2. In other cases, under the same circumstances, a state of extreme anæmia occurs. These, too, not unfrequently recover eventually. The restoration, however, is necessarily very tedious, and full of anxiety.

When either of these conditions, whether of nervous exhaustion or of sanguineous impoverishment, is present, oedema of the feet and ankles often makes it appearance. Nay, the dropsy sometimes becomes general. But even then, the effused fluid may become absorbed under the use of appropriate remedies, and every trace of disease, save of a slight cardiac lesion, may be ultimately dissipated.

3. Symptoms of most grave disorder in some portion of the cerebrospinal axis may occur in a patient, after his having passed through the acute stage of pericardial or endocardial inflammation, and suddenly carry him off, when everything promises the fair prospect of his speedy recovery.

"Coincident with symptoms referable to the endocardium or pericardium, in one case there has been maniacal delirium, in another epileptic or tetanic convulsion, in another chorea, in another coma, in another fatuity. The patients have died, and dissection has found the brain healthy, and the spinal marrow healthy, and the endocardium and the pericardium alone inflamed. Now, have all the experiments that were ever done or perpetrated upon living animals given intimation of an influence like this, proceeding from the heart to the brain, and from the heart to the spinal marrow; Has not disease here been our teacher ?

"All these affections of the brain and spinal marrow, coming on in the course of inflammation of the heart, should be carefully watched and ministered to from the least to the greatest. Wild delirium, epileptic, or tetanic convulsion, chorea, coma, fatuity, are the greatest and the rarest; and mutterings, reveries, transitions from torpor to excitement, subsultus, are the least and the most frequent. But they are all akin one to another. The least may mount up to the greatest, and the greatest run down to the least.

"Moreover, where any of these have been during the progress of the disease, and the patient has survived, they are liable to be continued or to recur during its reparation. Or they may then arise for the first time, as if they took advantage of the weakness and exhaustion of the nervous system."-P. 19.

How

These attacks of Cerebral mischief, occurring during the continuance of, or the convalescence from, cardiac inflammation, very generally prove fatal. Their pathological history is far from having, as yet, been satisfactorily made out. The necroscopic appearances of the encephalic contents have been, in not a few instances, obscure and inconclusive. strikingly was this true in the case of suppurative inflammation of the muscular substance of the heart, quoted by Dr. Latham from an early volume of the Medico-Chirurgical Transactions:-"A boy, twelve years of age, was in perfect health on Saturday night and dead on the following Tuesday afternoon at two o'clock. He had, in the opinion of all who saw him, the severest inflammation of the brain. The attack was sudden with great heat and frequency of pulse. He had delirium and convulsions, and pointed to his forehead as the seat of his pain. At length he sank into a state of insensibility and died. Upon dissection, not a vestige of disease was found within the cranium, but the heart was the seat of the most intense inflammation pervading both the pericardium and the muscular substance. Four or five ounces of turbid serum with flakes of coagulable lymph floating in it were found in the cavity of the pericardium, which had its internal surface covered in various situations with a thin layer of

1847]

Secondary Endocarditis and Pericarditis.

35

reticulated lymph. Thus far there were the evidences of acute inflammation of the pericardium at an early stage. There was no adhesion of the opposite surfaces: the lymph and the serum had been effused together, and the serum had partially washed away the lymph as it was deposited. Further, when the heart itself was divided, the muscular fibres were darkcoloured almost to blackness, loaded with blood, soft and loose of texture' easily separated and easily torn by the fingers; and at the cut edges of both ventricles small quantities of dark-coloured pus were seen among the muscular fibres. The internal lining was of a deep red colour without any effusion of lymph."

There is good reason to believe that the Cerebral attacks, to which we have been alluding, are often associated with a vitiated state of the blood, in connection with granular disease of the Kidney. Hence the importance of watching the state of the urine.

ap

Supposing, however, that the patient has escaped, or that he has entirely recovered from, all the casualties which we have been mentioning, and that nothing but a very inconsiderable cardiac lesion,--the slightest narrowing, for example, of one of the arterial orifices, or the smallest deposit on one or more of the valves—is left behind, it must be still borne in mind that he will remain extremely liable to a relapse of Carditis from parently trifling causes. An accidental exposure to cold, a single act of intemperate indulgence, or the putting forth of some unusual bodily effort may soon rekindle the mischief, and thus most seriously aggravate the amount of lesion that already exists. It is, indeed, this very liability to the recrudescence of the primary disease that constitutes one of the most serious features in all cases, where there is reason to believe that the heart has once suffered from rheumatic inflammation.

