[Reprinted from the Roston Medical and Surgical Journal of 
November 25, 188(3.] 
TWO CASES OF MALIGNANT OR ULCERATIVE 
ENDOCARDITIS. 
A CLINICAL LECTURE DELIVERED AT THE PHILADELPHIA 
HOSPITAL, X / 
BY .JOHN H. MUSSER, M.D., 
Physician to the Hospital, and Pathologist to the Presbyterian Hos- 
pital. 
I have here some specimens showing the lesions 
of malignant or ulcerative endocarditis as seen in a 
case recently in the wards of the hospital, and also 
some photographs of a case which came to my notice 
in the Presbyterian Hospital some time ago. I also 
have here the specimens from the latter case, and shall 
demonstrate to you as well as I can, the pathological 
lesions. In this heart there are seen on the leaflets 
of the mitral valve, a fringe of soft vegetations which 
were very friable when first removed, and in fact still 
are easily broken. They project into the ventricle 
and auricle, interfering seriously with the circulation. 
They are also seen on the aortic valves, and in this 
instance we find the rather rare occurrence of the 
lesions on the tricuspid and pulmonary valves. On 
microscopical examination of a teased preparation, 
these larger masses seemed to be made up of a granu- 
lar substance in which were innumerable micrococci. 
In addition to this hyaline structureless appearance of 
the mass, a croupous or fibrinous exudation, cell pro- 
liferation was seen, with leucocytes in large numbers. 
The micrococci not only invested the proliferating 
membrane, but also dipped deeply into the lymph 
spaces of the neighboring structures looking not un- 
like the penetrating pegs of epithelioma. The smaller 
masses were less free from granular material and con- 
tained more of the cellular structure, and showed 2 
especially, old connective tissue elements most mark- 
edly. These proliferating structures while to a certain 
extent limited to the valves, are in this case also seen 
on the chord® tendineae, and on the wall of the heart 
itself, budding out from the endocardium. 
In cases of malignant or ulcerative endocarditis, not 
only do we find these proliferative masses, but quite 
frequently we also find ulcerations with or without 
fungoid growths of inflammatory material. These 
ulcerations are found in the valve and in the heart 
muscle, and may lead to perforation. Microscopical 
examination of such ulcers shows abundant micrococci 
and the presence of round cells and granulation tissue. 
The ulceration may perforate the valve or the heart 
muscle itself, and lead to the development of aneu- 
rism, or to leakage from one cavity to another, or 
from the cavity of the heart into the pericardium, 
causing a iatal result. In addition to the fungous 
growths and these ulcerations, there are found in some 
instances, minute abscesses. The pus in these ab- 
scesses contains an abundance of micrococci. 
In this second specimen the mitral valve is affected 
alone. The enormous degree of proliferation of the 
new growth can be readily seen. That on the ante- 
rior leaflet of the mitral valve projects into the ven- 
tricle, while that on the posterior leaflet projects into 
the auricle. 
The presence of this granular material and the ex- 
istence of micrococci in the new growths, would of 
necessity lead us to infer that the blood was infected, 
and such is the case. Microscopical examination shows 
abundance of micrococci floating free in the blood, and 
some are also found in the leucocytes. The infection of 
the blood and the presence of micrococci in these free 
situations where they can be readily disturbed by the 
blood current, lead us to expect structural changes in 
the peripheral circulation. By the force of the blood 3 
current, micrococci, cells and granular debris are car- 
ried into the distal circulation and form infarcts. 
When the disease is on the left side of the heart, 
these infarcts are seen in almost all parts of the arte- 
rial circulation; for instance, in the case recently 
under observation, there were innumerable infarcts in 
the skin, and nearly all the internal organs. Micro- 
scopical examination would show in addition to the 
haemorrhage of the infarct, the presence of micrococci, 
occluding some minor capillary. The mucous mem- 
brane and the serous membranes may also be similarly 
affected in these cases. In this instance, infarcts were 
seen in the peritoneum and in the pericardium over 
the surface of the heart. The mucous membrane of 
the gastro-intestinal tract, showed numerous infarcts. 
