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Etiology of Valvular Heart Disease
F O C I O F IN F E C T IO N IN BO D Y D IS E A S E . . . V O L U M E 42, J U N E 1951 • 463
usual physical activity, fatigue and ex posure to dampness and cold appear to be contributory causes, but, in the ma jority of cases, the disease cannot be as cribed to these factors and the illness seems to originate spontaneously. Treat ment is symptomatic and supportive. Roentgen therapy, fibrositic vaccines and the administration of vitamin E have proved disappointing and ineffective treatments. Bursitis and Tendonitis • Inflammation o f a bursa may be caused by trauma, in fection, unusual use of the part, or the cause may be unknown. Treatment is similar to the treatment for fibrositis. Tenosynovitis • Specific infection, such as tuberculosis, may be the etiologic factor, but more often the cause is unknown. Fascitis and Panniculitis • Some cases have to be treated by injection o f pro
caine2 and some by excision of “ herniated fat.” Shoulder-Hand Syndrome • This form of nonarticular rheumatism may follow myocardial infarction or painful intrathoracic lesions, vascular accidents, trauma or other irritative lesions about the neck or upper extremity. Usually it is treated by analgesics and physical ther apy and frequently by block anesthesia of the brachial plexus or superior cervical ganglion. Psychogenic Rheumatism • Treatment consists o f removing emotional conflicts and rationalization o f problems. In this review by the committee of the American Rheumatism Association there appears no suggestion that pulpless teeth be removed as a treatment for conditions which in most instances are of unknown etiology.
V A L V U L A R H E A R T DISEASE E T IO L O G Y O F V A L V U L A R H E A R T D IS E A S E
As Kinsella78 pointed out concisely in 1944, endocarditis is an inflammation o f the tissue lining the cavity o f the heart, particularly the tissue o f the valves. T h e simplest classification o f the different types is as follows: 1. N onbacterial (sim ple) : (a ) acute non rheum atic; ( b ) acute rheumatic. 2. Bacterial (m ycotic) : (a ) acu te; ( b ) subacute.
Kinsella79 added further information about the etiology o f these different types o f heart disease. H e associated acute non rheumatic endocarditis with disseminated lupus erythematosus and acute rheumatic endocarditis with rheumatic fever. R e garding acute bacterial endocarditis, he stated, “ It develops both as a complica tion o f such infections as pneumonia in
which immediate infection of valvular erosions is presumed to occur, and as an infection o f an old cardiac injury during the course of a bacteremia.” He pointed out that Staph, aureus, hemolytic strepto cocci, and the pneumococci are the or ganisms especially prominent in the eti ology of acute bacterial endocarditis.80 The etiology of subacute bacterial endo carditis he ascribed to two essential fac tors; that is, a pre-existing injury o f the valve and a recent infection which may invade the blood stream. In a typical case, a patient with rheumatic valvular heart disease suffers from tonsillitis, ab scesses of the teeth, or otitis media. Bac teria from these foci may enter the blood stream and invade the damaged valve. “ The nonhemolytic streptococcus is re sponsible for 90 to 95 per cent of the cases of this type of endocarditis. The gonococcus is an important causative or
bt 4
• THE J O U R N A L O r THE A M E R IC A N D E N T A L A S S O C IA T IO N
ganism in the remaining 5 to 10 per cent.” 80 Regarding the etiology of acute rheu matic disease, Swift81 summarizes: “ The most constantly demonstrable microor ganisms associated with attacks o f rheu matic fever are hemolytic streptococci belonging to Group A (Lancefield). These streptococci are demonstrable in the throats of between 50 and 75 per cent of patients at the time of onset of an attack of rheumatic fever.” Northrop and Crowley,51 in 1943, re ported a review o f 138 case histories of patients suffering from subacute bacterial endocarditis during the preceding 17 years. O f these 138 patients, 54 (38 per cent) gave histories of surgical trauma or serious illness prior to the onset of symp toms and of these 54 patients, the surgical trauma in 23 instances consisted o f den tal extractions. In 1945, Kelson and White82 reported a study of a series of 250 well substanti ated cases o f subacute bacterial (strepto coccal) endocarditis which were followed from January 1927 to March 1939. All of the patients had cultures positive for viridans streptococci or, rarely, anhemolytic streptococci. Most of the 250 pa tients