Ulcerative Endocarditis.

Synonyms.—Malignant Endocarditis; Infectious Endocarditis; Mycotic Endocarditis; Diphtheritic Endocarditis.

Definition.—A form of endocarditis developed during some severe infectious or septic disease, and usually characterized by ulceration or suppuration of the valves. It seldom occurs as a primary affection, though a few cases have been reported.

Etiology.—One of the most frequent diseases to be followed by ulceration is pneumonia. Of two hundred and nine cases reported by Osier, twenty-five per cent were due to pneumonia; in fact, endocarditis with pulmonary lesions is very apt to be malignant in character. Rheumatism precedes this form of the disease much less frequently than in the simple form. Septicemia, puerperal fever, and the infectious fevers generally, may act as a primary cause. Tuberculosis, typhoid fever, and diphtheria are seldom accompanied or followed by this form.

Gonorrhea more frequently precedes this form of the disease than the acute variety. Simple acute endocarditis occasionally terminates in the ulcerative form, some septic process of unknown origin having developed. Old valvular lesions are frequent factors in causing endocarditis. It is mostly a disease of middle life, few cases being found in the extremes of life.

Pathology.—As in the simple form, it is the valves that are first affected and upon which the ulcerative and suppurative process expends itself, though there is a tendency to extend to greater areas of the endocardium. The sites most frequently selected are the ventricular surface of the aortic, and the auricular face of the mitral valves, these surfaces being subjected to the greatest friction. The relative frequency of the different valves may be seen from a report of 209 cases examined. Aortic and mitral valves together, 41; aortic valves alone, 53; mitral valves, 77; tricuspid in 19, pulmonary valves in 15, and the heart-wall in 33 instances. In 9 cases the right heart alone was involved.

The vegetative excrescences are the seat of the ulcerations. They become yellow, soft, and finally may break down, forming abscesses. The ulceration may pass deeper than the membrane, even to suppuration and sometimes perforation. As a result of the partial destruction of the valves, an acute valvular aneurism may occur, though this is rare. As a result of direct extension, purulent myocarditis or pericarditis sometimes takes place.

The secondary or distant lesions of ulcerative or malignant endocarditis are due to septic intoxication or to embolism. When due to the former, we find the spleen, liver, and kidneys enlarged and undergoing degeneration. In case of the latter the softened vegetative deposits may be washed into the blood-current as in the acute cases, with the same result.

If the mitral and aortic valves are the ones involved, the systemic circulation is poisoned and the emboli are lodged in the spleen, kidneys, brain, or cutaneous vessels, while if the tricuspid or pulmonary valves are the seat of ulceration, the lungs are the seat of infarction. Where the brain is involved in this way, meningeal lesions are found, or the deeper structures may be involved, paralysis and softening of the brain following. Various micro-organisms are found at the points of ulceration, the pus-forming kind predominating.

Symptoms.—The symptoms embrace the widest range, including all that are observed in the simple form, with the addition of all those due to intoxication and embolic complication, or they may be so obscure as not to arouse even a suspicion of heart lesion; in fact, quite a large per cent of endocardial cases are only recognized post-mortem. This being the case it is exceedingly difficult to give a satisfactory description of the symptoms of this lesion.

There may be an aggravation of all the symptoms of the primary disease, plus an irregular and frequent pulse, slight pain, and more or less dyspnea. If the patient is suffering with acute rheumatism, and there is a sudden rise of temperature, an irregular pulse, and oppression in the precordial region, our attention should be turned to the endocardium; or if there are no local symptoms pointing to the heart, and yet a sudden rise of temperature takes place, with irregular pulse, even though there is no aggravation of the joint affection, endocarditis should be suspected.

Should there be emboli, the symptoms would depend upon their location. For example, if located in the kidney, there would be scanty secretion of urine, containing more or less blood. Where the infarcts are in the spleen, there would be severe pain in the left hypochondrium, great tenderness, and more or less peritonitis. If the meningitis develop or hemiplegia suddenly occur, followed by coma, we think of cerebral emboli; while gangrene of the lung with the accompanying pulmonary symptoms, would leave no doubt as to the cause.