"Remember," says Dr. Latham, "acute rheumatism is (if we may so speak pathologically) the great parent root of inflammations of the heart. It is also, undoubtedly, one of those diseases for which men are found to have a constitutional proneness. When it has been once suffered early in life, there is a fearful likelihood that it will be oftentimes suffered again. Moreover, the first attack is generally the type of every attack which is to follow. They may not all be equally severe, but they will all take the same course, and involve the same structures. If the first involve the heart, so, probably, will they all. Thus, the thought of a healthy child first seized with acute rheumatism is full of sorrowful forebodings. Its heart is very likely to be inflamed, and it may die; but, whether it die or not, its heart is very likely to be damaged for life. Having had acute rheumatism once, though it may perfectly recover, it is very likely to have it again; and, whenever it again has acute rheumatism, it is very likely again to have inflammation of the heart as its accompaniment."--P. 29.

Now, in reference to these second and third attacks of Carditis, it is of especial importance to bear in mind that the diagnostic symptoms can never be so satisfactory and conclusive as in the first attack of the disease; nay, that they may be even so obscure as to be extremely liable to be entirely overlooked.* Nor are we surprised at this circumstance in reference

* This remark holds true of other organs besides the heart:-

"It is a general truth, never formally declared perhaps, but well worth our notice, and of great practical importance, that organs must be previously sound to show clearly the nature of the injury or malady which they suffer, and that, in

to the heart, when we consider that the organ was not completely sound, and consequently that the auscultatory characters of its sounds were not normal, when the new inflammatory invasion supervened. If there was adhesion of the Pericardial surfaces left by the preceding attack, there may be no exo-cardial or attrition sound heard at all; and, with respect to any fresh deposit on the Endocardial surface, the only effect of this on the auscultatory phenomena will be merely to aggravate the previously-existing murmurs, but not to induce new ones. "There is the permanent murmur of the old unsoundness, and the recent murmur of the new disease; but how much is due to the old, and how much more to the new, is too delicate an affair for the nicest ear to discriminate." How pregnant with good sense, aye too, and with the soundest medical logic, are these reflections of the author!

"After all, then, you will observe, that, for the actual presence of this secondary inflammation in any case, and for our guidance in treating it, we have only the warrant of conjecture. It is most true.

"But there is such a thing as sober conjecture, as well as sober certainty. And diseases are treated, and cures are achieved, and lives are saved, as often under the guidance of one as the other. Such conjecture, however, is altogether different from the arrogant guess-work, which has no basis of action, and which succeeds once and fails twenty times, and knows as little why it succeeds as why it fails.

"The conjecture which should guide the physician, is rigorous, and calculating, and honest. It acts strictly by rule, and leaves nothing to chance. It does not absolutely see the thing it is in quest of, for then it would no longer be conjecture. Bnt, because it does not see it, it ponders all its accidents and appurtenances, and, noting well whither they point, it takes aim in the same direction, and so oftener hits the mark than misses it. And succeeding thus, it knows

why it succeeds, and it can succeed again and again upon the same terms. "Next to knowing the truth itself, is to know the direction in which it lies. And this is the peculiar praise of a sound conjecture.-P. 54.

Inconclusive, however, as the diagnostic symptoms of second or third attacks of Carditis must be acknowledged to be, it will be sufficient for the wise physician to know that, with every fresh accession of Rheumatism in a person who has once suffered, there is almost invariably such an increase of uneasiness and palpitation of the heart, of dyspnoea, and præcordial anxiety, as to make him keep a strict watch upon the seat of the chief mischief.

Dr. Latham has very convincingly shown, in his former volume, that Pneumonia and Pleurisy are often associated with the first attack of Carditis in rheumatic cases. We need scarcely say that the same complications. are common attendants upon all relapses of the heart-disease.

proportion as they are unsound, they are spoiled for giving true expression to the ills which afterwards befall them. The brain, the lungs, the kidneys, the abdominal viscera, being previously sound and healthy, proclaim themselves inflamed at once. But the brain, with a clot of blood lodged within it, tuberculated lungs, granulated kidneys, a scirrhous stomach, an ulcerated bowel, have their functions and sensibilities in utter disorder and confusion, and are not in a condition to give requisite notice of a new inflammation. A broken instrument is ever out of tune: whatever key you touch, you can never bring out the right note corresponding with it."-P. 33.

1847] Treatment of Secondary Endocarditis & Pericarditis.

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His remarks on the treatment of these secondary attacks of Cardiac Inflammation have chiefly in view to guard the physician against pushing general blood-letting too far. Although the action of the heart and arteries be tumultuous and violent, and the thoracic anxiety and oppression be great, large depletions of blood are seldom, if ever, required. Even mercury is not commonly necessary, in his opinion, in the majority of those cases of secondary carditis. The rule, which he gives for its exhibition, is this:

"Leeches applied to the region of the heart will, by the immediate effect which they produce, test the sort of inflammation you have to deal with, and show whether any and what other remedy will be needed in counteraction of it. If they at once afford marked relief, they thus denote both that the inflammation is easily controllable, and that they, without the aid of any other remedy properly antiphlogistic, will be able to control it. And so it will turn out in the majority of cases. But if they afford no marked relief at once, or, still more, after their repeated application, then they plainly proclaim the inflammation beyond their power to cope with, and they call for the help of mercury (as at first) to withhold it from a fatal issue but this does not often happen."-P. 59.