had a history o f rheumatic valvular disease although a few had congenital de fects, including five instances o f patency o f the arterial duct. The most common predisposing cause of illness (excluding the indefinite condition called grippe) was some dental procedure, especially ex traction. Exact figures could not be sup plied but the estimate was that one in each four cases of subacute bacterial endocarditis gave such a history. In 1947, Macllwaine,30 following a pathologic study of the heart tissues o f 34 cases o f subacute bacterial endocarditis and 12 cases of acute bacterial endocar ditis, inferred that myocardial Aschoff nodules are a specific reaction o f tissues to rheumatic fever and that a large number showed evidence of rheumatic arteritis and the presence of Aschoff bodies cor
responding in age to the clinical duration o f the endocarditis. It would appear, from a brief review o f the literature, that heart valves may become damaged (1 ) by congenital de fects; (2) by disease states, principally rheumatic fever; (3) by initial bacterial injury, principally the hemolytic strains o f streptococci (Lancefield’ s Group A ), and by secondary bacterial injury, princi pally viridans strains of streptococci. V A L V U L A R H E A R T D IS E A S E C A U SE D B Y R H E U M A T IC FE V E R
W yckoff and Lingg,83 in 1926, reported a statistical study o f the incidence and clas sification o f heart disease. They found that to the total of heart disease, rheu matic fever contributed 25 per cent; syphilis, 10 per cent; arteriosclerosis, 45 per cent; cases of unknown origin, 10 per cent; all other origins, 10 per cent. They found, further, that 90 to 95 per cent of rheumatic cardiac disease developed be fore 50 years and more than 50 per cent before 30 years o f age. Schwartz and Salman84 reported, in 1942, that rheumatic heart disease was found at necropsy in approximately 90 per cent o f all cases o f subacute bacterial endocarditis caused by viridans strepto cocci, and congenital malformations were found in approximately 4 per cent of all necropsies. Following a continuous study o f the natural history of rheumatic fever for 15 years, Cohn and Lingg,85 in 1943, re ported on some 12,000 patients. The on set of the disease manifested itself in valvular lesions in 866 o f the patients studied. They86 continue, “ When the dis ease begins in childhood, carditis is the most frequent but rarely the only type of infection.” In 1943, Northrop and Crowley87 re ported a study o f subacute bacterial endo carditis conducted over a period of 17 years. The number of patients treated was 138. Seventy (approximately 50 per
usual physical activity, fatigue and ex posure to dampness and cold appear to be contributory causes, but, in the ma jority of cases, the disease cannot be as cribed to these factors and the illness seems to originate spontaneously. Treat ment is symptomatic and supportive. Roentgen therapy, fibrositic vaccines and the administration of vitamin E have proved disappointing and ineffective treatments. Bursitis and Tendonitis • Inflammation o f a bursa may be caused by trauma, in fection, unusual use of the part, or the cause may be unknown. Treatment is similar to the treatment for fibrositis. Tenosynovitis • Specific infection, such as tuberculosis, may be the etiologic factor, but more often the cause is unknown. Fascitis and Panniculitis • Some cases have to be treated by injection o f pro
caine2 and some by excision of “ herniated fat.” Shoulder-Hand Syndrome • This form of nonarticular rheumatism may follow myocardial infarction or painful intrathoracic lesions, vascular accidents, trauma or other irritative lesions about the neck or upper extremity. Usually it is treated by analgesics and physical ther apy and frequently by block anesthesia of the brachial plexus or superior cervical ganglion. Psychogenic Rheumatism • Treatment consists o f removing emotional conflicts and rationalization o f problems. In this review by the committee of the American Rheumatism Association there appears no suggestion that pulpless teeth be removed as a treatment for conditions which in most instances are of unknown etiology.
V A L V U L A R H E A R T DISEASE E T IO L O G Y O F V A L V U L A R H E A R T D IS E A S E
As Kinsella78 pointed out concisely in 1944, endocarditis is an inflammation o f the tissue lining the cavity o f the heart, particularly the tissue o f the valves. T h e simplest classification o f the different types is as follows: 1. N onbacterial (sim ple) : (a ) acute non rheum atic; ( b ) acute rheumatic. 2. Bacterial (m ycotic) : (a ) acu te; ( b ) subacute.
