ENDOCARDITIS. 



349 



1st with a reduction of the energy of the heart, which may fairly be at- 

 tributed to its infiltration with serum, the pulse is frequently small, and 

 the fever assumes the character of extreme adynamy, so that it be- 

 comes liable to be mistaken for other asthenic fevers, typhus, etc. 

 The statement that an unobserved endocarditis is the source of many 

 fevers spoken of as nervous, febris simplex, versatilis, torpida, putrida, 

 etc., is an exaggeration, as the disease seldom takes the latter form. 

 When endocarditis is attended by metastasis, especially metastasis to 

 the spleen, the fever becomes aggravated, and rigors occur, but the 

 presence of septicaemia cannot be inferred from such symptoms alone, 

 since both of them arise (although they are not constant) when 

 metastases form in the spleen, from the detachment of clots, or frag- 

 ments of the valves, in cases of long-standing valvular disease, where 

 septicaemia is out of the question. 



Palpitation of the heart is a more common symptom than excite- 

 ment of the pulse. THe reason for this is at once clear, when we re- 

 member that the action of the heart is always embarrassed by infiltra- 

 tion of its muscular substance, and that palpitation is .usually com- 

 plained of the most when the performance of its function has become 

 laborious, as well as excessive, and that it does not proceed from the 

 abnormally vigorous action of the hypertrophied heart. This serous 

 infiltration of the cardiac muscles, which sometimes arises in endocar- 

 ditis, and the consequent debility and imperfect action of the heart, 

 also account for the dyspnoea which accompanies the palpitation. 



In the chapter upon hyperaemia of the lung, we have explained 

 why these symptoms are attended by passive hypersemia. If insuffi- 

 cience of the mitral actually be established while the endocarditis is 

 still in progress, if blood be regurgitated into the auricle during the 

 systole of the ventricle, the venous engorgement of the lungs and the 

 dyspnoea are all the more severe. 



From what we have said regarding the symptoms of endocarditis, 

 especially from the fact that, in a great number of cases, there is abso- 

 lutely no disturbance of the functions, it will readily be perceived that 

 the malady seldom runs its course in a well-defined manner, like in- 

 flammation of other important organs. Neither does the commence- 

 ment of the disease often admit of detection, nor can its progress often 

 be followed up, nor, to say the truth, can we well fix the point where 

 endocarditis ceases, and that malady begins which we call valvular 

 disease. Disease of the valves is indisputably the most common 

 sequel of endocarditis, the valves either remaining thickened, and 

 afterward shrinking, or the chordae tendineae and edges of the valves 

 adhering, or rupture of one or other of these parts occurring. As re- 

 traction of the thickened valves commences gradually, and progresses 



