the State to fill the gap which is left by the of a vein on Jan. 22nd, Feb. 15th, and March 27th yielded charity organisation societies, and while there is room enough the tubercle bacillus on cultivation and guinea-pigs for these they show no signs of rendering Poor-law establish- inoculated with the fibrin contracted tuberculosis. At ments superfluous. the necropsy on the patient the absence of tuberculosis from all the viscera except the heart was proved by PRIMARY TUBERCULOUS ENDOCARDITIS microscopic as well as by macroscopic examination. There were extensive pleural adhesions. Scattered through the DIAGNOSED DURING LIFE. The heart was hyperwere numerous infarcts. lungs TUBERCULOUS endocarditis has been found at necropsies. The aortic and mitral and tricuspid valves showed It has been regarded as a rare lesion which may occur in trophied. vegetations which contained the tubercle bacillus. The cases of tuberculosis of other organs but has never entered liver, spleen, and kidneys were swollen from passive into the sphere of the clinician. At the meeting of the This case shows the value of bacteriological Societe Medicale des Hôpitaux of Paris on July 3rd M. congestion. examination of the blood in tuberculous patients suffering Braillon and M. André Jousset related a most important case from endocarditis and in patients apparently not tuberculous under the care of M. Babinski in which tuberculous endofrom endocarditis the nature of which is obscure. carditis was for the first time diagnosed during life by suffering examination of the blood. Moreover, the tuberculosis was THE FRAUENSPITAL AT ZÜRICH. primary and accompanied by " tuberculous septicaemia " and the patient died from the cardiac lesion. Previously it was HOSPITALS may be classified in various ways according to taught that in tuberculous endocarditis the patient died with the systems on which they are conducted and the purposes the lesion, not from it. A male nurse, aged 22 years, which they are intended to serve. They may, for instance, was admitted to hospital on Jan. 2nd, 1903. Since be either general or reserved for special forms of disease, they Dec. 26th, 1902, he had been suffering from lassitude may be supported either by voluntary contributions or out and fever. There was marked dyspncea; the respira- of the rates, they may be free to all who obtain admission tions were from 60 to 65 and shallow. Examination of the or they may receive both paying patients and non-paying lungs was almost negative. Only some disseminated ex- patients. Some admit only males, some admit only females tremely fine subcrepitant rales were heard at the middle and young children, and others, like seamen’s hospitals, are The sounds of the heart practically restricted to certain classes of the population. and posterior part of the chest. were very muffled. The temperature oscillated between In another column (p. 561) of our present issue we 100.4° and 103.6° F. and the pulse between 80 and 90. The publish an account of a hospital which combines a variety Its principal departure from British urine was albuminous. From Jan. 10th to 15th there was of special features. the of urine passed in the 24 hours ideals consists in the fact that only paying patients are quantity polyuria, varying from three to four litres and the albuminuria dis- received, although a large part of the funds required for Then the quantity of urine passed became establishing it were raised by voluntary subscription. In appeared. normal. On the 15th a slight systolic murmur was heard this country the existence of a subscription list would almost at the cardiac apex. It gradually became more intense necessarily imply at least a preponderance of free admisand by the 22nd assumed all the characters of a mitral sions as compared with the number of paying patients and regurgitant murmur. On the 18th the dyspncea began to some administrative ability would be required to make the diminish and by the 22nd the respiration was normal. dual arrangement work harmoniously. The hospital in On the 24th the morning and evening temperatures were question has about 60 beds and is situated in the immediate The improvement was vicinity of Zurich, a city of about 150,000 inhabitants and 100.4° and the pulse fell to 60. It maintained until Feb. lst, when the fever reappeared and the principal centre of population in Switzerland. became continuous, but the respiration remained normal. is for females only and the majority of the cases From the 12th to the 26th the large joints of the! are either obstetric or gynaecological. The patients’ payupper limbs were spontaneously painful and very tender ments vary from two francs to ten francs per diem and 718 on the least movement. They were neither red nor patients were admitted during 1902. In different countries -

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