RHEUMATIC HEART DISEASE* By U. P. BASU, m.b., f.r.c.p.i., f.s.m.f. Visiting Physician, Calcutta Medical College Hospitals There was a day in the history of the medical profession "in India when the presence of rheumatic carditis in this sub-continent was denied. Thus, Dr. Wig (1935) quoted Colonel Keats who after 25 years' experience in the Punjab was of opinion that rheumatic fever was practically non-existent among the indigenous population of the province. Again, Sir Leonard Rogers (1925) stated in the year 1925 that out of 4,800 postmortem examinations in Calcutta one only showed rheumatic carditis. Even those who believed in its existence held that in the overwhelming majority of cases of rheumatic carditis the disease was contracted in the hills of India.
Senior
*
Being
an
Medical Club
address delivered before the the 3rd September, 1940.
on
Calcutta
THE INDIAN MEDICAL GAZETTE
12
[Jan.,
1941
'
In 1910 Sir John Megaw (1910) said out of 37 rheumatic heart cases 8 cases contracted the disease in the plains against 25 contracted in the hills of India and Europe To-day, however, the position is fundamentally different. We not only recognize the prevalence of this infection in our soil, but admit that rheumatic heart disease is an important cause of cardiac disability in this country. It must be confessed, however, that medical science is still far away from having solved the problems of its causation and treatment. It is a great pity that even to this day the suffering and loss of time which result from its ravages still assume the most alarming proportions. The writer of this paper in 1925, Hughes and Yusuf in 1930, Stott in 1930 and 1938, Hodge in 1932, 1935 and 1938, Wig in 1935, Carruthers in 1936, Kelly in 1940 and many others have recorded the existence of rheumatic heart disease in Bengal, in the United Provinces, in the Punjab and in the Bombay Deccan. During the period January 1930 to July 1940, all told, 4,716 patients were admitted into the author's wards at the Calcutta Medical College Hospitals. Out of these, 86 (1.8 per cent) were Of these 86 cases, 13 cases of rheumatic heart. were of acute rheumatic carditis and 73 were of chronic rheumatic heart disease.
Bulletin de International D'Hygiene Publique in its chapter on rheumatism in India (Stott, 1939) it is stated that carditis exists always in this affection, even when it is not clinically apparent. My own belief is that bedside physical signs are not sufficient to detect all cases of carditis, and that if we electrocardiograph all the acute rheumatic infections as a routine, we could possibly get such evidences of carditis as partial heart block or bundle branch block or alteration in the voltage of T wave in lead IV, or even inversion of T in this lead, although bedside evidences may be absent. I feel sure that if necropsies are held on patients who died of acute rheumatic fever, Aschoff's nodes could be found in the inflamed valves and in the myocardium in a good many of those cases where the hearts were held to be innocent antemortem. If such is the position, then rheumatic fever should be looked upon as the most malignant of all acute infections, both on account of its immediate consequences and remote effects. For the successful handling of this deadly disease at this stage, we have to look up to the general practitioners, particularly medical officers attached to schools; they are the people who come across this disease at this early stage, when the possibilities of complete cure are immense. Even if carditis develop, chances
Table I Acute rheumatic Endocarditis with poly-
Period
synovitis
Pericarditis with polysynovitis
infections Polysynovitis without carditis
Total rheumatic infections
Total medical admissions
Acute rheumatic
infection, per 1,000
admission
January 1930 Average
to
July
per year
1940 ..
12
1
10
23
4,716
1.14
0.09
0.9
2.1
449.1
It will be seen from table I that of the acute carditis cases, 12 were cases of endocarditis and In all of these carditis one only of pericarditis. cases there was polysynovitis. The total number of acute rheumatic infections during the period was 23, the remaining 10 cases being of polysynovitis only. In the author's series of cases therefore, carditis was present in 56.5 per cent of the acute rheumatic infections. There is, however, a divergence of opinion amongst the different workers of the British school. Sir Thomas Lewis (1936) is of opinion that 'the heart is involved in a high percentage of cases; it is probably always involved in prolonged or recurrent infections of low grade\ But the ' late Dr. Poulton held that if all. cases were taken together including so-called subacute rheumatism, in about half the cases there were merely some fever and arthritis without any findings of cardiac involvementIn the
of its cure are far better during the first attack than after repeated attacks. The writer of this article emphasized the importance of the preventive aspect of this disease in the year 1932. If the general practitioner at this stage makes an effort in collaboration with the patient s relations to remove him to a home where the hygienic conditions are satisfactory and where and proper nursing arrangements are available then in rest bed, enjoins upon the patient strict and then only, can the patient be saved from falling a victim to chronic rheumatic heart :
?
disease.
