352 DISEASES OF THE HEART. 



lunar valves of the aorta, whence it is conducted to the apex. In the 

 normal heart, the entrance of blood into the ventricle is unaccompanied 

 by any murmur or other sound. If, however, in endocarditis, the 

 auricular face of the mitral-valve be studded with warty excrescences, 

 and if the blood have to flow over a rugged surface instead of a smooth 

 one, friction of the blood-stream produces a murmur which is audible 

 at the apex during the diastole of the ventricle. The second tone, 

 propagated from the aorta, may also be heard with it, or the latter 

 may be drowned by the intensity of the new murmur, and thus be im- 

 perceptible. The larger the excrescences, and the more they encroach 

 upon the orifice, so much the more intense is the friction of the blood, 

 and so much the louder the murmur. In the extremely rare cases in 

 which the right ventricle is the seat of endocarditis, similar symptoms 

 may be made out at the lower part of the sternum, where we listen to 

 the sounds of the tricuspid. It would be exceedingly difficult, how- 

 ever, to make a diagnosis here, as the right ventricle is hardly ever the 

 sole seat of disease, and we should scarcely be able to distinguish 

 whether the sounds were conducted from elsewhere or actually origi- 

 nated at the tricuspid. The sounds of the aorta are usually pure, as its 

 valves are far more seldom attacked by endocarditis. Should it occur, 

 however, should warty growths form upon the lower sides of the senu% 

 lunar valves, a murmur, produced by friction of the blood upon these 

 asperities, arises during systole of the ventricle, which is best heard at 

 the root of the aorta i. e., at the sternum, on a level with the second 

 intercostal space, and which is conducted hence along the carotids. It 

 is much less common to hear a diastolic murmur at this point than a 

 systolic one. 



We hear normal heart-sounds at the pulmonary artery almost 

 always, as the disease hardly ever extends as far as this. On the 

 other hand, we often hear a remarkably loud and sharp accentuation 

 of the second sound of the pulmonary artery, which is a sign of im- 

 portance. The fuller the pulmonary artery becomes, so much the 

 stronger does the shock grow which its semilunar valves must sustain 

 during diastole. Now, as an acute insufficience of the mitral develops 

 in the majority of cases of endocarditis, the pulmonary artery must 

 suffer distention and its second sound must become intensified. 6 



DIAGNOSIS. Endocarditis occurring in the course of acute rheuma- 

 tism is often overlooked, and quite as often its presence is diagnosti- 

 cated where it does not exist. In order to avoid the former error, 

 never fail to auscult all patients with acute articular rheumatism daily, 

 even in the absence of all complaint or constitutional disturbance. 

 That you may not rush from Scylla into Charybdis, however, beware 

 how you declare an endocarditis upon the mere occurrence of a blow 



