Acute endocarditis may occur in the course of phthisis. It is most frequent in acute miliary tuberculosis, but a true diagnosis of its tubercular character is impossiule during the life of the patient. Pericarditis and endocarditis arc usually fatal complications in phthisis, and their occurrence becomes the more rapidly fatal the more advanced the patient ap pears to be in the lung affection. Von Puck (Jour. of Tuber., April, 1900).
A ease of acute simple endocarditis has never been observed in the New York Foundling Hospital in the past twenty-Y,even years. the service covering the admission of 27,000 infants, with au topsy in between 2000 to 3000; heart murmurs have been frequently noted, but they have been transitory or unex plained at the autopsy; one case of ma lignant endocarditis has been seen as a part of a septicceinia. Northrup (Jacobi Festschrift ; Phila. Med. Jour., May 20, 1900).
Number of cases in which the disease followed septic infection of the ordinary nature that had nothing to do with rheumatism. One of these is remarkable for the fact that, although the patient was under observation for a number of months, and at the autopsy numerous vegetations were found upon the aortic valve, no murmur had been heard at any time during the course of the disease.
We cannot discriminate between staphy . lococeic and streptococeic infection by the type of temperature. The diagnosis of the condition is to be made from the presence of symptoms of sepsis and murmur in the heart, and confirmed by the existence of a palpable tumor of the spleen. Lenhartz (Miinchener med.
Woehen., July 16, 1901).
Pathology.—It has already been said that clinically there is no dividing-line between the simple and malignant forms of endocarditis. This is also true patho logically. The simplest lesions consist in minute warty vegetations, varying from one to four millimetres in diameter, seated upon the valves. These consist of masses of fibrin, leucocytes, blood-plate lets, and micro-organisms. Sometimes the vegetations are so large as to obstruct the valvular orifice. Even in the simple form (endocarditis vcrrucosa) there is more or less ulceration of the valvular endocardium. In the malignant form (endocarditis ulcerosa Tel diphtheritica) necrosis is more extensive. The valve may be so thinned as to give way under the pressure of the blood, thus produc ing a valvular aneurism, or actual per foration of the valve. A portion of the
valve may be destroyed and broken off, or some of the chorche tendinue may be ruptured.
The vegetations are situated mainly on that surface of the valve which is op posed to the blood-current. Thus, the lower surface of the aortic valves and the upper surface of the mitral valves are chiefly affected.
Exceptionally the heart-wall suffers, sometimes leading to cardiac aneurism or perforation of the ventricular septum or perforation into the pericardium.
The associated lesions peculiar to endo carditis are mainly caused by emboli; and yet it is a surprising fact that sometimes, even when the valvular lesions are de cidedly ulcerative, no evidence of em bolism may be found post-mortem.
Embolism affects the spleen and kid neys most frequently, and also many other organs, as above enumerated. If the right side of the heart is affected, there may be multiple pulmonary ab scesses.
Autopsies of 23 cases of endoearditis. Five patients showed acute VC1'111COSe endocarditis with superficial bacteria; 7 were subacute verrucose endocarditis with organized vegetations in which bacteria were imbedded; 5 were old ulcerative endocarditis with deform ity and calcification of the valve leaf lets: and 6 were fresh endocarditis in tuberculous, cancerous, or old people. Every verrucose endoearditis is mycotic in origin. J. Bartel (Wiener Id in. Wochen., Oct. 10, 1901).
Prognosis.—First, it is possible that very slightly developed cases of simple acute endocarditis recover without any real damage. The great danger front the non-ulcerative form, besides em bolism, is the setting up of a chronic fibroid deterioration of the valve, ulti mately destroying its efficiency.
The malignant forms are almost in variably fatal. Cases in which the acute process has been kindled upon the re mains of a former valvular inflammation arc somewhat more hopeful.
prophylaxis: matic patients should he kept as quiet as possible. The salicylates do not seem to lessen the liability of such patients to endocarditis. It may be that the admin istration of alkalies in sufficient amounts to keep the urine neutral is of some ad vantage.