It will be evident from the graph that not a single case was admitted into the hospital below 5 years of age which is in keeping with the finding of Miller (1938) that the first attack of the disease is commonest among children of school age. From the same graph it will be evident that the maximum age incidence of
Jan., 1941] rheumatic when the
RHEUMATIC HEART DISEASE
infection is between 15 and 20 years has reached the peak^
curve
Graph 1 Age incidence of rheumatic infection.
:
BASU
13
a finding which is in the English authorities. Of the three communities generally admitted into the hospitals, 54 were Hindus, 18 Muslims and 9 Jews. The remaining number comprised Indian Christian, Parsee, Armenian and Chinese.
higher than in males, harmony with that of
Graph 3 Class of people. Class of
Age in years. Total number of cases?89. Total Maximum age incidence between 15 to 20 years. It will be apparent from graph 2 that the of rheumatic carditis is between the ages of 10 and 15 years. These findings aie in agreement with those of Colonel Stott who at the request of the Government of India prepared an excellent monograph on the distribution o rheumatism in India which was presented at the International D'Hygiene Publique at its Paris Session in April 1938 and was subsequent } published in its bulletin wherein it has been
highest incidence
Graph 2 Age incidence of rheumatic carditis. 40r
Poor Middle class .. Rich of cases?89. Total number cases?89. of Total number Maximum class?52. middle class?52. incidence among among middle Maximum incidence Minimum rich?9. Minimum among among rich?9.
It would appear from graph 3 that the middle class people were more affected (their number being 52) than the poor (their number being 28), and the latter more than the rich. This again is consistent with the findings of the British Committee on chronic rheumatic diseases (Hench, 1937) appointed by the Royal 1College of Physicians who held that it was the decent ' poor children of the respectable working classes who were affected. In my series of cases, people affected were mostly clerks and their wives subject to the fact that patients belonging to the rich class do not commonly seek admission into the hospitals. Graph 4 Ace of deaths. Age
Age in years. lotal number Total of cases?79. cases?79. number of ?iximum Maximum age 15 years. 10 to to 15 incidence between between 10 age incidence years. ,
. .
that the maximum number of entrances Jnto the different hospitals attached to the medicolleges of India for carditis ranged between t le ages of 11 and 15 and for all acute cases of rheumatic infection between the ages of 11 and r?- As regards the sex incidence of this disease in my series of cases it was equally divided amongst the males and females. Thus, out of "6 cases of rheumatic infection, 48 were male Patients and 48 female patients, although the dumber of female beds under me is half that of the male beds. It is obvious therefore that the lncidence of this disease amongst females is
observed
al
mz 5
10
15 20
Age
2,5
30
35
40
4-S
in years.
Total number of deaths?9.
From graph 4 it will be evident that the maximum number of deaths occurred within 30 years of age. According to Sir Thomas Lewis (1936) the heaviest death rate in chronic rheu matic heart cases is between 15th and 30tl years.
THE INDIAN MEDICAL GAZETTE
14
[Jan.,
1941
Table II Chronic rheumatic heart diseases All cases with heart failure Mitral
Aortic
cases
Combined cases
mitral
and
aortic
Predomi-
nantly
mitral stenosis January 1930 to July 1940. Average
13
Combined mitral S and R
Mitral R
34
Aortic S andR
Aortic R
4
1
Chronic rheu-
Auricular fibrillation with
matic heart disease
Total
Mitral Mitral congestive S and R and cardiac failure I aortic R aortic R
2
2
2
per
1,000
admissions
66
13.9 I
1.2
3
0.76
0.38
0.09
0.18
0.18
0.18
13.9
6.2
per year.
