had been at variance as regards symptoms, blood pictures, age incidence, cardiac signs and symptoms, variations in the streptococcus cultures, and the diverse lesions of the disease.

Our observations have illustrated possibility of correct diagnosis without cultures, and they have shown the frequent diagnostic mistakes of the pre-culture period.

in order to obtain a positive culture. In other words, one must not be satisfied with but one attempt, or with one bacteriologist. The necessity of repeated cultures, I feel may be due to faulty bacteriological technique.

My experience with blood cultures has been that some cultures have been reported positive within twentyfour hours. Ninety-six hours is the

Dr. F. R., aged sixty-two, had had an old mitral and aortic lesion since his eighteenth year. At this time, he thought he had rheumatic fever. While playing golf, he got wet feet and was chilled. He went to bed immediately with gastrointestinal symptoms, fever to 105°, nausea, poor appetite, dyspnea, anginoid pains, myalgia and arthralgia. Streptococcus viridans was found in the blood culture during the first week. The leucocyte count was 48,000. I had never before observed a case of this acute type. He lived three weeks. The autopsy showed mitral vegetations with large vegetations on the left auricular wall and on the aortic valves. The specimen is at the Pathological Laboratories of the Washington University Medical School.

C. S., aged sixty-one, in December, 1922, contracted mild influenza. He had hiccoughs for thirteen days and was greatly prostrated. He was removed to Barnes Hospital. His condition was of the low septic type. He had to my knowledge an old mitral lesion. Blood cultures were requested, and at five different periods, cultures were made, but no growth obtained. The sixth blood culture was taken by a different bacteriologist and showed very numerous colonies of Streptococcus viridans.

Libman and others have called attention to the oft-repeated attempts which are frequently necessary

waited for a positive report. Others have found that six days are sometimes necessary for the appearance of the positive growth.

In 1916, I saw in consultation, G. L., aged sixteen, a high-school boy, with an old mitral valvular lesion well compensated. A mild attack of laryngitis ushered in the early symptoms which were of a mild septic type. The blood culture showed Streptococcus viridans. In a short period the temperature became high, with irregular chills, and a great tenderness over an enlarged liver was elicited. Liver abscess was diagnosed. An operation was performed, but no abscess was found, but instead, myriads of petechial hemorrhages and miliary lesions were observed. The boy made to all intents a successful recovery. He returned to high school and later entered college where he participated in mild athletic sports. During the summer of 1923, he was again bedridden with the previous symptomatology. He was removed to Barnes Hospital where the Streptococcus viridans was found in the blood culture. Death occurred in September, 1923.

The peculiarity of this case is the interval of seven years between attacks. We felt certain of the correctness of the clinical and bacteriological report of 1916.

The remaining cases show nothing of unusual interest and ran a course

varying from a few weeks to eleven months in duration. The 17 cases all told present a varying panorama, rather intense and interesting, especially during the late or embolism period of the disease. We have observed infarctions, small aneurysms, hemorrhages,

inflammation. Suppuration I have never observed. I have noted that practically any age that has an old valvular lesion is prone to this infection. Four of my cases were individuals over sixty years of age. The history in the majority of my cases began with a throat infection; one was prostatic; the others, indefinite. All had chronic heart lesions.

The usual blood count for white cells has only in one instance gone over 20,000. That was an acute case with a leucocyte count of 48,000. The usual figure has ranged between 12,000 and 15,000, and in one instance, a normal leucocyte count was reported.

To 7 of these patients I was the family physician previous to the attack of subacute endocarditis, and all had heart valve lesions, that were well compensated.

When one observes for a period of time a heart lesion accompanied by a fever of irregular remittent type, with loss of weight, joint pains, myalgia, progressive anemia of secondary type, anorexia, leucocytosis

of moderate degree, and all characteristics of a mild or moderate septicemia-with such symptomatology, persistent blood cultures should be made, and in 90 per cent of such cases, according to Harder and others, the organism will be found.

As to treatment, we have faithfully tried all the arsenicals, including cacodylates, neo-arsphenamins. We have given quinine hydrochloride, salicylates, mercurials, both in large doses intravenously and in the varying doses suggested by others. We have given the ordinary vaccines, both autogenous and stock preparations, and we tried out lipoid autogenous vaccines in 1 case.

Blood transfusions have been given many times.

All types of tonics and foods were selected.

Up to the present time our results show death in 100 per cent of the cases. Billings, in 100 cases he has seen, says that 97 per cent died. Libman thinks 4 out of 150 of his cases recovered.

In conclusion, with the observations noted up to the present time, in cases where an old valvular lesion is accompanied by the symptomatology given, and a positive Streptococcus viridans culture is obtained, the prognosis is extremely grave. Mortality is almost 100 per cent.

I

N OUR experiences with blood cultures we have isolated Strep tococcus viridans in 40 cases. Our relationship to these cases was that of clinical pathologist and from the nature of this relationship our clinical observations are necessarily incomplete. We have been interested in the bacteriological, pathological and clinical aspects of the

cases.