The nature of these infarcts depends largely upon the 
nature of the primary infecting material. If there is 
an abundance of pus, they rapidly change into ab- 
scesses. In other instances, they remain as simple 
haemorrhagic infarcts, and if the patient lives, undergo 
the changes usually seen after emboli. Here is a sec- 
tion of the intestine which shows the haemorrhages in 
the mucous membrane. In this case, the most remark- 
able lesions were the number and extent of the in- 
farcts in the stomach, particularly toward the cardiac 
end. In the first case, the only infarcts found were 
in the kidneys. There was also most marked glomer- 
ulo-nephritis. In the second case, the renal infarcts 
were not so large, but there were innumerable small 
ones in the capsule of the kidney, and microscopical 
examination would in all probability reveal -the evi- 
dences of glomerulo-nephritis. The spleen, you ob- 
serve, shows the infarcts very distinctly. 
Not only are the lesions found in these structures, 
but capillary emboli may also occur in the brain. And 
not alone are the capillaries involved, but large plugs 
may be broken off and carried into the cerebral 4 
arteries, cutting off the circulation of a large portion 
of the brain structure producing hemiplegia and other 
grave cerebral symptoms. In the second case, a large 
thrombus had formed in the iliac artery, with obstruc- 
tion to the blood supply of the lower extremity. It 
was evidently a recent formation, as it had produced 
no symptoms during life. 
In addition to these changes which are noted in 
most cases of malignant endocarditis, namely, the 
changes in the structure of the valves; of the en- 
docardium and of the heart muscle and changes in 
the blood, and secondarily, the presence of emboli and 
infarcts throughout the arterial circulation, there are 
often other lesions. For instance, in many cases the 
lesions of rheumatism or pneumonia or diphtheria 
are present. In other cases there are found in some 
portion of the body small abscesses, disease of the 
bones or some suppurative process. In such cases 
the endocarditis is secondary to the disease in the 
peripheral structures. Many cases, for instance, have 
been reported in which a pelvic abscess had been 
the primary origin of the disease. In the same way, 
in disease of the bone and in rapidly growing cancer 
which has undergone inflammatory changes, malig- 
nant endocarditis may develop. 
These anatomical conditions have led to the divi- 
sion of the disease into three classes : First, those 
cases in which there are present only lesions of the 
heart and of the blood, and lesions due to emboli, are 
classed as cases of idiopathic or spontaneous malignant 
endocarditis; Second, those cases in which the lesions 
of rheumatism or pneumonia are found in addition, 
are classified simply as cases of associated malignant 
endocarditis ; Third, those cases in which the disease 
is due to the presence of suppurative inflammation in 
the distal circulation or to a general septic process, are 
classified as cases of secondary malignant endocarditis. 5 
By the knowledge of the anatomical characters of 
the disease, one can readily trace and keep well in 
mind the clinical history of these cases. First, from 
the fact that micrococci are found in the blood and in 
the inflamed structures, we should infer that there 
must be some general symptoms due to the septic 
process, and such is eminently the case. Second, the 
severe local cardiac lesion produces symptoms charac- 
teristic of obstruction in the orifices, while finally, the 
character of the primary lesion determines the presence 
and nature of the third class of symptoms, namely, 
those arising from peripheral infarcts and inflamma- 
tions. 
Cases of malignant endocarditis are characterized by 
rigors, irregular fevers and sweats, and by the occur- 
rence in the later stages, of jaundice due to disorgani- 
zation of the blood. There may also be vomiting and 
diarrhoea which examination shows is not dependent 
upon organic lesions of the stomach and bowels, but 
on the septic process. Enlargement of the spleen, 
another accompaniment of the septic process is also 
observed. The affection is sometimes accompanied 
by inflammation of the serous membranes, especially 
of the brain. Indeed, the only prominent symptoms 
of malignant endocarditis may be cerebral. 