Table III Mitral heart disease with Mitral S with AF
Mitral Mitral S S and and R R with with gallop AF rhythm
ij'regularities
Mitral R Mitral S and Mitral R Mitral S Total mitral with R with with gallop with extra- paroxysmal right bundle cases with nodal branch rhythm systole irregularity block tachycardia
Total mitral cases
January 1930 to
55
12
July 1940. It is only natural that in hospital practice one does not come across chronic rheumatic heart whose chief manifestation is valvular disease which is not accompanied with any symptoms. Consequently such cases do not figure in the tables shown above. From table II it would appear that all the cases of chronic rheumatic heart disease were accompanied by cardiac failure, their total number being 73 as stated above in 7 of which details were not available. In the remaining 66 cases, 55 were cases of mitral heart, 5 were cases of aortic, 2 were cases of mitral stenosis with aortic regurgitation, 2 were cases of mitral regurgitation and aortic incompetence and 2 were cases of auricular fibrillation with congestive type of cardiac failure. Of the mitral hearts 13 were predominantly cases of mitral stenosis, 34 were cases of combined mitral stenosis and regurgitation and the remaining 8 were cases of mitral regurgitation only. As regards aortic hearts, 4 were cases of combined aortic stenosis and regurgitation and one aortic regurgitation only. It would thus be evident that mitral stenosis was the predominant lesion in a chronic rheumatic heart and that aortic disease was much less frequent. The latter when present was very often a double lesion, aortic stenosis alone was significantly absent in my series of cases and in one case only was there aortic incompetence only. Turning to table III one finds that of the rheumatic cardiac irregularities auricular fibrillation headed the list. Thus, out of 14 cardiac
due to rheumatic cause auricular fibrillation alone numbered 9, five of these auricular fibrillation cases were combined with double mitral, 2 with mitral stenosis only, and 2 were associated with congestive type of cardiac failure without any valvulitis.- Consequently, that type of auricular fibrillation which accompanies mitral stenosis, yet is not associated with cardiac enlargement, fairly common in European clinics, and in which quinidine therapy is so successful, was not present in the author's series of cases. Of the other 5 irregularities of heart one was a case of extra-systole in association with mitral stenosis, one was a case of paroxysmal nodal tachycardia associated with mitrai regurgitation, one was a case of right bundle branch block (new nomenclature) in association with mitral stenosis and regurgitation, one was a case of gallop rhythm with mitral stenosis and regurgitation and the last one was also a case of gallop rhythm with mitral regurgitation only. Regarding the aortic cases the noteworthy feature was that there was not a
irregularities
_
single
case
manifesting
coronary
disease,
nor
which showed the anginal syndrome. The total number of cardiovascular disease was 338, i.e., 7.1 per cent of the total admissions during the period mentioned above and of these no less than 86 (25.4 per cent) could be accounted for as due to rheumatic infection. What ultimately happens to these cases ? The present-day treatment is wholly unsatisfactory as far as permanent cure is concerned and death
one
Jan., 1941]
RHEUMATIC HEART DISEASE
:
BASU
15
ments under proper medical and nursing superin about 5 per cent of the cases vision. It should be the duty of such a cardiac in and first the in year during the active stage society or association to agitate continuously about 20 per cent in the first 10 years of onset, until the Corporation and the Government take In the chronic rheumatic heart cases as will^ be up the question of housing reforms and removal evident from the age-of-death chart, the heaviest of slums which are so essential for the success s author the In death rate is within 30 years. of the battle that should be waged against this continue cases experience these chronic rheumatic disease. to suffer from time to time from cardiac failuie Treatment.?In order to save the heart from and for which they seek admission into hospital leave being involved, it should be the practice to they relieved when they are temporarily confine the patients to bed during any rheumatic the hospital to come back again with cardiac infection for at least 3 months, whether the failure until ultimately they succumb, either to attack is severe or not, or whether there is any cardiac failure, to pulmonary infarction, to acute cardiac mischief or not. It is far better to err endobacterial pulmonary oedema, to subacute on the side of overdoing this precautionary carditis or to a coronary attack and angina measure. For the attainment of this purpose pectoris. There are however a very limited timely removal