We may find reports of Streptococcus viridans sepsis without endocarditis. This organism is said to occur in the blood in rheumatic fever in rare instances. We must bear in mind these observations in the interpretation of blood cultures, and we must also bear in mind the possibility of error in the laboratory.

All of the 40 Streptococcus viridans blood cultures in our series were in cases of Streptococcus endocarditis. No other types of cases are represented. The clinical and bacteriological diagnoses received confirmation by a fatal termination in every case.

We may all agree on the importance of blood cultures; we may all say with Blumer: "A positive blood culture is the most important diagnostic sign" in subacute bacterial endocarditis,

Read before the American Congress on Internal Medicine, St. Louis, Mo., February 18 to 23, 1924.

but we, no doubt, hold opinions in regard to blood cultures in this disease which do not entirely harmonize.

Our experience has been peculiar in that in each of the 40 cases the streptococcus was found in the first culture; when cultures were repeated they were found positive in the same degree as the first culture. We have never made a diagnosis by repeated cultures.

We do not wish that our position be misinterpreted. We do not claim that we have never failed to isolate the streptococcus in cases of streptococcus endocarditis, but we can say that no one has to date brought us proof of our failure. The point we wish to emphasize is that the streptococcus is rarely absent from the blood in this disease. We are certain that it is not demonstrated as often as it should be.

Six of our cases had given negative cultures in other laboratories. Several of them had been repeatedly negative. Two of these cases we cultured only a few days after negative cultures had been obtained, and we found very numerous colonies.

We favor the opinion that the reported bacteria-free cases frequently represent faulty laboratory technique.

Our technique for blood cultures is extremely simple. We collect the blood in citrate solution, and the blood is taken to the laboratory where a

flask of glucose broth and three agar plates are inoculated. The broth cultures have always been positive. Possibly twice in our series the plates have remained sterile. In the latter cases the cultures were repeated with the same result.

Many of our cultures were positive within twenty-four hours; with few exceptions they were positive within forty-eight hours; very few did not become positive until the third or fourth day; no cultures became positive after the fourth day.

It has been observed that there are many variations in the streptococcus cultures which have been isolated in cases of subacute streptococcus endocarditis. We have made no attempt to study the variations in sugar reactions or the serological variations We did observe the following variations: Some few cultures were not true viridans as no pigment was produced; some viridans cultures produce

hemolysis; only one culture would not grow on the surface of blood agar; one culture produced large colonies suggestive of staphylococcus; variations in the time of the appearance of visible colonies have been noted.

We have never observed a cure in subacute streptococcus endocarditis; but, as in cancer, we have no reason to doubt that spontaneous recovery may take place. Some of the reported cures of viridans endocarditis are not well substantiated from the standpoint of diagnosis. As stated, a positive blood culture in rare instances does not mean endocarditis, and if endocarditis is present it may not be of the type under consideration. When the disease is diagnosed on the basis of repeated positive blood cultures together with the essential signs and symptoms we expect fewer "cures" until a more successful therapy is devised.

W

HEN one stops to consider that digitalis has been used almost as long as the United States has been a nation, it is surprising that so many phases of its action are still not understood. If one were to put certain questions to this Congress does digitalis slow the pulse, does it act upon the heart muscle, does it produce diuresis, is it effective only in auricular fibrillation, should it be used in pneumonia?-if one were to put such questions I dare say there would be a variety of answers. One of these questions I wish to discuss briefly: i.e., the effect of digitalis upon the ventricular rate.

A large part of the misconception upon this question that exists in the minds of many clinicians is due to the fact that cases are often not properly differentiated. Patients with auricular fibrillation must be clearly distinguished from others.

We know that digitalis slows the ventricular rate when this is rapid as a result of auricular fibrillation, and we know that it does so by depressing the conductivity of the a-v connecting tissues. Upon this all are agreed. But does it slow the rate of a rapid ventricle when the auricle is contracting nor

Read before the American Congress on Internal Medicine, St. Louis, Mo., February 18 to 23, 1924.

mally? This question would receive different answers.

I am convinced, and I think most of you will agree, that digitalis does not slow the pulse, through any direct action, in patients with normal cardiac mechanism. We have been studying, at Barnes Hospital, the effects of the drug in such cases. I had the pleasure of going over our results with some of you during this meeting and showed you the records of patients who underwent striking improvement as a result of digitalis administration-patients with normal mechanism. These patients showed diuresis, they lost weight, their symptoms improved in impressive manner, but they did not show any slowing of the pulse until they got better. Such patients as had an increased pulse rate did show slowing, if there was improvement otherwise, but the reduction in pulse rate followed the improvement. The patients who had a normal rate to begin with showed no slowing along with the improvement from digitalis. In adults one should not expect slowing in patients with normal cardiac mechanism as a direct effect of digitalis. Dr. McCulloch found slowing in children with sinus rhythm, but in adults a reduction of ventricular rate should not be an object of digitalis therapy when the mechanism is normal. Digi