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absorption of the products of intestinal putrefac- tion. Imperfect aeration of the blood in the em- barrassed lung makes for suboxidation in the tis- sues and clogging of bunko bonanza casino the circulation with the pro- ducts of imperfect combustion. And if the circula- tion fails the elimination of toxines is lessened. Interest specially centres on the specific toxaemia. What we particularly desire to know is the extent to which the specific toxaemia disturbs the heart: Does the pneumotoxine act regularly as a notable heart poison, and has it a special antipathy for the cardiac apparatus like the specific toxine of diph- theria and influenza? In the general run of cases, in the majority of cases, does the specific toxsemia cause serious disturbance -or degeneration of the nervomuscular apparatus of the heart? Facts throwing any light on this difficult and complicated subject are scarce. The following, considered together, are at least suggestive: 1. As has been stated, the living pneumococcus does not in a pure culture produce a strong, soluble toxine, and we assume the same condition to hold in the human body. We know that in many or most cases of pneimionia the pneumococcus gets into the blood. We conclude that the amount of the specific toxaemia depends on the number of pneumococci in the blood which escape the phago- cytes and die a natural death ; for it is from dfsso- lution of the dead bacteria that the toxine is proba- bly derived. This conclusion harmonizes with the observation that when there is a high leucocytosis severe toxaemic manifestations are less likely to ap- pear than when the leucocytosis is slight or absent. 2. Clinically we are familiar with a tolerably large group of cases of pneumonia in which the heart seems to be overwhelmed by the toxsemia, and sometimes in an early stage of the disease. Ther' is also a group, first described by Romberg and Passler. in which failure of the heart seems to be secondary to great dilatation of the arteries, par- ticularly in the splanchnic area, apparently caused by toxsemic paralysis of the vasomotor centre. 3. As a very rare occurrence, which may be a result of toxaemic disturbance, but i? not necessarih so, we find sudden failure of the heart after defer- vescence, sometimes several days after, when the patient is apparently in good condition. I have seen one such case, in which the patient died sud- denly from heart failure five clays after defer- vescence. There was no discoverable cause for this accident, unless it may have been the ammoni- um carbonate which the patient had been taking steadily in five grain doses ever}- four hours for over a week. 4. In perhaps the majority of cases in which there is no preexisting myocardial bunko bonanza free play weakness, we find the left ventricle maintaining an approximately normal blood pressure until after the failure of the right ventricle has diminished the supply of blood which it receives. In fact, in very many cases the left ventricle does not in its action indicate any dis- turbance of its muscle or nerve connections that can be ascribed to a toxaemic cause ; it acts quite as well as could be expected in view of the mechan- ical difficulties under which its partner on the right is laboring-. Witness Delafield on this point: "At about the fourth day of pneumonia we find only too often that the bronchi and lungs are beginning to fill up with mucus and serum. This is a most unfavorable symptom. The failure seems to be on the part of the right heart." Again Delafield says: "It seems to be failure of the right ventricle which causes the venous congestion and oedema of the lungs. It is curious in some cases to observe a good radial pulse at the same time with evidence of failure of the right ventricle." W. G. Thomp- son says : 'Tt is a curious fact that patients in an advanced grade of cardiac valvular disease some- times bear pneumonia much better than one would expect." The wonder in these cases is lessened if we suppose that the left ventricle suffers no tox- aemic weakening; if the right heart does not fail, the left has no reason to be disturbed, provided its defective valvular action was originallv compen- sated. 5. In a majority of cases we find that the thin walled right ventricle maintains an abnormally high blood pressure, which is shown by the accentuated closure sound of the pulmonary valves ; and when the right ventricle does begin to fail we usually get such a response to stimulation as we would expect under the circumstances bunko bonanza 2 from a relatively sound myocardium, and not from one vmdergoing toxaemic degeneration. 6. Osier says : "A bunko bonanza slot review patient with complete consoli- dation of one lung may show no signs of a general infection." The suggestion made by the foregoing facts seems to be, that while the specific toxaemia is the effective cause of heart failure in a certain propor- tion of cases of pneumonia, in a larger proportion, perhaps the majority, it cannot be considered a powerful primary factor in disturbing the heart. In the majority of cases of pneumonia with origi- nally healthy hearts, the picture presented seems to resemble more a struggle against a mechanical ob- struction in the lesser circulation than it does the bad action of a heart which is undergoing toxseniic degeneration and paralysis. And in the cases in which the heart does fail from intrinsic weakness instead of from exhaustion of the right ventricle by overwork, it is not always easy, as Mackenzie says, to distinguish between those due to direct in- vasion of the heart by the pneumococcus and those due to general infection. A partial explanation of this difficulty lies in the fact that acute pneumonic pericarditis, endocarditis, and myocarditis often ex- ist without giving distinctive signs. Looked at from the clinical standpoint, a closer resemblance seems traceable between pneumonia and the streptococcus and staphylococcus infec- tions, as regards the anticardiac manifestations of their bunko bonanza online toxaemia, than between pneumonia and those infectious diseases like diphtheria and influenza, whose specific toxines are regularly serious dis- turbers of the heart. In a streptococcus or staphy- lococcus infection the local lesion, though it may be attended bunko bonanza game with constitutional symptoms, is not CORNWALL: HEART IN PNEUMO\UA. 73 regularly attended with serious toxsemic heart dis- turbance; it is onlv bunko bonanza slot when pronounced septichaemia occurs that the heart is apt to suffer. So in pneu- monia, the pneumococcus septichaemije, which oc- curs in marked degree only occasionally, seems to be the toxaemia that gravely disturbs the heart and vasomotor system. In this conception of the heart as always over- taxed on its right side and always in danger of failure from exhaustion of the right ventricle, and occasionally subjected to a severe disturbing tox- jemia. we find our main indications for treatment, pending further developments along the line of se- rum and vaccine therapy, along which line hope continues to beckon in spite of disappointments. In the light of our present knowledge a case of pneu- monia, from the therapeutic viewpoint, appears es- sentially a heart case, in which the regular problem is to support the heart until a temporary obstacle in the pulmonarj' circulation is relieved, and in

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