NOTES ON 250 CASES OF SUBACUTE BACTERIAL (STREPTOCOCCAL) ENDOCARDITIS STUDIED AND TREATED BETWEEN 1927 AND 1939

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Abstract
A series of 250 well-substantiated cases of subacute bacterial (streptococcal) endocarditis studied in 5 Boston hospitals and in private practice from Jan., 1927, to Mar., 1939, has been analyzed. All the patients had cultures positive for nonhemolytic streptococci of the a (viridans) or, rarely, the [gamma] (anhemolytic) variety. The ratio of positive cultures to all cultures taken was 74.4%, being 66.8% from 1927 through 1932 and 78.8% from 1933 through 1938. The [male] sex was preponderant in the ratio oi about 2 to 1 (161 to 89, or 64.4% to 35.6%). The avg. age of the entire group was 31.8 yrs., with a range from 2 1/2-78. The average age of [female][female] (25.7 yrs.) was less than that of [male][male] (35.2 yrs.). The great majority of the 250 cases had rheumatic heart disease (224 or 89.6%). Mitral valve involvement alone was diagnosed in 96 cases (42.9% of the rheumatic group). Aortic valve involvement was diagnosed in 130 cases (58% of the rheumatic group). Congenital defects were diagnosed in 13 patients or 5.2% of the 250 cases, including 5 instances of patency of the ductus ar-teriosus and 5 cases of ventricular septal defect. The most common predisposing cause of the illness in the cases studied, if so-called grippe is excluded, was some dental procedure, especially extraction. It is estimated that almost 1 in 4 cases of subacute bacterial endocarditis will give such a history. The incidence of salient clinical findings in this group of 250 cases was as follows: heart murmurs in 992%, petechial hemorrhages in 86.5%, palpable spleen in 59%, hematuria ''in 49%, clubbed fingers in 46.7%, and chills in 40.5%. Analysis of this series revealed instances of the concurrence of rheumatic fever and subacute bacterial endocarditis. The latter diseases may serve as a factor to activate rheumatic fever in susceptible individuals, and also bacterial endocarditis may arise during the course of rheumatic infection. Of the 250 eases of subacute bacterial (streptococcal) endocarditis studied, 246 were adequately followed up and all died of the disease except one who succumbed to rheumatic myocarditis after a period of 1 yr. of freedom from evidence of bacterial endocarditis. The duration of the disease to death averaged 5.9 mos., with longer duration for [female][female] (7.0 mos.) than for [male][male] (5.3 mos.). The numerically largest group survived 3-4 mos., the second largest 4-5 mos. The longest survivor lived 19 mos. An appreciable number[long dash]18[long dash]lived more than a yr. No therapy was curative. Therapy included whole blood transfusions in 45 patients, and transfusions from immunized donors in 3 cases, and from a "recovered" patient in 1, bacteriophage in 8, autogenoua vaccines in 9 cases, stock vaccines in 2, antistreptococcal serum of various kinds in 7 and inoculation with living organisms from the patient''s blood in 5. Intramusc. injs. of sterile milk and of turpentine were administered in 2 cases each, and hyperthermia, radio-therapy, and ultraviolet radiation in a few scattered instances. Various chemicals were used, including Na caco-dylate in 4, neoarsphenamine in 2, metaphen in 2, acriflavine in 2, gentian violet in 3, mercurochrome in 3, and in the early days of sulfonamide therapy, Prontosil in 5, sulfanil-amide in 24, and sulfapyridine in 4. Use of this last group of drugs was followed in some cases by reduced fever and negative blood cultures, neither of which persisted.

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