Malignant Endocarditis with Vegetations in 
the Right Auricle, and a Perforation of the 
Inter-Auricular Septum; Mitral and Aortic 
Regurgitation. 
CLINICAL LECTURE DELIVERED AT THE POST-GRADUATE MEDICAL 
SCHOOL, CHICAGO. 
BY JOHN A. ROBISON, A.M., M.D., 
Adjunct Professor of Medicine in the Rush Medical College; Professor of General 
Medicine in the Post-Graduate Medical School; Attending Physician 
for Throat Diseases and Internal Medicine, Presby- 
terian Hospital, etc., Chicago. 
[Reprinted from International Clinics, Vol. I., Fifth Series.] MALIGNANT ENDOCARDITIS WITH VEGETATIONS 
IN THE RIGHT AURICLE, AND A PERFORATION 
OF THE INTER-AURICULAR SEPTUM; MITRAL 
AND AORTIC REGURGITATION. 
CLINICAL LECTURE DELIVERED AT THE POST-GRADUATE MEDICAL SCHOOL, 
CHICAGO. • 
JOHN A. ROBISON, A.M., M.D., 
Adjunct Professor of Medicine in the Push Medical College; Professor of General 
Medicine in the Post-Graduate Medical School; Attending Physician 
for Throat Diseases and Internal Medicine, Presby- 
terian Hospital, etc , Chicago. 
Gentlemen,-In my previous lectures I have made the statement 
that disease of the right side of the heart is generally due to intra- 
uterine or congenital causes. It is seldom that we have an opportunity 
to study a case in adults of post-congenital origin, but I am especially 
fortunate in being able to present to you to-day the report of a case of 
disease of the right side of the heart in which.the tricuspid valves 
were involved. This patient some of you saw with me in the hospital 
a few days ago. • The history was as follows : 
L. W. entered the Presbyterian Hospital on the 21st of December, 
1894. He is a boiler-maker by occupation, single, twenty-one years of 
age. Family history good. About fourteen months ago he fell from a 
scaffold, striking his chest upon the ground in the region of the heart. 
The marks of the injury were visible in the praecordial region. There 
was osteomyelitis of the left fourth, fifth, and sixth ribs near their 
costo-sternal articulations. He thought he was injured internally also, 
and was confined to his bed for several days. Since that time he has 
suffered a good deal of pain in the praecordial region, but has never 
been seriously ill until nine weeks ago, when he noticed shortness of 
breath, pain in the region of the heart, in the back, and his legs were 
slightly swollen before he came to the hospital. You will notice that 
he cannot lie down in bed. His movements are painful. There is an 
anaemic and pallid appearance of the face and anxious countenance, 
Vol. I. Ser. 5.-7 97 . 98 
INTERNATIONAL CLINICS. 
with slight cyanosis. His skin is covered with a profuse, cold perspi- 
ration. The respirations are shallow and rapid; his tongue is furred ; 
his digestion very poor. He has no appetite; there is great thirst, and 
the bowels are constipated. His most troublesome symptoms are 
dyspnoea and insomnia. 
Physical examination of the heart .shows the apex beat is very 
slightly moved downward and to the left, but there is marked increase 
Fig. 1. 
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in the superficial and deep areas of cardiac dulness; the transverse 
diameter of the heart seems increased ; there is also epigastric pulsation 
and lessening of the oblique angle between the heart and the liver. 
There is a blowing systolic murmur heard a little above and to the left 
of the ensiform cartilage, which becomes less towards the apex. You 
also notice excessive jugular congestion and a venous pulse. 
Temperature chart of a case of malignant endocarditis. MALIGNANT ENDOCARDITIS. 
99 
I here show you a chart of the temperature, pulse, and respirations 
from the time of the patient's entrance to the hospital (the 21st of 
December) until his death on the 3d of January. (Fig. 1.) The highest 
temperature at any one time was on the second day, when it was 105° 
in the afternoon, pulse 120, respirations 28. In the forenoon of the 
fourth day the temperature fell to 95.4°, pulse 78, and respirations 15. 