of such patients to the proposed number of cases who live on to old age. The heart hospital, if established, should be insisted period of economic usefulness of a rheumatic victim is generally assessed to be less than^ 9 upon, as it is very unlikely that the importance of such a measure, namely rest, could be properly and not more than 11 years after the initial realized by the inmates of the patients' houserheumatic infection. hold. It is my well considered opinion that it is high Just as some bacteriologists still deny that time that concerted action must be taken to cope rheumatic infection is a streptococcal disease or with this scourge of humanity. The_ prevention bacterisemia, there are many physicians who still of this disease is a matter of national importance, underrate the value of salicylates and tonsillecas was pointed out by the writer in 1932, when tomy in the treatment of this disease. I have he wrote 'the more the author ponders over reasons to believe that when salicylates are given the subject the more is he convinced that there in doses the drug does seem to preadequate cannot be any other problem greater in magnivent or modify carditis, at any rate in some tude and far reaching in consequence before the cases. It is true that tonsillectomy does not State, people and the profession than the ques- prevent recurrences of rheumatic infections, but tion of prevention of heart affections among the undoubtedly the mortality is about twice as high People of India \ Indeed in March 1925 he among those who had tonsils at the onset of the emphasized the importance of heart disease as disease, as among those whose tonsils had prethe cause of premature death among Indians and viously been removed. It is feasible therefore said that ' it should be looked upon as one of that should the tonsils be definitely diseased, the causes of national ruin'. The success in the tonsillectomy should be done when the early rearLondon County Council Orphan Homes in disease is relatively inactive. For then it is less children with rheumatic hearts has estab- likely that serious carditis will develop. The lished beyond doubt how change of environment value of vaccines and bacterial filtrates is modifies the outlook of the unfortunate victims unproved. The administration of cevitamic acid of this disease. The prognosis is most unfavour- or diet rich in vitamin C does not seem to inin patients living in crowded and un- fluence the course of rheumatic infection. Simihygienic homes. Twenty years ago when the larly, the concentrated use of vitamins A and D author started his practice of cardiology in this has proved to be of little value in this disease. "ty, few others were interested in the subject; sincere thanks are due to Lieut.-Colonel My out the situation has improved considerably J. C. De, i.M.S., superintendent of Medical Colnow for there are now a band of capable men Hospitals, for his kind permission to use the who have taken branch lege up cardiology as special hospital records, to Dr. Jyotsna Chatterjee, my ?r their life work. It is incumbent upon us to junior house physician, and to Dr. B. Sinha, combine together and form an association on the registrar, for their kind help in collecting the Jnes of the Cardiac Society of Great Britain and materials upon which this paper is based from J-reland, or the American Heart Association and the records of the hospital and also for the establish a national heart hospital in this first statistical works. C1ty of India where patients affected with this and other forms of heart References disease, whose home U. P. (1925). Indian Med. Gaz., Vol. LX, surroundings are unfavourable, who have no Basu, responsible people to take proper care of them, p. 307. U. P. (1932). Ibid., Vol. LXVII, p. 566. Basu, who do not possess the means to obtain early Carruthers, L. B. (1936). Ibid., Vol. LXXI, p. 137. reatment and who cannot afford proper nursing Hench, P. S. (1937). Chronic Rheumatic Diseases, could properly be looked after. By No. 3, p. 78. H. K. Lewis and Co.. Ltd., London. Sllch a measure alone will the prognosis of these Hodge, E. H. V. (1932). Indian Med. Gaz.,Vol. LXVII, p. 241. cases be rendered favourable and there is not Hodge, E. H. V. (1935). Med. College Magazine, 10 least will Vol. IX, No. 2, p. 1. doubt that the signs of infection (Continued at foot of next page) completely disappear in such improved environ-
takes
place
ing
able
acj|ities,
(Continued from previous page) Hodge, E. H. V. (1938). Indian Med. Gaz., Vol. LXXIII, p. 275. Hughes, T. A., and Yusuf, M. (1930). Indian J. Med. Res., Vol. XVIII, p. 483. Kelly, G. (1940). Ibid., Vol. LXXV, p. 129. Lewis, T. (1936). Diseases oj the Heart. Macmillan and Co., Ltd., New York. Megaw, J. W. D. (1910). Indian Med. Gaz., Vol. XLV, p. 81. Miller, R. (1938). British Encyclopaedia oj Medical Practice, Vol. X, p. 639. Butterworth and Co., Ltd., London.