From the blood lesions, depending upon the extent to 
which the blood has become disordered and infected 
with the micrococci, and secondarily, upon the reaction 
of the structures to the micrococci in the blood, we 
have different types of the disease. Clinical experi- 
ence has led us to divide the cases into four classes, 
the pymmic, the typhoid, the cerebral and the cardiac. 
The pyaemic type, as its name indicates, resembles 
pyaemia in its symptoms and course. The cere- 
bral type simulates inflammation of the meninges of 
the brain in its symptoms. Possibly without any 
symptoms referable to the heart, there will be pain in 6 
the head and in the back of the neck, with high fever, 
drowsiness, stupor, convulsions and coma. In the 
typhoid type, the symptoms simulate those of typhoid 
fever in many respects, the affection beginning with 
irregular chills, irregular fever, and being accompan- 
ied by profuse perspiration, emaciation, low muttering 
delirium, a dry, brown tongue, and even the occurrence 
of diarrhoea. In the cardiac form of the disease, the 
symptoms depend not so much upon the condition of 
the blood, as upon the primary cardiac lesions. While 
a healthy heart may undergo the changes which I 
have demonstrated to you, a diseased heart is much 
more likely to do so. In many cases of cardiac dis- 
ease, the diseased structures seem to furnish a hot-bed 
for the development of the micrococci. More cases of 
malignant endocarditis are found in old cases of car- 
diac disease than in any other class. In the cardiac 
type, we have in addition to the symptoms referable 
to the heart, namely, dyspnoea, pain and distress about 
the praecordia, and palpitation,— also irregular fever 
and sweats. 
The local symptoms due to the presence of this 
severe and extensive inflammation of the cardiac 
structure are pronounced and distressing. From the 
appearance of this enormous outgrowth on the mitral 
valve (second case), you can infer considerable ob- 
struction to the blood-current, and bence the produc- 
tion of a murmur. So, in all cases, a murmur is heard 
at the orifice affected. Sometimes it is heard at several 
points, according to the diverse seat of the lesion. 
The murmur is usually strong and low in pitch. It 
may be systolic or diastolic. It is conducted or trans- 
mitted in accordance with the laws that govern mur- 
murs, but differs in the variation of its character. 
From time to time it may be high or low pitched, loud 
or soft, strong or feeble, indeed, may temporarily dis- 
appear, such changes depending on the change of the 7 
outgrowths by loosening and floating oif in the blood- 
stream. With the murmur, would arise other evidence 
of obstruction, such as dilatation of one or more of the 
chambers of the heart, with increase in the area of dul- 
ness and of impulse. Under these circumstances, the 
heart acts more violently, is likely to be irregular and 
very frequent, while palpitation and cardiac dyspnoea 
would be present. 
Finally, we look to the nature of the central lesion 
for the character of the symptoms developed in the 
peripheral circulation. If largely purulent in char- 
acter, the infarcts would rapidly be converted into 
abscesses. In most instances, simple haemorrhagic 
infarcts are observed. In both, crococci abound. 
The infarcts or capillary haemorrhages are observed 
in the skin, the conjunctivas, and the external mucous 
membranes. They are seen in the retina, and their 
presence in the gastro-intestinal or urinary tracts may 
be inferred from the occurrence of blood in the natu- 
ral discharges, or of haemorrhages from these localities. 
Their presence in the brain is determined by the 
phenomena common to cerebral emboli. In the skin, 
these infarcts are most abundant, and are distinguished 
by their bright red color and their persistence on pres- 
sure. 
