Definition:—This form of endocarditis is distinguished from the benign form just described by the fact that ulceration may occur as the result of inflammatory action, with possible suppuration, or these conditions occur when no previous endocarditis was known to have existed. From this ulceration there may be destruction of valvular tissue or perforation of a valve or perforation of the ventricular septum. While it is possible that the disease may occur independently of any previous inflammation it is not probable that it does so occur, except perhaps in extremely isolated cases.
Etiology:—The ulcerative form occurs more commonly as a secondary infection, from the micro-organisms of acute infectious disorders, such as scarlet fever, diphtheria, erysipelas, measles, smallpox, typhoid fever, tuberculosis, chorea, chronic nephritis or gonorrhea. The micro-organism would thus depend largely upon the primary disease.
Symptomatology:—The symptoms are no more conspicuous usually than in the benign form of the disease. There may be no elevation of the temperature above that which has previously existed, from the primary disease, or the temperature may have fallen to normal and show no increase upon the occurrence of ulceration. Constitutional symptoms similar to those that occur in typhoid conditions, or in acute septicema, may develop, with some cerebral manifestations. There is usually persistent chilliness, with erratic fever, and occasionally sweating occurs. There is suppression of the secretions, the tongue becomes dry, thin and pointed and usually coated in the center with a dark brown or black coat, with sordes on the teeth. If these typhoid symptoms develop there will be a persistently high temperature, with but slight remissions occurring irregularly; there will be tympanites, gastro-intestinal irritation, with diarrhea, enlargement of the spleen, with tenderness on pressure and acute, lancinating pains, with delirium of a mild type and scanty urine.
If malarial toxemia co-exists there will be marked remissions in the temperature at regular intervals, with perhaps chilliness also occurring periodically and slowly developing anemia. In other cases there may be renal complications or marked cerebral manifestations, which may be mistaken for some of the forms of meningitis.
The local symptoms are usually not conspicuous, pain in the heart, oppression of breathing, irregularity of the heart's action or violent action may be either present or all absent. Usually there are valvular sounds, which are more or less distinctive; there is a plain murmur on systole, and the second sound of the heart is somewhat increased in force. There may be signs of local pulmonary consolidation.
Diagnosis:—This depends upon the previous existing conditions and is usually unsatisfactory, as there are so few distinctive phenomena. Exclusion should be made of pericarditis and of the infectious diseases without ulceration. If previous benign endocarditis has existed, or if the symptoms of this disease are present during the course of severe infectious disease, and all the phenomena, especially those of the heart, become greatly aggravated, endocardial ulceration will probably be present.
Treatment:—The suggestions for treatment which are found present in pericarditis and in endocarditis of a benign form will apply in this case, with the addition of our most positive measures to antagonize septic infection and the development of pus. These are echinacea in full doses, with the use of calcium sulphide, to partial saturation. The supportive treatment should be most carefully selected and of the most vigorous type. Stimulants may be given when prostration is marked. It must be borne in mind that the condition is a very serious one, and the treatment must be constitutional rather than local. Other alteratives may be selected according to the judgment of the physician.
The Eclectic Practice of Medicine with especial reference to The Treatment of Disease, 1910, was written by Finley Ellingwood, M.D.