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[May 1 6, 1896 viagra prescription strength INTRA-UTERINE FCETAL ENDOCARDITIS. In addition to various malformations of the heart and defects of development, the new-born infant may pre- sent evidences of endocarditis of intra-uterine or pre- natal origin. Under such circumstances almost in- variably the right side of the heart is affected, in consequence of being the more active during fcetal life, just as the left side is usually involved when the endo- carditis occurs during post-uterine existence. The most recent instance of this localization is reported by Brindeau,' who details the case of an infant dying a few hours after birth and presenting post-mortem evi- dences of tricuspid valvulitis with insufficiency. The child was born at term of a mother twenty-two years old, in excellent health, free from infectious diseases during pregnancy, and without a history of syphilis or rheumatism. The child was well developed, except for its head, which though well ossified was dispro- portionately small. Respiration was evidently inter- fered with and the face was deeply cyanotic. In the submaxillary region upon either side was a regular, soft tumefaction, as large as an egg upon one side and as a walnut upon the other, yielding on pressure, but resuming its original fulness on removal of the pres- sure. Each presented viagra prescription strength pulsation and appeared to com- municate with the other. Auscultation disclosed a bruit viagra prescription strength synchronous with the cardiac systole. The child lived only a few hours after birth and the post-mor- tem examination disclosed a condition of tricuspid insufficiency. The heart was greatly enlarged, prin- cipally at the expense of the right side, and almost en- tirely filled the viagra best thing thoracic viagra best thing cavity. Puncture of the right auricle permitted the escape of a large quantity of blood, with viagra best thing the disappearance of the tumor upon either side of the face. The superior vena cava was greatly dilated and the jugular vein in even greater degree. The latter viagra prescription strength formed the facial swelling. All of the com- municating veins were likewise dilated. The wall of the auricle was thinned, but that of the ventricle was thickened, exceeding viagra best thing even the thickness of the left ventricle. The tricuspid orifice was greatly dilated, permitting the introduction of the whole hand. The valve leaflets were thickened, shortened, and incom- petent. The pulmonary orifice displayed no abnor- mality. The orifice of the superior vena cava was en- larged; that of the inferior was normal in size. The foramen of Botal was closed; the ductus arteriosus was obliterated. The left side of the heart presented no abnormality. Histologic viagra best thing examination of the tricuspid valve disclosed a round-cell infiltration in process of fibrous transformation, but without the presence of mi- cro-organisms. Zariquiey' has reported a case of tricuspid and pul- monary obstruction and insufficiency, with right-sided ventricular hypertrophy, in an infant dead at the age of eleven months, which presented at birth cyanosis and a soft, prolonged cardiac murmur following the first sound of the heart, and occupying the period of si- lence. The murmur viagra prescription strength was audible over the whole car- diac area, though heard with greatest intensity at the 1 Journal de Mcdecine de Paris, l8g6, No. 13, p. 150. Maladies de l'Enfance November, 1894, p. 620. left base, and was propagated toward the left clav- icle. Railton ' has reported the case of a boy who died at the age of four years, and presented, in addition to a deficiency of the interventricular septum and right- sided hypertrophy of the heart, old tricuspid valvulitis, which was believed to be of prenatal origin, together with recent endocarditis, which was assumed to be a continuation of the original process. That a pregnant woman suffering from infectious disease may give birth, prematurely or at term, to a child suffering from the same disease has long been recognized; and recent experience demonstrates that the transmission takes place through the placenta. We have also learned that any infectious process is capable of viagra prescription strength causing endocarditis. It may thus happen that the pregnant woman is attacked with rheumatism, or typhoid fever, or influenza, or pneumonia, or other infection, while her unborn infant, though possibly escaping the primary disease, is the victim of an in- flammation of the endocardium of the right side of the heart, the consequences viagra prescription strength of which persist throughout life. THE CONDITION OF THE STOMACH IN PERNICIOUS AN. KM I A. Whether or not anaemia may be primary in the sense of originating in modifications of the normal processes of hamogenesis and haemolysis is a question that we are not prepared to discuss here. Of its pos- sibility there can be little denial, although demon- strable proof may be wanting; and it is a well-recog- nized clinical fact that in a considerable number of cases of profound and even fatal anaemia an adequate cause of the blood state may elude detection. The fact likewise must not be ignored that recovery often but transitory, though sometimes, perhaps, permanent may take place in cases presenting the typical clinical picture of pernicious anamia. In a number of these .mm:s it is not unlikely that destructive changes are induced in the blood as a result of processes that take place in the stomach and intestines as a result of mo- tor and secretory insufficiency. By reason of such con- ditions not only is the nutritive supply curtailed and the blood thus deprived of the elements necessary for its regeneration, but also is viagra prescription strength opportunity afforded for viagra best thing the development of chemic products capable when ab- sorbed into the blood of exerting directly deleterious effects, and thus leading to increased destruction. Whether, however, these two factors are sufficient alone to induce viagra prescription strength the lesions and bring about the train of symptoms constituting the clinical picture of per- nicious anamia, is yet to be determined. viagra best thing That they may act at least as contributing influences on any giv-