348 DISEASES OF THE HEART. 



totally or partially occluded, it causes the formation of haemorrhagic 

 foci (capillary apoplexy) with their consequences, or else gives rise to 

 partial anaemia, and consequent necrosis of the anaemic portion of the 

 brain (yellow softening). Indeed, occlusion of the greater vessels of 

 the extremities, by a large embolus, may even occasion spontaneous 

 gangrene of the toes. 



We are entirely unauthorized, by the occurrence of metastasis, to 

 infer that perforation of an exudation from the deeper layers of the 

 endocardium to its free surface has taken place, as the coagula entirely 

 suffice to account for the symptoms. Nor are we warranted in diag- 

 nosing a septicaemia, from the appearance in an endocarditis of signs 

 suggestive of septic poisoning, since it is not to be supposed that any 

 exudation which might make its way to the free surface of the endo- 

 cardium could be a septic one, or could infect the blood. 



SYMPTOMS AND COTJKSE. When endocarditis supervenes upon an 

 attack of acute inflammatory rheumatism (and, as stated above, this is 

 by far its most common commencement), there are often no subjective 

 symptoms to warn the patient of the new enemy which is stealing 

 upon him, and who frequently does not declare himself in all his malig- 

 nance for weeks, months, nay, for years afterward. If we ask a patient, 

 with valvular disease, whether he has ever had articular rheumatism, 

 he often answers in the affirmative ; if, however, we ask him whether 

 during his attack he has ever suffered from pain in the region of the 

 heart, or from oppression or palpitation, he almost always will deny 

 it. It is not very different if we watch the patient ourselves. Gen- 

 erally he does not complain, even when we make special inquiry as to 

 the existence of this kind of trouble ; and we must depend for our 

 diagnosis upon physical examination alone. 



In other instances, however, functional disturbance, more or less dis- 

 tinct in character, certainly does arise. Pain in the cardiac region, how- 

 ever, never appears to proceed from simple, uncomplicated endocar- 

 ditis, even although we make pressure upon the thorax or epigastrium, 

 In a few, but very rare instances, the frequence of the pulse increases 

 with the commencement of the endocarditis, and may even become 

 extremely great. We shall not lose ourselves in speculations as to 

 the cause of this augmented frequence of the heart's action, which is 

 sometimes enormous, nor shall we attempt to decide whether it be due 

 to sympathy of the muscular portion of the heart, or to irritation of 

 the ganglia seated in its walls, but shall confine ourselves to announ- 

 cing the fact. It is at least equally hypothetical to assume that there 

 is an ulcerative form of the disease in the cases of endocarditis marked 

 by acceleration of the pulse. 



As increased frequence of the heart and pulse-stroke often coex- 