The case from which the first specimens were re- 
moved was a typical example of malignant endocardi- 
tis, and I shall ask your attention to the prominent 
points in its history : W. J.,1 white, was admitted to the 
medical wards of the Presbyterian Hospital, October 
3, 1884, suffering with rheumatism, localized in the 
left knee and the right shoulder and elbow. He stated 
that he had been feeling badly for some time, and had 
been losing flesh and strength. Previous to the recent 
illness he had had small-pox, syphilis, and gonorrhoea. 
The fever was very high, and out of proportion to the 
' See Transactions College of Physicians of Philadelphia. 1886. 8 
local symptoms. It was irregular, and at times there 
were profuse, exhausting sweats. This case was typi- 
cal in its marked remissions and intermissions, the 
temperature sometimes going as high as 10a°, and on 
one occasion, going as low as 9G.5°. Some time after 
admission, the patient complained of pain about the 
praicordia, and, on examination, a murmur at the mit- 
ral valve wras found. No particular stress was laid 
upon the cardiac trouble, which was regarded as a 
simple endocarditis, which often arises in the course 
of rheumatism. During the course of the rheumatism, 
he had, one month after admission, an attack of pneu- 
monia of the lower lobe of the l ight lung. The fever 
continued and the exhaustion became extreme, and 
finally, one day, after a chill, congestion of the lungs 
took place, and death resulted. The duration of the 
illness was sixty-eight days. 
An interesting feature of this case was the develop- 
ment of malignant endocarditis in the course of rheu- 
matism, and the occurrence, during the disease, of 
pneumonia. 
Pneumonia is often a primary affection in this dis- 
ease. Moreover, in those cases in which the right 
heart is affected, an infarct may form in the lung, 
causing pulmonary apoplexy and associate pneumonia, 
and such was possible in this case. Otherwise, it is 
not liable to complicate endocarditis. 
The irregular fever, the exhaustive sweats, and the 
diarrhoea due to sepsis were marked. The cardiac 
murmur and the dyspnoea caused by the local lesion 
were present, but the occurrence of infarcts was not 
demonstrated during life. Such is a summary of the 
interesting clinical features observed. 
The case from which the second specimens were re- 
moved was N. S., aged twenty-seven years, a German, 
who was admitted to my wards in this hospital, 
August 26, 1886. At the same time, her husband and 9 
children were admitted suffering with some febrile com- 
plaint, thought to be malarial. This is important, as 
indicating that the family were in straitened circum- 
stances, and probably living in an unhealthy locality. 
The patient had been ill for six weeks with an irregular 
fever, said to be malarial. At this time she was nurs- 
ing an infant one year of age. The labor had been 
natural, and she had a good getting up. Three years 
ago she had an attack of malarial fever, and at one 
time had rheumatism of the leg. She never had any 
other ailments, and was strong and hearty, and of 
temperate habits. The family history was good. The 
parents and several brothers and sisters are still living. 
One sister died of pneumonia; the cause of death of 
another is unknown. 
On admission, it is noted that the patient is pros- 
trated, and complained of chilly sensations and of 
nausea, and sweat profusely. The tongue was clean 
and moist. The bowels were loose, there being five 
movements in the twenty-four hours, the stools thin and 
greenish in color. The nausea disappeared in the course 
of twelve hours. There was some tenderness in the epi- 
gastrium, but none in the iliac fossa. The spleen ex- 
tended in the axillary line, from the sixth rib to the 
margin of the ribs. There was no eruption. Both cheeks 
were flushed, the skin and mucous membranes were pale, 
the hands quite anaemic, and the body somewhat ema- 
ciated; the mind was clear. The lungs and heart were 
normal. A nutritious diet, with stimulants and quinia, 
were ordered. Five days later a cardiac murmur was 
detected. The general condition and symptoms were 
about the same. The apex-beat of the heart was in 
the fifth interspace, in the nipple line. The impulse 
was moderately feeble ; there was no thrill. The pul- 
monary second sound was somewhat accentuated. A 
low-pitched, systolic murmur was heard at the apex, 
and transmitted into the axilla. There was no mur- 10 
mur at the aortic orifice. The pulse was rapid, small, 
and feeble. There was no cough nor dyspnoea. Ul- 
cerative endocarditis was suspected. 