In the afternoon, about 2 p.m., he had a severe chill, and the temper- 
ature rose to 103°, pulse 148, respirations 36. The next day it was 
normal in the morning, and rose to 102° in the afternoon, and fluctu- 
ated between 104° and 99.4° until noon of the 3d of January, when 
he died. On the ninth day after admission to the hospital he had a 
slight chill in the afternoon, on the tenth there was extreme dyspnoea, 
and the next day the pulse became very weak, irregular, and intermit- 
tent, and finally he died from cardiac exhaustion. You will notice 
from the chart that the pulse varied in its frequency as well as the 
respirations. 
The following sphygmographic tracing (Fig. 2) was taken the third 
day after the patient's admission into the hospital. It will be noticed 
Fia. 2. 
Sphygmographic tracing of the pulse in malignant endocarditis. 
that this tracing is similar to that which we obtain in aneurism of the 
ascending portion of the arch of the aorta. There is evidently re- 
tardation of the pulse-waves, and there is not sufficient elastic recoil 
of the arteries to produce the ordinary curves. 
The physical signs that have already been elicited point to the fact 
that the disease is due to insufficiency of the tricuspid valves. What 
form of disease would produce tricuspid insufficiency? It might be 
simple endocarditis or malignant endocarditis, or an infectious disease 
with endocarditis, or the result of chronic valvular disease. In simple 
endocarditis there is generally present rheumatic fever with no marked 
symptoms of cardiac disease; whereas in malignant endocarditis there 
need not necessarily be any rheumatism; the constitutional symptoms 
are more severe, and indications of grave heart-disease rapidly develop.. 
The patient is subject to rigors, profuse perspirations, and intermittent 
or remittent forms of fever, and embolic infarctions may occur. 
Typhoid or py?emic symptoms are common, and the disease is gen - 
erally fatal and runs a rapid course. Again, malignant endocarditis 100 
INTERNATIONAL CLINICS. 
might be mistaken for typhoid fever; but the former disease begins 
abruptly, progresses rapidly, high temperature* is remittent, and the 
remissions frequently fall below normal; whereas in the latter disease 
there is a gradual rise and fall of temperature before and after the 
fastigium. In malignant endocarditis the pulse is increased in fre- 
quency independently of the fever; whereas in typhoid the pulse is 
increased coincidently with the fever. In malignant endocarditis there 
is evidence of valvular heart-disease in the earliest stages; the symp- 
toms of embolic infarction are common; whereas in typhoid fever 
there is seldom endocarditis; the abdominal symptoms are marked 
and characteristic of the fever; and, finally, there is the presence of 
the typhoid bacillus. 
Again, malignant endocarditis may be confounded with ague. In 
the former disease, however, the intermissions are seldom regular; 
whereas in the latter they are. The constitutional symptoms are more 
severe in the former, and the latter runs a longer course and is seldom 
fatal. Finally, no evidence exists of disease of the other valves. 
Therefore all signs point to the fact that this case is one of malignant 
endocarditis affecting the right side of the heart. 
It is stated that malignant endocarditis more frequently affects 
women than men, being especially liable to accompany puerperal fever. 
It is also stated that not over two per cent, of the cases of endocarditis 
that arise after birth occur in the right side of the heart. 
There is, undoubtedly, a casual relation between the osteomyelitis 
that we find present and the existing malignant endocarditis; and 
there is little doubt in my mind that the commencement of this disease 
dates from the time of his injury fourteen months ago. There was, 
doubtless, endocarditis produced then, and vegetations were formed, 
and the disease recently assumed a malignant form. 