We think that Dr. Latham is rather chary in his use of Mercury in the cases alluded to. His very admission, that fresh and progressive deposits of coagulable lymph on or within the heart may take place without the presence of any very well-marked symptoms at the time, might rationally suggest a somewhat more energetic practice. We are by no means friendly to the active administration of this potent medicine— more especially in the commonly-adopted form of calomel-whenever there is reason to suspect recrudescence of Rheumatic Carditis; but the moderate use of some of the milder preparations, as of the hydrarg. ĉ creta, in combination with the soda carb., or the inunction of the mercurial ointment, only very gently to touch the gums, should, in our opinion, be seldom omitted. If we employ the mercurial inunction, the Hydriodate of Potash may be advantageously exhibited internally, at the same time. The application, moreover, of one or two blisters on the cardiac region is always advisable. We have again to express our surprise that so experienced a practitioner as our author should never make any reference to the state of the urine, as affording a very useful guide for determining the proper duration of the antiphlogistic treatment to be adopted. As long as this excretion is high-coloured, or exhibits a tendency to lateritious deposit, we may feel assured that the patient should be treated by a cooling antiphlogistic-mild though this may be-regimen. The use, too, of alkaline diuretics, to which Colchicum be generally added with much advantage, should seldom be omitted. The organic lesion induced by Endocardial Inflammation may vary so much in point of seriousness as well as extent, that we cannot be surprised at the different effects produced upon the general health of different patients. In some, the only evidence of their having had an attack of endocarditis is the persistence of an endocardial murmur, notwithstanding the perfect integrity of their health, and their capability of active and even of laborious exertion. In others, although their general health is perfectly good, there is, in addition, a tendency to palpitation of the heart, and to a certain degree of dyspnoea, whenever they exert themselves much, as in running, mounting up stairs quickly, or lifting any

may

heavy weight mental excitement, too, will have the same effect. Now, we may reasonably infer that the only injury, left behind in these two sets of cases, is a slight lesion-varying in point of degree-in some part of the valvular apparatus of the heart. In a third set of patients, besides the admonitory symptoms just alluded to, the heart is found alwayswhether the individual be at rest or not-to beat with greater force than it was wont to do before the attack. When this is the case, there will be reason to suspect that hypertrophy-with or without dilatation-of the muscular substance of the heart, may have commenced. Still, life may be prolonged for many years without much increase of the mischief, provided the person be not exposed to the operation of those exciting causes which aggravate all cardiac diseases, acute and chronic.

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Taking the three descriptions of cases in their order, I believe," says Dr. Latham, "it to be the tendency of each to pass progressively onward into the others. The endocardial murmur left by acute endocarditis may be simple and alone, and so it may remain for years, but it is ever apt to have a palpitation added to it. The palpitation accompanying the murmur may be occasional only, and so it may continue for years; but, in the mean time, it is ever ready to become permanent. The permanent palpitation may remain for a while moderate in degree, but it is always tending to become greater and greater. Of these three conditions then, the best that experience allows us to hope is, that each may remain stationary; for their changes are never retrograde, but always progressive and always for the worse. Each condition becomes worse as it is converted into the other, and the condition of permanent palpitation passes on to new results, and to the final and fatal event. -P. 97.

It is the consideration of this tendency, however slow and gradual, to a progressive aggravation of the cardiac lesion, which will make the wise physician never fail to instruct and earnestly admonish every patient in whom a persistent endocardial murmur, after a rheumatic attack, is discoverable, to guard himself as much as possible against those influences which are well known to inevitably accelerate the progress of all structural changes of the heart.

There is no sure and constant auscultatory sign or indication of byegone Pericarditis, even when the adhesion between the pericardial surfaces is loose and extensive, as there unquestionably is in a great majority of cases of Endocarditis. It appears to be highly probably that, whenever the pericardium has once been the seat of decided inflammation, it seldom or never resumes its complete or original integrity. The amount of change may, indeed, be inconsiderable, if the attack has been single. and not very severe; but nevertheless there it is. That a great tendency often exists to the exudation of lymph on the pericardial surface is proved by the frequent occurrence of loose slender adhesions between its opposite faces, or between the pulmonary artery and the aorta, even when there is no record of the person having ever been suspected of hav

ing had any cardiac disorder. "Some of these (loose slender adhesions)

Mr. Paget never fails to discover, wherever there are white spots upon the heart, and from the coincidence of the two, he has drawn the sound conclusion that both are the effect of inflammation; inflammation, however, of which there are commonly no traces in the history of men's lives, to match these sure and authentic ones met with after their deaths."