If pneumonia or gonorrhea is supposed to be the cause of the endocarditis, injections of stock vaccines should perhaps be used. If the form of sepsis is not determinable, streptococcic or staphylococcic vaccines might be administered. It is still a question whether such "shotgun" medication with bacteria is advisable. Patients recover at times from almost anything, and the interpretation of the success of such injection treatment is difficult. Exactly how much harm such injections of unnecessary vaccines can produce in a patient is a question that has not been definitely decided. Theoretically an autogenous vaccine is the only vaccine which should be successful. The vaccine treatment of ulcerative endocarditis was not shown to be very successful by Dr. Frank Billings [Footnote: Billings, Frank: Chronic Infectious Endocarditis, Arch. Int. Med., November, 1909, p. 409.] in his investigation, and more recent treatment of this disease, when caused by the Streptococcus viridons, by antogenous vaccines has confirmed his opinion.
Other treatment of malignant endocarditis includes treatment of the condition which caused it plus treatment of "mild" endocarditis, as previously described, with meeting of all other indications as they occur. As in all septic processes, the nutrition must be pushed to the full extent to which it can be tolerated by the patient, namely, small amounts of a nutritious, varied diet given at three-hour intervals.
Whether milk or any other substance containing lime makes fibrin deposits on the ulcerative surfaces more likely or more profuse, and therefore emboli more liable to occur, is perhaps an undeterminable question. In instances in which hemorrhages so frequently occur, as they do in this form of endocarditis, calcium is theoretically of benefit. Quinin has not been shown to be of value, and salicylic acid is rarely of value unless the cause is rheumatism.
Alcohol has been used in large doses, as it has been so frequently used in all septic processes. If the patient is unable to take nourishment in any amount, small doses of alcohol may be of benefit. It is probably of no other value. It is doubtful whether ammonium carbonate tends to prevent fibrin deposits or clots in the heart, as so long supposed. In fact, whenever the nutrition is low and the patient is likely to have cerebral irritation from acidemia, whenever the kidneys are affected, or whenever a disease may tend to cause irritation of the brain and convulsions, it is doubtful if ammonium carbonate or aromatic spirit of ammonia is ever indicated. Ammonium compounds have been shown to be a cause of cerebral irritation. Salvarsan has not been proved of value.
Intestinal antisepsis may be attained more or less successfully by the administration of yeast or of lactic acid ferments together with suitable diet. The nuclein of yeast may be of some value in promoting a leukocytosis. It has not been shown, however, that the polymorphonuclear leukocyte increase caused by nuclein has made phagocytosis more active.
Malignant endocarditis may prove fatal in a few days, or may continue in a slow subacute process for weeks or even months.
CHRONIC ENDOCARDITIS
It is not easy to decide just whew all acute endocarditis has entirely subsided and a chronic, slow-going inflammation is substituted. It would perhaps be better to consider a slow-going inflammatory process subsequent to acute endocarditis as a subacute endocarditis; and an infective process may persist in the endocardium, especially in the region of the valves, for many weeks or perhaps months, with some fever, occasional chills, gradually increasing valvular lesions and more or less general debility and systemic symptoms. Such a subacute endocarditis may develop insidiously on a previously presumably healed endocardial lesion and cause symptoms which would not be associated with the heart, if an examination were not made. Sometimes such a slow-going inflammatory process will be associated with irregular and intangible chest pains, with some cough or with many symptoms referred to the stomach, so that the stomach may be considered the organ which is at fault. There may be dizziness, headache, feelings of faintness, sleeplessness, progressive debility and a persistent cough, with some bronchial irritation and with occasional expectoration of streaks of blood, which may cause the diagnosis of incipient tuberculosis to be made. The need of a careful general examination must be emphasized again before a decision is made as to what ails the patient, or before cough mixtures are given unnecessarily, quinin is prescribed for supposed malarial chills, or various diets and digestants are recommended for a supposed gastric disturbance.
The term "chronic endocarditis" should be reserved for a slowly developing sclerosis of the vavles. This may occur in a previous rheumatic heart and in a heart which has suffered endocarditis and has valvular lesions, or it may occur from valvular strain or heart strain from various causes; it is typically a part of the arteriosclerotic process of age, and is then mostly manifested at the aortic valve.