ADDITIONS TO THE REVISED EDITION OF 1880. 393 



valve is closed, then the blood may bore its way into the interla- 

 mellar connective tissue and distend the unbroken side of the valve 

 into a blood-filled sac of the size of a cherry an acute aneurism 

 of the valve. This, by subsequently bursting, may cause a perfora- 

 tion or detachment. Quite rarely the endocardium is destroyed at 

 some point covering the fleshy wall of the heart ; and then (but 

 only then) is it possible for the muscle of the heart to take part in 

 the inflammatory process, and for the blood to penetrate forcibly 

 into its substance, producing an acute aneurism of the heart that 

 is, a rounded, circumscribed, sacculated appendix, filled with blood, 

 situated upon the surface of the heart, and surrounded by uptorn 

 muscular fibres. A false passage between the ventricles has been 

 known thus to form though the destruction of the non-muscular 

 spot in the septum at its upper part. 



In addition to any concomitant myocarditis which may exist, 

 the muscles of the heart exhibit a participation in the endocarditis 

 by an abnormal yielding of the walls and dilatation of its cavities. 



Besides these manifestations directly observable in the heart 

 itself, there are other secondary phenomena of great importance 

 occurring at remote points in the body. 



5. P. 352. 



Metastatic processes from embolism occur less frequently in 

 common endocarditis than in the ulcerative form, but they are not 

 rare. Of the signs of infarction of the spleen or kidney which may 

 then arise, we shall treat elsewhere, merely remarking for the pres- 

 ent that when the diagnosis of endocarditis is doubtful, and the 

 symptoms of metastatic infarction arise, such as the appearance of 

 albumen and blood in the urine, the development of a painful tu- 

 mor of the spleen, or the like, the diagnosis is materially support- 

 ed. Sudden blindness of one eye has been known to arise from 

 embolism of the arteria centralis retinae. Blocking up of one of 

 the main arteries of a limb may cause painful lameness with ar- 

 rest of the pulse below the point of stoppage, and sometimes even 

 gangrene may arise. But the most serious of all are the cerebral 

 embolisms which induce not only apoplectiform seizures with palsy, 

 but sudden death. In the rarer endocarditis of the right heart em- 

 bolic infarctions in the lungs may arise. 



The Symptoms of Ulcerous Endocarditis. This form is char- 

 acterized by intense fever, with very high temperature and irregular 

 remissions, together with frequent rigors, and typhoid adynamic 

 symptoms. Such manifestations impart to the disease a certain re- 

 semblance to typhus, or to pyaemia, and perhaps even to intermit- 



