The Woman's Medical Journal. A Monthly Journal Published in the Interests of Women Physicians January, 1917 STREPTOCOCCUS VIRIDANS SYSTEMIC BY JOSEPHINE WALTER, M.D., This paper is presented under the title of "streptococcus viridans systemic infection," rather than under the title of "bacterial endocarditis," be cause: "be A, as will be seen later when the case, in illustration of this paper, is described, while the streptococcus viridans was found in the circulating blood, the symptoms referable to the heart were negative. B, the case offers many interesting points, as a systemic infection,-in its bacteriology,-in its clinical course,--in its treatment,-in its termination in recovery, followed, in little more than a year later, by a typhoid fever, and again re covery. C- the writer desires to emphasize, through this case, the probability of the greater frequency of this organism in many conditions not at all suspected,-in many conditions almost obstinately ignored, and again in many conditions fully recognized. Perhaps this neglect may be due to the fact as Horder says, "most physicians are accustomed to think of this disease as an acute, fulminating process, attended by high temperatures, grave symptoms, and running a fatal course. For one such type there are a dozen in which the onset is insidious, and the course prolonged." D, the writer desires to prove that in some cases of streptococcus viridans infection, endocarditis plays no role,-that in other cases it may be so localized (mural, auricular) and circumscribed, as to play but an insignificant role,-and in cases where it does play a role, it may be an old endocarditis, long quiescent, such as due to former rheumatism, syphilis, scarlet fever, measles (the third cause, according to Wunderlich of early endocarditis and a cause very much ignored), this old endocarditis being activated anew by this organism in the circulating blood, thus the previously injured, diseased endocardium being an attractive nidus for its infectious activity. E- it is the belief of the writer that the slight, almost insignificant symptoms which may or may not bring a patient to a doctor, in the earlier days of the infection, are due to the toxaemia (general, systemic)-and the latter, more significant symptoms, are due to its action on the endocardium. *Read at the annual meeting of the Woman's Medical Society of the State of New York, May 15, 1916, at Saratoga Springs. $2 per year in advance 3 HISTORY OF THE STREPTOCOCCUS VIRIDANS. having no capsule,-no hemolytic property, and Further differentiation tests have been added, No one organism, with the exception of perhaps viridans culture, and a culture of this animal's blood, after death, gave a pure pneumococcus, also, he changed a streptococcus hemolyticus (an organism known to affect joints), in symbiosis with a bacillus subtilus, on blood-agar, into a streptococcus viridans, which, when injected into healthy animals, produced not joint disease, but endocarditis. He has effected the same change of the pneumococcus into the hemolyticus, and vice versa, and during these transformations the viridans was always, noticeably, one of the intermediate strains. These experiments of Rosenow are very suggestive, and the writer strongly urges attention to them by every one interested in the study of diseases due to infection,--and who shall say which disease is not due to infection! These studies of Rosenow are emphasized, because, A-, in the different strains he obtained by transmutation, were (1), the hemolyticus, having affinity for joints (rheumatism),--(2), the pneumococcus having affinity for the lungs (pneumonia) and other tissues,-(3), the viridans, having affinity for both mucous and endocardial tissues (endocarditis, tonsillitis, etc), (4), the mucosus, having affinity for the gastro-intestinal tract (appendicitis, ulcer), and, B, specially, because he - specially, because he makes a point which it would be well for all of us as clinicians, to bear in mind, namely, that these transmutations are favored, or prevented, by certain local (artifical) conditions:10 AOxygen tension,- BB, Salt concentration,C, Symbiosis with other bacteria, DClosed cavities,--, all of which conditions can exist in the human, and similarly modify organisms from focal lesions. A table prepared by Davis,1 demonstrating, as regards the properties of (a), color, of (b), hemolysis, of (c) capsule, of (d) solubility in bile, of (e) effect on inulin, of (f) result as to experimental arthritis,— and experimental endocarditis, of these different strains, is strongly corroborative of Rosenow's work. This author significantly says, "emphasis has been placed on minute, and often unimportant details as to points in the differentiation of the organisms, rather on the points which might help demonstrate their close relationship." 