Post-mortem.-This heart weighs thirteen ounces; the aortic and 
pulmonic valves are normal. There is no hypertrophy of the left ven- 
tricle, but there is a slight degree of hypertrophy in the right ventricle, 
which measures at its thickest part three-eighths of an inch. There 
is dilatation of the right auricle, it holding about an ounce and a half 
of fluid. At the base of the front anterior segment of the tricuspid 
valve upon its auricular surface there is a vegetation about an inch in 
length, situated upon an oblong base half an inch long and one-quarter 
of an inch wide, and projecting into the cavity at least half an inch. 
Near the end of the vegetation on the auricular septum, just at the 
upper margin of the auriculo-ventricular cavities, there is a perforation 
leading from the right auricle into the left auricle, piercing the walls of Fig. 3.-Interior of right auricle and ventricle. A bristle has been 
introduced into the perforation in the inter-auricular septum. Upon the 
auricular surface of the anterior segment of the tricuspid valve a large 
vegetation with an oblong base is situated. 
Fig. 4.-Interior of left auricle and ventricle. A bristle is seen protruding 
from the inter-auricular septum just below the aortic valves. The perforation 
measures one-quarter of an inch in diameter. The ventricular walls are not 
hypertrophied. MITRAL AND AORTIC REGURGITATION. 
101 
the latter just below the aortic valves. This perforation is one-quarter of 
an inch in diameter. Dr. D. D. Bishop made cultures from the granu- 
lations and demonstrated the presence of the staphylococcus pyogenes 
aureus. Examination of sections of the granulations demonstrates 
the presence of the same organism. The examination of the specimen 
shows that there were, undoubtedly, three abnormal currents of blood 
produced during the heart's action: (1} A tricuspid direct current; 
(2) a tricuspid regurgitant current; and (3) a current from the left side 
of the heart into the right side through the perforation during systole. 
During the systole of the heart a murmur would be produced which 
was heard, as has already been stated, over the lower portion of the 
sternum near the ensiform cartilage ; but this murmur was lost as we 
approached the base or apex of the heart. The cause of the jugular 
congestion and venous pulse was undoubtedly the dilated condition of 
the right auricle and the tricuspid insufficiency, as has been admirably 
explained by Paul, which permits the blood propelled by the ventricle 
to flow back into the vein. 
The photographs show the position of the granulations above the 
tricuspid cusp and the perforation in the septum. (Figs. 3 and 4.) 
Recapitulation of the Signs and Symptoms of Tricuspid Incompe- 
tence.-Dilatation of the right auricle and ventricle lessens the supply 
of blood to the systemic arterial circulation, and the normal sphygmo- 
graphic tracing is lost; at each contraction of the right ventricle the 
backward flow of blood into the superior and inferior vense cavse pro- 
duces a venous pulsation in the neck and sometimes in the liver. 
There is a soft-blowing systolic murmur in the tricuspid area, propa- 
gated upward and to the right. There is increased dulness over the 
lower end of the sternum and epigastric cardiac impulse. These 
patients suffer from dyspnoea and insomnia. I think there is such a 
disturbance of the cerebral circulation that it causes sleeplessness. 
Having reviewed the signs and symptoms that accompany tricuspid 
regurgitation, I desire to relate a case of mitral and aortic regurgi- 
tation to illustrate the difference in the signs and symptoms which 
occur in the separate forms of disease. 
F. C., single, American, aged twenty-three years ; admitted to the 
hospital December 17, 1893. Several years ago he had an attack 
of pneumonia, followed in two months by inflammatory rheumatism. 
