little faith. A vapor bath, with the internal use of diaphoretic doses of lobelia, and a free administration of vegetable diuretics, will excite absorption secondarily by the removal of the normal quantity of serum from the blood vessels. When the case is of a sthenic form, the administration of the following pill to produce a hydragogue effect, will prove efficacious:—

Divide into two grain pills and give from one to two at night and in the morning, if a free hydragogue effect is desired. The diuretics in the chapter on pleuritis are equally applicable in pericarditis with effusion.

In asthenic cases and those of a chronic character, the spiritvapor bath, should not be so long continued as to cause much prostration. The object is to produce a fullness of the cutaneous capillaries, and to add tene to the general system. More nourishment and mild stimulants should then be given than in the more sthenic forms of the disease. For a counter irritant the plaster and poultice recommended in the article on pleuritis may be used. A plaster applied over the spine, alternately with one over the præcordia is often useful. It should be continued until the podophyllum or lin, on its surface, has time to produce its irritant and vesicating effects.

As soon as there is a return of the friction sounds, and an increase in the loudness of the beatings of the heart, together with the general symptoms of amendment, tonics should be used in combination with nourishing, yet easily digestible diet. More especially are these means necessary, when the blood is in an anæmic state, and when oedema of many parts of the system is manifest. In such a condition of the blood, the preparations of iron administered in combination with hydrastis and pupulus will be effectual means of cure. As a general stimulant and diaphoretic and laxative the following pills are excellent :

:

Dose-from one to three, three times per day. This is a remedy which can be used instead of an emetic. When the pills are continued a number of days they almost always restore the equilibrium of the circulation, and thus tend to prevent those congestions which always precede inflammation; and while they do so they increase the digestive functions, and secure to the patient the formation of the elements of the blood. In case no laxative effect is indicated, the last article in the formula should be left out and the gum acacia used in its stead to form a pill mass.

Patients laboring under this disease should avoid all kinds of excitement, whether mental or corporeal, and live upon such food as is nutritious but not exciting.

CHAPTER III.

ENDOCARDITIS.

The term endocarditis from the Greek word avdov within *apa heart, and itis, inflammation, is applied to inflammation of the endocardium, or the internal membrane of the heart. This disease gives rise to alterations in the cardiac valves, and in its muscular structure. In its secondary effects, exist the dangerous results of the disease, rather than in its primary. This is known from two sources. In individuals previously healthy endocardial inflammation very often terminates in structural changes of the valves. And secondly, in those who have died of valvular disease, traces of previous inflammation almost always exist. This opinion, however, is not in strict agreement with that of Dr. Fuller. contends that the depositions on the valves are due to the presence of an unusual quantity of fibrin in the blood, and to the weak state of solution in which it is held in consequence of that abnormal degree of acidity in the system, which so often accom

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panies or precedes endocarditis. The inflammation may make according to his view, the liability of deposition greater, inasmuch as it tends to roughen the surface of the valves, and in this way tends to favor the adhesion of the particles of fibrin passing along in the current of circulation. From these opposite opinions we may safely conclude that the structural changes are the result of more than one cause, and that medical investigation has not yet accurately determined just how much of the result is due to the influence of the one, or to that of the other. That same condition of the blood which favors the deposition also favors the production. of inflammation. So that from one cause,--a general one existing in the blood,—more than one injurious effect arises.

PATHOLOGY.-Inflammation of the endocardium cannot on account of the motion of the circulating fluid leave behind all those products which are formed in the pericardium. To the membrane itself we must, therefore, look for the changes resulting from this disease. On examination we find its natural transparency replaced by whiteness and opacity; fibrin may be deposited upon it forming beaded or wart-like fleshy excrescences, and lymph may be effused either beneath or on its surface giving rise to thickening, rigidity, and puckering. In some cases ulceration ensues, giving rise to irregular vegetations, partly consisting of lymph partly of calcareous matter, producing perforations of the valves or a ragged state of their edges, or extending to the chorda tendineæ, and eating through them and sometimes causing a perforation of the septum ventriculorum.

