All cases of bacterial endocarditis confirmed or diagnosed at autopsy in the Philadelphia General Hospital during two periods were studied. Each period included approximately 10,000 consecutive autopsies. They were designated period I, the pre-antibiotic era, and period II, the antibiotic era. In period I there has been a significant decrease (p < 0.001) in the number of cases of bacterial endocarditis observed at autopsy. Infection in period II has been replaced by congestive heart failure in period II as the most common cause of death. Perforations of heart valves have increased from 15.6 per cent in period I to 44.5 per cent in period II, and are associated with most cases (64.5 per cent) of congestive heart failure in period II. The relationship of perforations of the valves to duration of illness, age of patient, valve involved, pre-existing valvular disease, adequacy of treatment and causative organism was studied. It is concluded that changes in the group of organisms associated with fatal cases account for the increase in perforations observed in period II, and that perforations of the valves secondary to the bacterial infection are responsible for the increased incidence of congestive heart failure.
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