The rheumatism was brought on by exposure to cold, and he was con- 
fined to his bed for seven months, after which he apparently completely 
MITRAL AND AORTIC REGURGITATION. 102 
INTERNATIONAL CLINICS. 
recovered. The patient then went to California and remained well for 
a time, working at blacksmithing. In January, 1891, he noticed that 
he was short of breath during active exercise. A second attack of 
rheumatism confined the patient to bed for two weeks. Soon after 
this, however, he began to work at times, but not steadily. Subse- 
quently he felt weak and fainted several times, and had great distress 
in the heart. This was followed by oedema of the lower extremities, 
anasarca, and ascites. Patient's habits are temperate. On inspection 
we notice anaemia, puffiness of the eyelids, blue lips ; skin is pale; pulse 
very weak and variable; has a great deal of thirst; pulsation of the 
carotids and venous pulsation of the external jugular; hands club- 
shaped ; cyanosis of the finger-tips and lips; apex-beat of the heart is 
four inches below and one inch to the left of the nipple. By palpa- 
tion, there is marked fremitus over the prsecordial region; the apex-beat 
strikes forcibly against the chest-wall; the pulse is full, but recedes 
rapidly from the fingers ; the areas of heart-dulness are increased ; the 
deep area of cardiac dulness extends from the right edge of the sternum 
at the junction of the second rib down to the ensiform cartilage, then 
to the left about four inches below the nipple, one inch to the left of 
the mammary line; then upward around the nipple in a curved line to 
the sternum with the junction of the second rib. On auscultation there 
is a murmur at the apex during systole transmitted to the left, also a 
murmur at the base of the heart with the second sound. His pulse 
varied during his stay in the hospital from 82 beats to 120; tempera- 
ture was either normal or subnormal; respirations from 22 to 30. 
The amount of urine varied from seventeen to twenty-nine ounces 
daily. From the 5th until the 16th of January he expectorated 
a slight amount of blood daily, and a portion of the time he was 
delirious at night. He had severe attacks of retching and slight 
vomiting. Urinalysis on January 3 showed the urine dark, amber 
color, alkaline reaction, specific gravity 1022; albumen sixteen and a 
half per cent. ; phosphates. January 6, urinalysis, same result, except 
the specific gravity was raised to 1030. January 13, color dark brown, 
reaction neutral,specific gravity 1025 ; albumen eighty percent.; phos- 
phates in the blood. 
The patient was given alcoholic sweats daily, and a diuretic pill, 
composed of one grain each of powdered digitalis, nitrate of potash, 
extract of buchu, and citrate of caffeine, three times a day for several 
days. A short time thereafter the albumen began to disappear from 
the urine, the ascites and anasarca became less, the patient's appetite 
returned, and he convalesced so that he was able to return to his home. MITRAL AND AORTIC REGURGITATION. 
103 
The hypertrophied heart in this case caused the arteries to be sud- 
denly filled with blood at each systole, and the aortic regurgitation 
allowed them to be as quickly emptied, producing the characteristic 
water-hammer pulse. The area of cardiac dulness extended downward 
and to the left, and the murmurs were propagated in their usual direc- 
tions respectively. 
The mitral regurgitation caused dyspnoea, orthopnoea, oedema, ana- 
sarca, and albuminuria in their turn, while the aortic regurgitation 
produced the painful symptoms of over-distention of the heart cavities, 
cardiac distress, palpitation, intermittent and irregular heart-action, and 
syncope. The pulmonary circulation was greatly embarrassed, as evi- 
denced by cyanosis and haemoptysis. 
Having looked upon these clinical pictures, the question of treat- 
ment presents itself. Unfortunately, the first case was one in which 
treatment is of little avail. Had it been a case of simple tricuspid 
incompetency without any malignancy, the treatment could be summed 
up in a few words: treat tricuspid incompetency in the same manner 
as mitral incompetency. 
Before the failure of compensation the treatment of mitral incom- 
petency, simple or complicated with aortic incompetency, should consist 
in maintaining nutrition at its highest perfection, by giving easily 
assimilated diet, keeping the digestive and eliminating organs active, 
having a serene mind, a quiet life, taking gentle exercise in the open 
air, and the avoidance of excesses of all kinds, Turkish baths and 
strong purgations. In the latter stages of the disease give cautiously 
the cardiac tonics, and treat the symptoms as they arise.