Rogers, L. (1925). Glasgow Med. J., Vol. CIII, p. 95. Stott, H. (1930). Indian Med. Gaz., Vol. LXV, p. 65. Stott, H. (1938). Ibid., Vol. LXXIII, p. 271. Stott, H. (1939). Bull. Mensuel L'Office Internal. D'Hyg. Pub., Vol. XXXI, p. 623. Wig, K. L. (1935). Indian Med. Gaz., Vol. LXX, p. 260.
Senior
*
Being
an
Medical Club
address delivered before the the 3rd September, 1940.
on
Calcutta
THE INDIAN MEDICAL GAZETTE
12
[Jan.,
1941
'
In 1910 Sir John Megaw (1910) said out of 37 rheumatic heart cases 8 cases contracted the disease in the plains against 25 contracted in the hills of India and Europe To-day, however, the position is fundamentally different. We not only recognize the prevalence of this infection in our soil, but admit that rheumatic heart disease is an important cause of cardiac disability in this country. It must be confessed, however, that medical science is still far away from having solved the problems of its causation and treatment. It is a great pity that even to this day the suffering and loss of time which result from its ravages still assume the most alarming proportions. The writer of this paper in 1925, Hughes and Yusuf in 1930, Stott in 1930 and 1938, Hodge in 1932, 1935 and 1938, Wig in 1935, Carruthers in 1936, Kelly in 1940 and many others have recorded the existence of rheumatic heart disease in Bengal, in the United Provinces, in the Punjab and in the Bombay Deccan. During the period January 1930 to July 1940, all told, 4,716 patients were admitted into the author's wards at the Calcutta Medical College Hospitals. Out of these, 86 (1.8 per cent) were Of these 86 cases, 13 cases of rheumatic heart. were of acute rheumatic carditis and 73 were of chronic rheumatic heart disease.
Bulletin de International D'Hygiene Publique in its chapter on rheumatism in India (Stott, 1939) it is stated that carditis exists always in this affection, even when it is not clinically apparent. My own belief is that bedside physical signs are not sufficient to detect all cases of carditis, and that if we electrocardiograph all the acute rheumatic infections as a routine, we could possibly get such evidences of carditis as partial heart block or bundle branch block or alteration in the voltage of T wave in lead IV, or even inversion of T in this lead, although bedside evidences may be absent. I feel sure that if necropsies are held on patients who died of acute rheumatic fever, Aschoff's nodes could be found in the inflamed valves and in the myocardium in a good many of those cases where the hearts were held to be innocent antemortem. If such is the position, then rheumatic fever should be looked upon as the most malignant of all acute infections, both on account of its immediate consequences and remote effects. For the successful handling of this deadly disease at this stage, we have to look up to the general practitioners, particularly medical officers attached to schools; they are the people who come across this disease at this early stage, when the possibilities of complete cure are immense. Even if carditis develop, chances
Table I Acute rheumatic Endocarditis with poly-
Period
synovitis
Pericarditis with polysynovitis
infections Polysynovitis without carditis
Total rheumatic infections
Total medical admissions
Acute rheumatic
infection, per 1,000
admission
January 1930 Average
to
July
per year
1940 ..
12
1
10
23
4,716
1.14
0.09
0.9
2.1
449.1
It will be seen from table I that of the acute carditis cases, 12 were cases of endocarditis and In all of these carditis one only of pericarditis. cases there was polysynovitis. The total number of acute rheumatic infections during the period was 23, the remaining 10 cases being of polysynovitis only. In the author's series of cases therefore, carditis was present in 56.5 per cent of the acute rheumatic infections. There is, however, a divergence of opinion amongst the different workers of the British school. Sir Thomas Lewis (1936) is of opinion that 'the heart is involved in a high percentage of cases; it is probably always involved in prolonged or recurrent infections of low grade\ But the ' late Dr. Poulton held that if all. cases were taken together including so-called subacute rheumatism, in about half the cases there were merely some fever and arthritis without any findings of cardiac involvementIn the
of its cure are far better during the first attack than after repeated attacks. The writer of this article emphasized the importance of the preventive aspect of this disease in the year 1932. If the general practitioner at this stage makes an effort in collaboration with the patient s relations to remove him to a home where the hygienic conditions are satisfactory and where and proper nursing arrangements are available then in rest bed, enjoins upon the patient strict and then only, can the patient be saved from falling a victim to chronic rheumatic heart :
?
disease.
