VALVULAR DISEASES OF THE HEART AND ENDOCARDITIS.
Endocarditis.
Definition.—Inflammation of the mem brane lining the cavities of the heart. The process may be acute or chronic. The acute form is variously described as "simple," "benign," or "verrucose," and "ulcerative," "septic," or "malignant," according to the mildness or severity of the disease; but between these two forms there is in reality no dividing-line. The disease attacks mainly the valves of the heart.
Acute Endocarditis.
Symptoms.—The onset of acute endo carditis is insidious. There may be no symptoms which call especial attention to the organ affected. There may be a slight rise of temperature, and some quickening, and possibly some irregu larity, of the pulse. In the benign form there may be no evidence of the disease until two or three months after it has run its course, when impairment of the valves is detected. In some cases there is pnecordial pain, or, if the patient is a child, there may be epigastric distress, with vomiting. The pulse is of low ten sion, and the patient may be restless and anxious, and may prefer a somewhat re cumbent to a horizontal position. Ex amination of the heart will disclose in most cases a murmur, usually of a blow ing character, and usually systolic in time. It may accompany or replace the normal sound. Even in the malignant form the symptoms may be masked by those of the original disease. In the severer eases sometimes there is a true chill or a succession of chills; and the fever may be either typhoidal or inter mittent or remittent in its character. The patient gives evidence of great pros tration. The pulse is rapid and irregu lar; the body bathed in profuse per spiration; the spleen enlarged and ten der. There may be a rose-colored erup tion upon the body; more often petechice are seen. The number of white corpus cles in the blood is greatly increased.
In some cases, even the worst, careful and repeated examination by competent observers may detect no cardiac murmur whatever.
The simple form may give rise to embolism in different parts of the body, and may also be complicated by pleurisy or pneumonia. The malignant form is still more apt to give rise to emboli than is the simple form, and also frequently distributes infection. In fact, scarcely
any tissue is exempt from these dangers. Thus, there may be embolism of the femoral or external iliac arteries, or of the capillaries of the skin. There may be infarctions in the spleen, causing a swelling and tenderness of that organ; in the kidneys, giving rise to renal hem orrhage; in the brain, with resulting paralysis or softening; in the intestines, , with bloody stools. The retina, conjunc tiva, gums, parotid gland, and stomach may be affected. In some cases there is acute jaundice, with symptoms simulat ing acute yellow atrophy of the liver; and, as just stated, these lesions are not merely mechanical, but infectious, and apt to give rise to suppuration.
When acute endocarditis is due to re currence of inflammation in a valve pre viously fibrotic, abscesses are unusual.
The duration of the disease in the milder eases is usually from two to six weeks, perhaps in most instances about four weeks. The malignant cases may reach a fatal termination in one or two days; or again, they may be prolonged for several months, or a year, and then prove fatal. Some cases of simple endo carditis are not suspected during their course nor betrayed by segue* thus, minute vegetations may be found, post mortem, upon the valves of patients who die of consumption or of carcinoma, which have been of no importance what ever. The great harm that simple endo carditis does the patient is not imme diate, but consists in laying a foundation for ultimate changes in the valves, which impair the functional integrity of the heart.
Diagnosis.—The first question to settle with regard to diagnosis is whether any endocarditis exists at all, and, secondly, whether the form is simple or malignant. There may be no objective cardiac signs distinctive of the disease. how ever, there is a systolic apical murmur, and the heart is enlarged, with a more widely diffused impulse than normal, and an excited—though feeble—action.
It should be borne in mind that many of the diseases with which acute endo carditis is etiologically associated give rise to functional cardiac murmurs; so that the mere discovery of an abnormal sound over the heart does not establish the diagnosis.