Some cases resemble a remittent fever, with irregular pulse and dyspnea, as additional symptoms, directing our attention to the heart. Sometimes in chronic valvular disease, fever suddenly develops, the temperature rises rapidly, there is an anxious expression of countenance, with a sense of oppression in the cardiac region with or without pain; in such cases endocarditis is present. Aside from these varied and irregular forms of endocarditis, two special types have been recognized,—the typhoid and the septic, or pyemic.

Typhoid Type.—Should the disease come on gradually with the customary prodromal symptoms, malaise, headache, etc., the physician is very apt to mistake it for typhoid fever, especially when the above is followed by high temperature, with daily remissions, tympanites, diarrhea, and an eruption somewhat similar to that of typhoid, a delirium not unlike it, and followed by coma and picking at the bedclothes.

The tongue is dry and brown, with sordes on the teeth and lips. In these cases, the cardiac symptoms are completely overlooked, and, even if suspected, a careful examination may fail to reveal the true condition.

The Septic Type is apt to follow suppurative processes, like necrosis of bone, puerperal septicemia, and similar lesions. The invasion is usually sudden, and announced by a chill or rigor. The fever is of a remittent type, the temperature frequently being very high. In some cases there is an intermittent fever, the chill being a characteristic feature. The patient takes on a cachectic appearance, has night-sweats, the tongue becomes dry and brown, the breath is foul, prostration is great, and emaciation rapid. The pulse is rapid, feeble, and sometimes irregular. When dyspnea is marked, the disease is recognized where it otherwise would be overlooked.

The disease runs a varied course, though usually a few weeks is sufficient time for a fatal termination.

Pericarditis and myocarditis are grave complications, and always add to the gravity of the disease. Pneumonia and pleurisy may complicate endocarditis, but are more apt to precede it. The physical signs differ but little from the acute form.

Diagnosis.—The diagnosis is many times extremely difficult, especially where the local symptoms are not pronounced. It may be taken for septicemia or typhoid fever, especially where the forming stage is of long duration. Usually, however, the onset is more sudden than that of typhoid, there is less engorgement of the spleen, and the rash is not the characteristic eruption of typhoid; coupled with this are the frequent chills, copious sweats, and great prostration. In nearly all cases, however, if the pulse is carefully studied, the breathing noted, and the chest carefully examined, the disease will be recognized.

Prognosis.—The prognosis is usually unfavorable, always so when of a severe type. Mild cases may recover, though such cases, when reported, may have been due to a mistaken diagnosis.

Treatment.—The treatment will be supportive and antiseptic. In the ulcerative or malignant form, the cause of the sepsis must not be overlooked, for if the source of the stream be poisoned, the body to which it flows must certainly partake of its character. The heart may be poisoned by an old metritis or gonorrhea, or a foul ulcerative condition of the. rectum, or there may be sepsis from some bone lesions, or tuberculosis in some one of its many forms. These wrongs must be corrected, for to overlook them is to court defeat.

The source of infection must be removed. The various anti-zymotics will then be indicated. Echinacea one dram, to water four ounces, or baptisia, or it may be the mineral acids, will be called for; if the tongue be red and dry, the latter would be specific. The chlorates would take the place of acids if there be a coated tongue or fetid breath, or the sulphites, if the tongue be coated with a moist, dirty coating.

The diet should be nutritious and easily digested. The secretions from the skin, kidneys, and bowels are to be carefully looked after, in the hope of removing the waste of the tissues, and preventing the toxins from further infecting the system. During convalescence, and for a long time after, the patient should exercise great care against taking cold. Recurring endocarditis is of frequent occurrence.

Cactus to assist the heart's action and relieve some of the unpleasant features, must not be overlooked. Stimulants will be used freely when the heart flags.

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.