September 8th. It is noted that the fever has con- 
tinued, in spite of the use of quinine. There were 
profuse sweats during the day, but not at night. The 
anaemic appearance of the face was marked, and the 
patient was evidently losing flesh and strength. The 
diarrhoea continued. The cardiac murmur had in- 
creased in intensity, and could be loudly heard at the 
angles of both scapulae, especially on the right side. 
There was marked tenderness on pressure, and some 
pain in the third left intercostal space. At the base 
of the right lung, impaired resonance and fine, moist, 
crepitant rfiles were observed. A few rales were also 
found at the right apex. 1'here was short, high-pitched, 
jerking inspiration and prolonged expiration at the 
right apex, and high-pitched inspiration at the left. 
September 12th. Two days ago, two small, purpuric 
spots were observed on both upper eyelids, and to-day, 
hajrnorrhagic infarcts are seen all over the trunk and 
on the upper extremities, pin-head to split-pea size, 
bright red in color, not disappearing on pressure. 
Haemorrhages in the bulbar and palpebral conjunctiva; 
of both eves, at the inner and outer canthus, were also 
seen. The patient was rapidly losing flesh and strength, 
and the sweats continued. The abdomen was distended 
in the epigastric and umbilical region, and a large, 
wavy impulse was detected in the epigastrium. Nausea 
and vomiting had recurred during the past five days, 
and the diarrhoea continued. The spleen was tender, 
and could be readily felt below the margin of the ribs. 
The pulmonary signs had disappeared. There were 
no cerebral symptoms. The heart’s action was irregu- 
lar, and the pulse small, feeble, rapid, and dicrotic. In 
the second interspace to the left of the sternum, a per- 
ceptible thrill was present. The systolic murmur was 11 
not so loud at the apex as it had been. Over the 
third rib, a loud, booming, systolic murmur, wish a 
“grinding” element, was heard. In the second inter- 
space to the left of the sternum, there was heard a 
loud, rough, high-piiched murmur. The pulmonary 
second sound was muffled. The murmur over the 
tricuspid valve was not so distinct as over the mitral 
valve. There was no oedema, and the mind continued 
clear. 
The day following there was a chill. The urine 
was scanty, high-colored, and contained blood and a 
small quantity of albumen. Blood and epithelial tube- 
casts were found in abundance. The chill was repeated 
the next day (14th). The patient was a little more 
drowsy, but there was no delirium. New capillary in- 
farcts were seen about the neck. Infarcts also in- 
volved the lips and end of the tongue. The conjunc- 
tiva; were slightly icterode. For half an hour there 
was severe dyspnoea. The exhaustion increased, and 
the patient died in the early morning of September loth. 
I have here the temperature chart showing the 
course of the fever during the disease. As will be 
seen, there were marked remissions. Twice the tem- 
perature was above 105°, and on one occasion it 
reached 10o.8°. At the same time the pulse was ex- 
cessively rapid and feeble. 
You will observe here again symptoms due to the 
general process, symptoms due to the local cardiac 
trouble, and symptoms due to the infarcts. The case 
presents a most typical example of the evolution of 
the clinical phenomena of malignant endocarditis. 