It will be evident from the graph that not a single case was admitted into the hospital below 5 years of age which is in keeping with the finding of Miller (1938) that the first attack of the disease is commonest among children of school age. From the same graph it will be evident that the maximum age incidence of
Jan., 1941] rheumatic when the
RHEUMATIC HEART DISEASE
infection is between 15 and 20 years has reached the peak^
curve
Graph 1 Age incidence of rheumatic infection.
:
BASU
13
a finding which is in the English authorities. Of the three communities generally admitted into the hospitals, 54 were Hindus, 18 Muslims and 9 Jews. The remaining number comprised Indian Christian, Parsee, Armenian and Chinese.
higher than in males, harmony with that of
Graph 3 Class of people. Class of
Age in years. Total number of cases?89. Total Maximum age incidence between 15 to 20 years. It will be apparent from graph 2 that the of rheumatic carditis is between the ages of 10 and 15 years. These findings aie in agreement with those of Colonel Stott who at the request of the Government of India prepared an excellent monograph on the distribution o rheumatism in India which was presented at the International D'Hygiene Publique at its Paris Session in April 1938 and was subsequent } published in its bulletin wherein it has been
highest incidence
Graph 2 Age incidence of rheumatic carditis. 40r
Poor Middle class .. Rich of cases?89. Total number cases?89. of Total number Maximum class?52. middle class?52. incidence among among middle Maximum incidence Minimum rich?9. Minimum among among rich?9.
It would appear from graph 3 that the middle class people were more affected (their number being 52) than the poor (their number being 28), and the latter more than the rich. This again is consistent with the findings of the British Committee on chronic rheumatic diseases (Hench, 1937) appointed by the Royal 1College of Physicians who held that it was the decent ' poor children of the respectable working classes who were affected. In my series of cases, people affected were mostly clerks and their wives subject to the fact that patients belonging to the rich class do not commonly seek admission into the hospitals. Graph 4 Ace of deaths. Age
Age in years. lotal number Total of cases?79. cases?79. number of ?iximum Maximum age 15 years. 10 to to 15 incidence between between 10 age incidence years. ,
. .
that the maximum number of entrances Jnto the different hospitals attached to the medicolleges of India for carditis ranged between t le ages of 11 and 15 and for all acute cases of rheumatic infection between the ages of 11 and r?- As regards the sex incidence of this disease in my series of cases it was equally divided amongst the males and females. Thus, out of "6 cases of rheumatic infection, 48 were male Patients and 48 female patients, although the dumber of female beds under me is half that of the male beds. It is obvious therefore that the lncidence of this disease amongst females is
observed
al
mz 5
10
15 20
Age
2,5
30
35
40
4-S
in years.
Total number of deaths?9.
From graph 4 it will be evident that the maximum number of deaths occurred within 30 years of age. According to Sir Thomas Lewis (1936) the heaviest death rate in chronic rheu matic heart cases is between 15th and 30tl years.
THE INDIAN MEDICAL GAZETTE
14
[Jan.,
1941
Table II Chronic rheumatic heart diseases All cases with heart failure Mitral
Aortic
cases
Combined cases
mitral
and
aortic
Predomi-
nantly
mitral stenosis January 1930 to July 1940. Average
13
Combined mitral S and R
Mitral R
34
Aortic S andR
Aortic R
4
1
Chronic rheu-
Auricular fibrillation with
matic heart disease
Total
Mitral Mitral congestive S and R and cardiac failure I aortic R aortic R
2
2
2
per
1,000
admissions
66
13.9 I
1.2
3
0.76
0.38
0.09
0.18
0.18
0.18
13.9
6.2
per year.