These morbid changes are found in the different chambers of the heart; but in the majority of instances they are located on the valvular apparatus, or in its immediate neighborhood. The aorta and mitral valves are peculiarly liable to these changes. The right cavities, however, with their tricuspid and pulmonary semilunar valves, are sometimes, though rarely, affected.

The fibrinous vegetations vary greatly in their appearance. They are often very numerous, and vary in size from a pin's head to a millet seed. They are at one time isolated, and at others partially confluent; and when several spring from a common base, they may form a mass of considerable size. Sometimes when

fibrinous accretion has taken place rapidly, its form and appearance is changed, which in other states of the system might have resulted in the deposition of small warty granules along the edges. of contact of the valves. In the sigmoid they are arranged in a double crescentic form; but when their growth is more luxuriant, they are more widely distributed over the endocardial membrane.

The surface of the valves is thickly studded with them. On the edges of contact of the valves, they form festoons or fringes; the chorda tendineæ of the mitral valves are sometimes loaded with an abundant crop of them; and occasionally in different parts of the heart, they are scattered profusely over the entire surface of the lining membrane. The cases in which the last form of vegetations occurs, are just those in which the accretions manifest a strong tendency to decay, and in which arise those formidable. erosions and ulcerations to which allusion has already been made.

In color and consistency these accretions greatly vary. They are sometimes gray and friable, sometimes of a pink or reddish color, soft and easily broken down, and can readily be detached from the smooth surface of the membrane on which they are deposited. At others they are less colored and of a much firmer consistency, but still admit of being separated from the membrane; whilst in another class of cases they become perfectly colorless, and so firmly adherent, that they can be removed only by tearing the membrane to which they are attached. At a still later period these warty growths or bead-like accretions cease in many cases. to exist as such upon the valves. They become by degrees more firmly agglutinated to the endocardial membrane, and incorporated with the structure of the valve; and merging gradually into one another, until the divisions between the several granules are effaced, they are ultimately replaced by a laminated ridge of fibrin. This is marked at first by serratures, corresponding to the divisious between the original granules, but after a time it also loses all traces of its origin or mode of formation, and becomes smooth and polished like the rest of the endocardium.

Another source of impediment to the circulation in endocarditis is the formation of fibrinous coagula from the blood, which are supposed to contract adhesions to the lining membrane at any accidentally rough or prominent point, and may be seen twisting

about the fleshy columns, and valvular tendons. (Bouillaud.) To these Laennec ascribed the origin of warty vegetations. Dr. Gerhard considers them more frequently the cause than the effect of endocarditis, and ascribes their origin to that fibrinous condition of the blood characteristic of inflammatory disease.

The fibrinous-sub-serous exudation that is seen in sthenic endocarditis is according to the best evidence sometimes changed into a fibrinous, cartilaginous or bony structure. Such a deposition on or near a valve, of course, causes permanent lesion.

During the progress of endocarditis the muscular structure of the heart is more or less affected. But the precise extent of the cardiac lesion it is difficult to demonstrate. According to Dr. Gerhard the heart increases in consistence, and becomes harder than usual immediately after the inflammation of the membrane has ended.

DIAGNOSIS.-General symptoms.-The general symptoms of endocarditis are very obscure. So nearly do they resemble those of pericarditis, that an enumeration of them cannot be of much utility. It is sufficient to say, that in general, they are not violent, and that in a large number of cases they are so slight, that the disease is quite latent. In the severe cases, the pain may be somewhat acute, but even then it is dependent upon the attending pericarditis, and the obstruction to the free circulation of the blood. So that in simple endocarditis pain is a symptom so variable, that it cannot be depended upon for the formation of diagnosis. Dyspnea is another symptom upon which we cannot with confidence rely. It is often violent, causing intense suffering, and attended with signs of obstructed capillary circulation. In such cases, the patient has a haggard, wild appearance.

The character of the pulse is another sign of endocarditis. It is tense, though small and irregular. Very great irregularity is indicative of a severe form of cardiac disease, and is usually the result of lesions of the valves. These three symptoms, the pain, the dyspnoea, and the pulse, are the most important, and almost the only ones which are generally attendant upon inflammation of the endocardium. Delirium may arise in the last stage.

Physical signs.-Usually the impulse of the heart is increased,