ACUTE ENDOCARDITIS WITH VALVULITIS. 565 



matoid inflammations exist, or where certain septic states of tlie 

 blood are present, and where undoubted cardiac disturbance 

 shows itself, either by peculiar and tumultuous action of the 

 heart and blood-flow in the vessels, or where abnormal sounds 

 may be detected in connection with the fimctional play of the 

 organ, we may be pretty certain that a diseased condition of 

 its fibrous and fibro-serous structures is going on; the difficulty 

 may be to determine whether the exocardial or endocardial 

 disease is in ascendency. 



Inflammation of the endocardium, as it largely affects the 

 valves of the heart, is usually followed by structural changes 

 connected Avith these ; also as a sequel of this valvular change, 

 with dilatation and alteration in the capacity of the cavities of 

 the heart, and with the consequent attendant symptoms of 

 certain of these changes, weakened cardiac action and dropsical 

 effusions in different parts of the body. 



Treatment. — The most important features of endocarditis, 

 both as respects frequency of occurrence and severity of 

 attack, are, as already noticed, associated with its connection 

 with rheumatism, rheumatoid inflammations, and some other 

 states of blood-contamination. In the treatment of this in- 

 flammation m such conditions it will be better to concentrate 

 our attention on the constitutional or general disturbance than 

 on this cardiac lesion, which is better regarded as a sequel or 

 S3rmptom of the primary and more extensive ; while it wiU 

 be found that in direct proportion as the general diseased 

 condition shows itself amenable to treatment, so will the 

 local and secondary morbid action in cardiac structures be- 

 have itself. 



In a general way it may be said that treatment of a nature 

 much similar to what has been recommended for pericarditis 

 is to be carried out here ; probably, m endocarditis, the good 

 results of blood-letting, even in the earlier stages, are less likely 

 to be unmixed with evil than in inflammation involving the 

 other great ffbro-serous membrane of the heart. Bleeding may 

 give temporary relief, but is apt, by lowering the tone of the 

 heart's action, to favour the production of fibrinous excres- 

 cences on the valvular and tendinous structures of the cardiac 

 cavities. For the same reason the employment of direct 

 cardiac sedatives, although indicated where the irritability and 