11 DISTRIBUTION OF THE STREPTOCOCCUS VIRIDANS. This organism is found in the human suffering from disease, and in the perfectly healthy. It has a very wide distribution. It lives in the healthy mouth, at times doing no harm,12 not unlike the tubercle bacillus and the Klebs-Loeffler bacillus, and like them having a preference for mucous membranes. It is also found on injured skin surfaces. It has been isolated from the secretion of conjunctivitis, of rhinitis. of acute and chronic bronchitis, of acute and chronic rhinitis, from the feces of enteritis, from the pus of brain abscess, lung abscess, empyema, and from the blood of cases of endocarditis (Schottmuller),13 --from tubo-ovarian abscess, from salpingitis, and chronic fibro-cystic ovaries (Rosenow and Davis), from the blood in chronic periostitis (Dana and Hastings),15-in smears from acute and chronic tonsillitis, tonsillar and peri-tonsillar abscess, sinusitis, alveolar abscess (Cecil), 1dental granuloma (Rhein).17 Rosenow isolated it from the secretion of an ingrowing toe-nail and of a crushed thumb, and cultures of each of these secretions produced in animals inoculated with the culture, endocarditis, Libman claims this organism is to be found in the lymph nodes of Hodgkins disease. The local picture due to its presence does not differentiate it in any particular, and in many cases its action is limited to that of a local lesion. However, in the majority of cases, it is just from such a local lesion, as mentioned above, that the organism finds its way into the circulating blood, developing the characteristic systemic picture of the disease, which runs, at times, a more or less acute, then again a more or less chronic course, presenting, during life, from none to very marked cardiac symptoms, with or without isolation of the organism,-and presenting post-mortem, from none to quite extensive involvement of the endocardium cardium (valves, walls, chordae), the organism being only, infrequently, obtained from the blood or the vegetations. ETIOLOGY. 19 20 an A focal lesion, in any part of the body, has long been recognized as the causative factor in systemic infections. Already in 1855 Virchow 18 demonstrated infectious endocarditis as due to a septic uterus,-and in experimentally produced endocarditis, by injections into rabbits of a pure culture obtained from valvular vegetations, the investigators noted that a previously injured or diseased valve of the heart of the experimented -on animal, developed endocarditis much more readily than in a healthy one. Wissowitch and others claim that when a local, predisposing condition in the way of injury or disease is lacking, endocarditis is not so apt to develop. Virchow,2 however, held that this predisposing factor is always present in the constant attrition of the edges of the valves, due to the mechanism of their closure. The focal lesion can be very circumscribed, very insignificant, often of such "every-day" occurrence, a physician may not be consulted, and if consulted, when the local trouble is better, the case is dismissed as one not demanding further consideration. Such can easily be lesions of the mouth, nose and throat,-trauma due to catherterization. Less circumscribed, less insignificant lesions may not pass unnoticed, and thus the source of the general infection may be investigated. "With the defenses of the body lowered due to cold, insufficient nourishment, unsanitary surroundings, or a previous valvular defect, the patient, having had tonsillitis, tonsillar or peritonsillar trouble, alveolar abscess, etc., may eventually come to suffer from acute rheumatic fever, chronic arthritis, chronic infectious endocarditis, pneumonia, ulcer of the stomach or duodenum, irrespective of what the organism was in the focal lesion" (Billings)." The author of these words evidently accepts Rosenow's theory that transmutation takes place under special, local conditions which give them new characteristics,— special affinities for different tissues (see page 4). One asks, where do these organisms acquire these new characteristics, these special affinities, how soon after they leave the original focus, is it in the blood, in the lymph stream, or in the tissues themselves? That some change must take place,-that the organism must develop diminished or increased virulence, or take on new characteristics that make it pathologically, infectious for different tissues, or, lose all its infectivity locally, is well demonstrated in the studies of Cecil,22 of "diseases of the upper respiratory tract. While he admits that the streptococcus viridans can be isolated from practically every normal mouth and throat, as well as other streptococci, he claims the "viridans" is most abundant. He studies the smears from the mouth and throat of 89 cases, these cases included acute and chronic bronchitis, acute and chronic tonsillitis, pyorrhoea, acute laryngitis, acute pharyngitis, alveolar abscess, otitis media, and 4 normal throats. In 50 of these, cultures showed streptococcus viridans, and only three (3) are reported as having endocarditis,-four (4) had chronic arthritis, and one (1) had chronic nephritis. It is to be regretted that in this interesting study of the "viridans" no blood cultures are reported. may be again asked why was systemic infection not more frequent? Why was endocarditis not more frequent? The author says it was noteworthy that of all infections due to the "viridans," in the in the upper respiratory tract, he has found that those of the tonsils and tooth sockets, occasionally those of the sinuses,—are exclusively associated with systemic infections! 24 It Attention23 has been called to "focal lesion" being the cause of ulcer of the stomach and of the duodenum, and to the fact that perhaps to appendicitis is unjustly attributed this condition, which, on careful investigation, might be traced to a previous or present focal lesion. Frauenthal, under the title "painful feet" claims that foot infections are frequently secondary to a focal lesion in distant parts of the body, as in the teeth, mouth, gums, nose, or, as occurring after grippe, pneumonia, typhoid fever. Rosenow and Davis25 assert that in their cases of fibrocystic ovaries and salpingitis, very few gave a history of previous pelvic trouble, while many gave a history of severe cold or tonsillitis about the time of the menstrual period, and therefore they say that excision and resection of the ovaries should not be done without due regard to the existence of chronic foci of infection, which may serve not only as the place of entrance, but also as the place for the bacteria to acquire the peculiar properties necessary to infect the ovary.' With this long, but incomplete list of focal lesions as indisputable causes of systemic infection, and with the emphatic assertion of one who has investigated over a thousand (1000) cases of streptococcus infection (Horder) 26 that, in correctly made blood cultures, in 90%, specially, if there is associated endocarditis, the result should be positive, it may be justifiably asked, why is this systemic infection not more frequently demonstrated? The writer advances the following reasons: 1-, because, the systemic infection due to this organism simulates so many other diseases: malaria, typhoid, para-typhoid, tuberculosis, Hodgkins, all of which seem of so much importance and so much more probable, that any one of them is accepted rather than an infection due to a past or present local lesion,-and no blood culture is made! 2, because, the condition it simulates, at times is of apparently so trifling a nature, such as the "run-downs, the "neurasthenics," the 3, because, the fact that such a systemic As already mentioned, the clinical picture of this systemic infection is almost characteristic,the very fact that it resembles so many other diseases, and still when each one is eliminated by proper tests, the diagnosis is still obscure, is its chief characteristic. The acute cases are sudden in their development, run a short course and are invariably fatal. The subacute cases are less intense,-vary in their duration, often end fatally, or pass into the more or less chronic type, eventually dying, or they may recover. The case to be reported later is an illustration of this last unusual type. The acute cases will not be considered in this paper. All authorities agree that the subacute type of cases is usually very insiduous in its onset,it is very difficult for the patient to say when she or he felt ill,-in fact, the host of this organism for quite a while does not know he or she is ill, there is a feeling of malaise,-of weakness, a peculiar tearing, drawing pain in the muscles and the limbs-perhaps some pallor, the patient is not conscious of any fever, can not give any history of increased temperature,— a physician may not be consulted, as patient does not feel ill enough, attributing all the symptoms to a previous attack of tonsillitis, or grippe, or to some gum trouble, -even an attack of appendicitis. Often if a physician is consulted, be it a private or a dispensary case, the condition does not receive much attention. Often no test for temperature is made,-or, it is taken in the mouth.-in the usual much-to-be-condemned way, and so slight, if any, elevation, is found, it but adds to the already decided unimportance of the case. The writer would again call attention, as very good examples of this type of case. to the series described by Oille,30-cases very |