It is of interest on account of the difficulty of diag- 
nosis. It was at first thought possible that the case 
was one of malarial fever of a remittent type. The 
failure of large doses of quinia to control the fever, the 
appearance of the infarcts and the development of the 
cardiac murmur, led us very soon to abandon the idea 12 
of malaria, ami look upon the case as one of ulcera- 
tive endocarditis. Until the development of the hmm- 
orrhagic infarcts in the skin and the occurrence of 
renal emboli, there was not sufficient evidence to war- 
rant a positive diagnosis, however. Typhoid fever 
was thought of. Many of the cases of malignant en- 
docarditis which have not been regarded as cases of 
intermittent fever have been considered to be cases of 
typhoid fever. In this case there was diarrhoea, en- 
larged spleen, and the occurrence of fever with pros- 
tration. In other cases the typhoid symptoms are 
more marked than in our case, so that a mistake in 
diagnosis is readily made. In this case, as in most in- 
stances, the temperature was not characteristic of ty- 
phoid fever. In the latter disease, the temperature 
follows a certain regular course ; further the abdomi- 
nal symptoms are more marked than in ulcerative en- 
docarditis, the lesions of the heart are absent, the 
pulse is not so frequent, the sweats are not so profuse, 
the haemorrhagic infarcts are wanting, and the rose- 
colored spots characteristic of typhoid fever are found. 
By bearing these points in mind a mistake is not apt 
to be made. A mistake is most likely to be made in 
those cases of typhoid fever in which the temperature 
range is very irregular. 
There are some cases in which typhoid fever occurs 
in a person who already has heart disease. This may 
obscure the diagnosis, but the uniform character of the 
murmur, the absence of capillary infarcts, the absence 
of jaundice and the presence of marked abdominal 
symptoms would lead us to a correct diagnosis. A 
point in the diagnosis of recent malignant endocar- 
ditis from long-standing heart disease complicating 
typhoid or intermittent fever is, moreover, the pres- 
ence of either hypertrophy or dilatation in the latter 
case. You may not be able to differentiate the cases 
from the seat or the character of the murmur, but if 13 
these changes in the structure of the museles were 
noticed, you would infer that the cardiac lesion was of 
long standing, and that a febrile affection had occurred 
in a subject of chronic heart disease. 
At one time, before the cardiac symptoms appeared, 
it was thought that this might be a case of tuberculo- 
sis. The sweats, irregular fever, prostration and the 
occurrence of rales in the lungs pointed in this direc- 
tion, but in our case, as in other cases of malignant 
endocarditis, there was wanting a symptom which is 
usually present in tuberculosis; that is, excessively 
rapid respiration. There was also absence of cause 
which is, however, not of much significance in acute 
miliary tuberculosis. The appearance of the cardiac 
symptoms and the peculiar range of temperature, led 
us to eliminate this affection. 
I have already mentioned that malaria is often sim- 
ulated by ulcerative endocarditis. Many cases treated 
as ague, have turned out to be instances of the pysemic 
variety of malignant endocarditis. The presence of the 
germ of Laverran in the blood, would at once confirm 
the diagnosis of ague, or the presence of pigment in 
the blood and tissues would point to malaria. The 
cases are sometimes very difficult to settle, and due 
attention must be paid to their minor details. 
Where a murmur develops in the course of articular 
rheumatism, it is sometimes difficult to decide whether 
it is due to a septic process or to a simple endocarditis 
which frequently complicates rheumatic affections, if 
in the course of rheumatism ulcerative endocarditis 
sets in, the temperature will be out of proportion to 
the rheumatic manifestations. The physical signs dif- 
fer from those of simple endocarditis. In the latter 
there is a soft, blowing, low-pitched murmur which is 
not so widely transmitted as in the former. The mur- 
mer of simple endocarditis is persistent and of one 
character continually, while the murmur of malignant 14 
endocarditis varies in seat and in intensity from day 
to day. One day it may appear to be limited to the 
mitral valve, the next day, to the aortic valve. This 
variation depends upon the amount of exudation pres- 
ent, and whether or not it is set free in the course of 
the disease. If a large mass of vegetation disappears 
from the valve, the symptoms will change in character. 
This is not the case in simple endocarditis Bearing in 
mmd this difference, and remembering that in simple 
endocarditis, infarcts do not occur, that jaundice does 
not develop, and that the spleen does not become en- 
larged, the differential diagnosis can usually be made. 