Table III Mitral heart disease with Mitral S with AF
Mitral Mitral S S and and R R with with gallop AF rhythm
ij'regularities
Mitral R Mitral S and Mitral R Mitral S Total mitral with R with with gallop with extra- paroxysmal right bundle cases with nodal branch rhythm systole irregularity block tachycardia
Total mitral cases
January 1930 to
55
12
July 1940. It is only natural that in hospital practice one does not come across chronic rheumatic heart whose chief manifestation is valvular disease which is not accompanied with any symptoms. Consequently such cases do not figure in the tables shown above. From table II it would appear that all the cases of chronic rheumatic heart disease were accompanied by cardiac failure, their total number being 73 as stated above in 7 of which details were not available. In the remaining 66 cases, 55 were cases of mitral heart, 5 were cases of aortic, 2 were cases of mitral stenosis with aortic regurgitation, 2 were cases of mitral regurgitation and aortic incompetence and 2 were cases of auricular fibrillation with congestive type of cardiac failure. Of the mitral hearts 13 were predominantly cases of mitral stenosis, 34 were cases of combined mitral stenosis and regurgitation and the remaining 8 were cases of mitral regurgitation only. As regards aortic hearts, 4 were cases of combined aortic stenosis and regurgitation and one aortic regurgitation only. It would thus be evident that mitral stenosis was the predominant lesion in a chronic rheumatic heart and that aortic disease was much less frequent. The latter when present was very often a double lesion, aortic stenosis alone was significantly absent in my series of cases and in one case only was there aortic incompetence only. Turning to table III one finds that of the rheumatic cardiac irregularities auricular fibrillation headed the list. Thus, out of 14 cardiac
due to rheumatic cause auricular fibrillation alone numbered 9, five of these auricular fibrillation cases were combined with double mitral, 2 with mitral stenosis only, and 2 were associated with congestive type of cardiac failure without any valvulitis.- Consequently, that type of auricular fibrillation which accompanies mitral stenosis, yet is not associated with cardiac enlargement, fairly common in European clinics, and in which quinidine therapy is so successful, was not present in the author's series of cases. Of the other 5 irregularities of heart one was a case of extra-systole in association with mitral stenosis, one was a case of paroxysmal nodal tachycardia associated with mitrai regurgitation, one was a case of right bundle branch block (new nomenclature) in association with mitral stenosis and regurgitation, one was a case of gallop rhythm with mitral stenosis and regurgitation and the last one was also a case of gallop rhythm with mitral regurgitation only. Regarding the aortic cases the noteworthy feature was that there was not a
irregularities
_
single
case
manifesting
coronary
disease,
nor
which showed the anginal syndrome. The total number of cardiovascular disease was 338, i.e., 7.1 per cent of the total admissions during the period mentioned above and of these no less than 86 (25.4 per cent) could be accounted for as due to rheumatic infection. What ultimately happens to these cases ? The present-day treatment is wholly unsatisfactory as far as permanent cure is concerned and death
one
Jan., 1941]
RHEUMATIC HEART DISEASE
:
BASU
15
ments under proper medical and nursing superin about 5 per cent of the cases vision. It should be the duty of such a cardiac in and first the in year during the active stage society or association to agitate continuously about 20 per cent in the first 10 years of onset, until the Corporation and the Government take In the chronic rheumatic heart cases as will^ be up the question of housing reforms and removal evident from the age-of-death chart, the heaviest of slums which are so essential for the success s author the In death rate is within 30 years. of the battle that should be waged against this continue cases experience these chronic rheumatic disease. to suffer from time to time from cardiac failuie Treatment.?In order to save the heart from and for which they seek admission into hospital leave being involved, it should be the practice to they relieved when they are temporarily confine the patients to bed during any rheumatic the hospital to come back again with cardiac infection for at least 3 months, whether the failure until ultimately they succumb, either to attack is severe or not, or whether there is any cardiac failure, to pulmonary infarction, to acute cardiac mischief or not. It is far better to err endobacterial pulmonary oedema, to subacute on the side of overdoing this precautionary carditis or to a coronary attack and angina measure. For the attainment of this purpose pectoris. There are however a very limited timely removal of such patients to the proposed number of cases who live on to old age. The heart hospital, if established, should be insisted period of economic