time varied considerably, ranging from fifteen to two hundred and thirty-eight minutes for the blood serum. Apparently the variations were due to the unstandardized unit potency of the heparin. Blood culture was positive for Streptococcus viridans on December 23, numerous colonies being found. However, on December 31 the blood cultures converted to normal and have remained so until the present, eighteen months later, the time of this report. Sulfapyridine and then sulfamethylthiazole blood levels were calculated daily. Urinanalyses were essentially negative except for a heavy trace of albumin on January 8, during the height of the heparin rection.The patient returned to her home after discharge from the hospital Jan. 20, 1940, at which time all therapy was discontinued. She was placed on a high caloric diet and given thiamine hydrochloride intravenously every other day in doses of 20 to 40 mg. The patient continued to regain her strength and gain weight. Three weeks after discharge she had her first menstrual period in eight months and has since had regular periods. The ataxia gradually improved so that now the patient walks moderately well. She has shown a gain of 25 pounds (11.3 Kg.), now weighing 108 pounds (49 Kg.). Periodic examination of the heart fails to show any notable change in the character of the heart murmurs except that they are more constant in quality. The patient does light work in the home and states that she feels as well as she did a year ago with the exception of the mild locomotor difficulty. Blood cultures taken at approximate monthly intervals since discharge from the hospital have consistently remained negative for Streptococcus viridans.COMMENT An analysis of the therapy in this case suggests the probability that the success of the treatment would have occurred without the use of heparin. The febrile course was interrupted on the first day following commencement of sulfapyridine. The first negative blood culture was reported prior to the use of heparin. Of five patients reported by Kelson and White 1 to have survived heparin treatment, only one had a positive blood culture at the beginning of heparinization. In this case no improvement occurred. The use of heparin, by greatly diminishing the clotting properties of the blood, has caused fatalities due to cerebral hemorrhages and emboli affecting vital functions. In addition, the possibility of overwhelming bacteremia by the sudden release of large quantities of bacteria from a disintegrated vegetation and the danger of febrile reactions in a weakened patient makes heparin a double edged sword. Further, if heparin could be discontinued it would save considerable inconvenience and expense to the patient. A review of the cases reported in the literature has been given recently by Lichtman and Bierman.3 It was shown that 3 per cent may represent the highest probable estimate for the incidence of spontaneous recovery.4 In 200 cases of subacute bacterial endocarditis collected from the literature recovery occurred in 12, an incidence of 6 per ...