Kinsella79 added further information about the etiology o f these different types o f heart disease. H e associated acute non rheumatic endocarditis with disseminated lupus erythematosus and acute rheumatic endocarditis with rheumatic fever. R e garding acute bacterial endocarditis, he stated, “ It develops both as a complica tion o f such infections as pneumonia in
which immediate infection of valvular erosions is presumed to occur, and as an infection o f an old cardiac injury during the course of a bacteremia.” He pointed out that Staph, aureus, hemolytic strepto cocci, and the pneumococci are the or ganisms especially prominent in the eti ology of acute bacterial endocarditis.80 The etiology of subacute bacterial endo carditis he ascribed to two essential fac tors; that is, a pre-existing injury o f the valve and a recent infection which may invade the blood stream. In a typical case, a patient with rheumatic valvular heart disease suffers from tonsillitis, ab scesses of the teeth, or otitis media. Bac teria from these foci may enter the blood stream and invade the damaged valve. “ The nonhemolytic streptococcus is re sponsible for 90 to 95 per cent of the cases of this type of endocarditis. The gonococcus is an important causative or
bt 4
• THE J O U R N A L O r THE A M E R IC A N D E N T A L A S S O C IA T IO N
ganism in the remaining 5 to 10 per cent.” 80 Regarding the etiology of acute rheu matic disease, Swift81 summarizes: “ The most constantly demonstrable microor ganisms associated with attacks o f rheu matic fever are hemolytic streptococci belonging to Group A (Lancefield). These streptococci are demonstrable in the throats of between 50 and 75 per cent of patients at the time of onset of an attack of rheumatic fever.” Northrop and Crowley,51 in 1943, re ported a review o f 138 case histories of patients suffering from subacute bacterial endocarditis during the preceding 17 years. O f these 138 patients, 54 (38 per cent) gave histories of surgical trauma or serious illness prior to the onset of symp toms and of these 54 patients, the surgical trauma in 23 instances consisted o f den tal extractions. In 1945, Kelson and White82 reported a study of a series of 250 well substanti ated cases o f subacute bacterial (strepto coccal) endocarditis which were followed from January 1927 to March 1939. All of the patients had cultures positive for viridans streptococci or, rarely, anhemolytic streptococci. Most of the 250 pa tients had a history o f rheumatic valvular disease although a few had congenital de fects, including five instances o f patency o f the arterial duct. The most common predisposing cause of illness (excluding the indefinite condition called grippe) was some dental procedure, especially ex traction. Exact figures could not be sup plied but the estimate was that one in each four cases of subacute bacterial endocarditis gave such a history. In 1947, Macllwaine,30 following a pathologic study of the heart tissues o f 34 cases o f subacute bacterial endocarditis and 12 cases of acute bacterial endocar ditis, inferred that myocardial Aschoff nodules are a specific reaction o f tissues to rheumatic fever and that a large number showed evidence of rheumatic arteritis and the presence of Aschoff bodies cor
responding in age to the clinical duration o f the endocarditis. It would appear, from a brief review o f the literature, that heart valves may become damaged (1 ) by congenital de fects; (2) by disease states, principally rheumatic fever; (3) by initial bacterial injury, principally the hemolytic strains o f streptococci (Lancefield’ s Group A ), and by secondary bacterial injury, princi pally viridans strains of streptococci. V A L V U L A R H E A R T D IS E A S E C A U SE D B Y R H E U M A T IC FE V E R
W yckoff and Lingg,83 in 1926, reported a statistical study o f the incidence and clas sification o f heart disease. They found that to the total of heart disease, rheu matic fever contributed 25 per cent; syphilis, 10 per cent; arteriosclerosis, 45 per cent; cases of unknown origin, 10 per cent; all other origins, 10 per cent. They found, further, that 90 to 95 per cent of rheumatic cardiac disease developed be fore 50 years and more than 50 per cent before 30 years o f age. Schwartz and Salman84 reported, in 1942, that rheumatic heart disease was found at necropsy in approximately 90 per cent o f all cases o f subacute bacterial endocarditis caused by viridans strepto cocci, and congenital malformations were found in approximately 4 per cent of all necropsies. Following a continuous study o f the natural history of rheumatic fever for 15 years, Cohn and Lingg,85 in 1943, re ported on some 12,000 patients. The on set of the disease manifested itself in valvular lesions in 866 o f the patients studied. They86 continue, “ When the dis ease begins in childhood, carditis is the most frequent but rarely the only type of infection.” In 1943, Northrop and Crowley87 re ported a study o f subacute bacterial endo carditis conducted over a period of 17 years. The number of patients treated was 138. Seventy (approximately 50 per