usefulness of a rheumatic victim is generally assessed to be less than^ 9 upon, as it is very unlikely that the importance of such a measure, namely rest, could be properly and not more than 11 years after the initial realized by the inmates of the patients' houserheumatic infection. hold. It is my well considered opinion that it is high Just as some bacteriologists still deny that time that concerted action must be taken to cope rheumatic infection is a streptococcal disease or with this scourge of humanity. The_ prevention bacterisemia, there are many physicians who still of this disease is a matter of national importance, underrate the value of salicylates and tonsillecas was pointed out by the writer in 1932, when tomy in the treatment of this disease. I have he wrote 'the more the author ponders over reasons to believe that when salicylates are given the subject the more is he convinced that there in doses the drug does seem to preadequate cannot be any other problem greater in magnivent or modify carditis, at any rate in some tude and far reaching in consequence before the cases. It is true that tonsillectomy does not State, people and the profession than the ques- prevent recurrences of rheumatic infections, but tion of prevention of heart affections among the undoubtedly the mortality is about twice as high People of India \ Indeed in March 1925 he among those who had tonsils at the onset of the emphasized the importance of heart disease as disease, as among those whose tonsils had prethe cause of premature death among Indians and viously been removed. It is feasible therefore said that ' it should be looked upon as one of that should the tonsils be definitely diseased, the causes of national ruin'. The success in the tonsillectomy should be done when the early rearLondon County Council Orphan Homes in disease is relatively inactive. For then it is less children with rheumatic hearts has estab- likely that serious carditis will develop. The lished beyond doubt how change of environment value of vaccines and bacterial filtrates is modifies the outlook of the unfortunate victims unproved. The administration of cevitamic acid of this disease. The prognosis is most unfavour- or diet rich in vitamin C does not seem to inin patients living in crowded and un- fluence the course of rheumatic infection. Simihygienic homes. Twenty years ago when the larly, the concentrated use of vitamins A and D author started his practice of cardiology in this has proved to be of little value in this disease. "ty, few others were interested in the subject; sincere thanks are due to Lieut.-Colonel My out the situation has improved considerably J. C. De, i.M.S., superintendent of Medical Colnow for there are now a band of capable men Hospitals, for his kind permission to use the who have taken branch lege up cardiology as special hospital records, to Dr. Jyotsna Chatterjee, my ?r their life work. It is incumbent upon us to junior house physician, and to Dr. B. Sinha, combine together and form an association on the registrar, for their kind help in collecting the Jnes of the Cardiac Society of Great Britain and materials upon which this paper is based from J-reland, or the American Heart Association and the records of the hospital and also for the establish a national heart hospital in this first statistical works. C1ty of India where patients affected with this and other forms of heart References disease, whose home U. P. (1925). Indian Med. Gaz., Vol. LX, surroundings are unfavourable, who have no Basu, responsible people to take proper care of them, p. 307. U. P. (1932). Ibid., Vol. LXVII, p. 566. Basu, who do not possess the means to obtain early Carruthers, L. B. (1936). Ibid., Vol. LXXI, p. 137. reatment and who cannot afford proper nursing Hench, P. S. (1937). Chronic Rheumatic Diseases, could properly be looked after. By No. 3, p. 78. H. K. Lewis and Co.. Ltd., London. Sllch a measure alone will the prognosis of these Hodge, E. H. V. (1932). Indian Med. Gaz.,Vol. LXVII, p. 241. cases be rendered favourable and there is not Hodge, E. H. V. (1935). Med. College Magazine, 10 least will Vol. IX, No. 2, p. 1. doubt that the signs of infection (Continued at foot of next page) completely disappear in such improved environ-
takes
place
ing
able
acj|ities,
(Continued from previous page) Hodge, E. H. V. (1938). Indian Med. Gaz., Vol. LXXIII, p. 275. Hughes, T. A., and Yusuf, M. (1930). Indian J. Med. Res., Vol. XVIII, p. 483. Kelly, G. (1940). Ibid., Vol. LXXV, p. 129. Lewis, T. (1936). Diseases oj the Heart. Macmillan and Co., Ltd., New York. Megaw, J. W. D. (1910). Indian Med. Gaz., Vol. XLV, p. 81. Miller, R. (1938). British Encyclopaedia oj Medical Practice, Vol. X, p. 639. Butterworth and Co., Ltd., London.
Rogers, L. (1925). Glasgow Med. J., Vol. CIII, p. 95. Stott, H. (1930). Indian Med. Gaz., Vol. LXV, p. 65. Stott, H. (1938). Ibid., Vol. LXXIII, p. 271. Stott, H. (1939). Bull. Mensuel L'Office Internal. D'Hyg. Pub., Vol. XXXI, p. 623. Wig, K. L. (1935). Indian Med. Gaz., Vol. LXX, p. 260.
