ENDOCARDITIS. 353 



mg sound, audible at tlie apex. The symptom may, indeed, be due to 

 thickening of the valve by inflammation, but it is quite as likely to be 

 dependent upon mere abnormal tension of a healthy valve, caused by 

 violence of fever or irregular action of the heart. Neither condition 

 can be determined from the quality of the murmur, and diagnosis re- 

 mains a matter of doubt until the signs of dilatation of the right ven- 

 tricle and overloading of the pulmonary artery, lateral extension of 

 cardiac dulness and intensification of the second pulmonary sound, 

 Bupervene upon the murmur. 



The differential diagnosis is still more difficult between a recent 

 endocarditis complicating articular rheumatism and an old valvular de- 

 rangement, which happens to preexist, especially insufficience of the 

 mitral. Such cases are by no means rare. There are few maladies 

 which have so great a tendency to relapse as acute articular rheuma- 

 tism ; indeed, we meet with sufferers who have had attacks of it, of 

 more or less severity, every year since its first onslaught. If we have 

 not previously seen or examined them, and if upon some fresh relapse 

 we hear a systolic blowing at the apex, the cardiac dulness extending 

 laterally, and the second pulmonary tone being sharply accented, we 

 must remain in doubt, unless the signs of dilatation of the right ven- 

 tricle have attained such a height as cannot be ascribed to acute in- 

 sufficience. In other cases we may perhaps ascertain if, after any of 

 his previous illnesses, the patient have remained short of breath, etc. 



PROGNOSIS. Rarely as life is threatened by endocarditis itself, the 

 prognosis of this malady as to complete recovery is bad. Indeed, in 

 the cases in which the disease is recognized, it almost always leaves 

 derangements behind it, which sooner or later imperil life. Endocar- 

 ditis, which attacks the wall of the heart, is, no doubt, far less dan- 

 gerous ; but it occurs rarely, and, moreover, is quite unrecognizable. 



Symptoms which would lead us to fear an unfavorable termination 

 to this disease are those which indicate considerable implication of the 

 muscle of the heart in the inflammation, such as an extremely frequent 

 pulse with scanty filling of the arteries. Rigors are quite as ominous, 

 ndeed more so, as well as acute swelling of the spleen, or pain in that 

 region, vomiting, or the appearance of blood or albumen in the urine, 

 or symptoms of hemiplegia, in short, the signs of metastasis. 



TREATMENT. The indication as to cause in treatment of endocar- 

 ditis cannot, as a rule, be met. A genetic connection undoubtedly ex- 

 ists between acute articular rheumatism and this disease, whether the 

 former merely predispose to the latter, or whether the alliance be still 

 more intimate. Great, however, as is the number of remedies and 

 modes of cure recommended for rheumatism, it is only equalled by 

 lieir untrustworthiness. We are no less helpless against the morbus 

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