Physical  Signs. — There  are  no  signs  of  importance  upon  inspection-
Palpation  yields  valuable  information  as  to  the  character  and  extent  of  Ite
impulse,  which  is  frequently  somewhat  displaced  to  the  right  and  may  bt


ENDOCARDITIS.  1211

sometimes  felt  in  two  interspaces.  Thrills  in  the  mitral  and  aortic  areas
may  be  felt.  Percussion  shows  the  heart  to  be  moderately  enlarged  in  its
transverse  diameter,  especially  to  the  right  of  the  sternal  border — dilata-
tion of  the  right  ventricle.  Upon  auscultation  the  signs  are  by  no  means
constant.  Errors  in  diagnosis  may  be  avoided  by  bearing  in  mind  the  fact
that  in  a  considerable  proportion  of  the  cases  no  murmur  can  be  detected
upon  careful  search.  Usually,  however,  there  are  well-marked,  often  harsh,
murmurs  in  the  mitral  and  aortic  areas,  mostly  systolic  in  time,  but  fre-
quently also  presystolic  or  diastolic  as  the  case  may  be,  and  often  chang-
ing their  quality,  rhythm,  and  intensity  from  time  to  time.  This  variabiHty
in  the  murmurs  and  in  thrills  when  present  corresponds  to  changes  in  the
dimensions  and  other  physical  characters  of  the  lesions,  and  constitutes  a
diagnostic  sign  of  the  highest  importance.
Diagnosis  of  Malis^nant  Endocarditis. — Direct. — In  the  absence  of
the  physical  signs  of  endocarditis  and  of  embolism  the  recognition  of  the
disease  may  be  impossible.  Sepsis,  associated  with  murmurs  which  vary
in  character  and  intensity,  or  the  signs  of  embolism  form  the  basis  for  a
positive  diagnosis.