The case which I now bring before you is one of 
rheumatism extending over a long period of time, and 
presenting some features which might lead one to in- 
fer the occurrence of malignant endocarditis, but there 
are some other features which negative that idea en- 
tirely. The points suggesting malignant endocarditis 
are the irregular temperature, as is seen from the 
chart, the long continuance of the case, the frequent 
exacerbations after a short period of normal tempera- 
ture and the presence of cardiac lesion. There are, 
however, two or three points which are in opposition 
to this view. In the first place, each exacerbation of 
fever occurred at a time when there was a fresh attack 
of joint pain. During the past two weeks, the joint 
symptoms have been limited to the knee, and have not 
been very marked. The pain complained of is, I think, 
at present largely of an hysterical nature. The patient 
has been under observation six weeks. There is pres- 
ent a murnnir which during the whole time that the 
patient has been under observation has not changed 
its character. The murmur is limited to the mitral 
valve, is low pitched and soft and blowing in charac- 
ter. These are the characters of the murmur of re- 
cent endocarditis. Moreover, the murmur is not 
accompanied by the profound disturbance of circula- 15 
tion that is found in cases of malignant endocarditis 
where there are large vegetations projecting into the 
lumen of the valves. 
A method of differential diagnosis which might be 
of value has not been referred to. Capillary haemor- 
rhages are known to occur in the fundus of the eye 
before they appear in the superficial structures, and 
an examination of the eye-ground would therefore be 
of great service in the recognition of endocarditis. 
The prognosis of malignant endocarditis is, of course, 
extremely grave. There are some cases which are 
said to have recovered, but in these cases, there is an 
element of doubt. It seems impossible that a mistake 
could be made where the local cardiac trouble, with 
the infarcts and the pyaemic symptoms are present. 
The reason that the disease has not been oftener diag- 
nosticated is because it has not been suspected. 
The treatment, as will be inferred from my remarks, 
is unsatisfactory. In the large number of cases it can 
only consist in the treatment of symptoms. The pres- 
ence of micrococci in this disease has only recently 
been demonstrated, and its septic character shown. 
Remedies to counteract the septic process have been 
administered. One case has recently been reported 
by Dr. Samson, in which the administration of sul- 
plio-carbolate of soda in thirty grain doses three times 
a day, had been followed by cure of the patient. 
Apart from the administration of the sulpho-carbolates, 
the use of carbolic acid and the bichloride of mercura in 
minute doses I believe would be valuable. Stimulants 
and iron in large doses, if the stomach will bear it, are 
indicated. It is, however, usually not possible to give 
iron, on account of the vomiting. The treatment of the 
pyrexia also requires attention. In our patient it 
seemed that the administration of antipyrine in five 
grain doses every third hour with a stimulant to pre- 
vent the depressing effects of the drug, was of advan- 16 
tage. Certainly the temperature range was not so 
great after the use of this drug as before, but as 
we have seen from the chart of the first case, the 
temperature is very variable, so that it is difficult to 
judge as to the effect of drugs. The patient also 
received three drops of tincture of belladonna three 
times a day, for the control of the exhausting sweats. 
The diet was of the most nutritious and stimulat- 
ing character, but as happens in most of these cases, 
all treatment was without avail. 
Malignant endocarditis is a disease that was not rec- 
ognized until within recent years. It is a rare dis- 
ease. This is shown by the fact that Dr. William 
Osier, in a thorough search of the literature, was able 
to find only 209 cases. Since his admirable lectures 
were delivered in London two years ago, a great im- 
petus has been given to the study of malignant endo- 
carditis, and many cases are now recognized which be- 
fore were entirely overlooked. The lines of investiga- 
tion which have been pursued and which are still being 
pursued are in the direction of the explanation of the 
septic process, and the relation of malignant endocar- 
ditis to pneumonia, rheumatism and other infectious 
diseases.