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Rheumatic fever
110
THE
AMERICA&’
HEART
JOURNAL
tination,
cross precipitation or cross: complement fixation among the isolated. It appears impossible to group these streptococci on the basis of their serological reactions. Lesions of the heart valves similar to those occurring in human beings can be produced experimentally in animals by injection of these organisms directly into the heart and intravenously. The cases reported were adults varying in age from twenty to fiftyeight years. One child of fifteen years is included. A history of rheumatic fever or tonsillitis was present in nearly every case. No description of the heart at autopsy is given. strains
Wood, J. Edwin, Jr., Jones, T. Duck&t, and Kimbrough,, Ray D.: The Etiology of Heart Dise#a,se: A Clinical Study of 623 Cases with Certain Observations on Ra,ce and Climates. Amer. Jour. Med. Sci., 1926, clxxii, 185. Two series of ca.ses of organic heart disease are presented for comparison. Series I included 300 cases admitted to the Medical Service of the University of Virginia Hospital from Oct. 1, 1925, to Jan. 1, 1926. Series II comprised 323 cases admitted to the Medical Service of the Massachusetts General Hospital from March 19, 1924, to Nov. I., 1924. From a study of the tables the authors conclude that heart disease is decidedly more common in the negro than in the white. It appears that the ratio is almost two times as frequent in the negro. It is interesting to note that hypertensive and syphilitic heart disease are in the main responsible for the increased incidence of heart disease in Males preponderate distinctly in the colored syphilitic this race. heart disease group. Rheumatic heart disease of all types is almost two times as common in Massachusetts as in Virginia, according to this study. The two series tend to show that rheumatic heart disease shows a gradual increase in occurrence from South to North in the Eastern part of the United States. Angina pectoris is.lcss common in the negro than in the white despite the fact that syphilitic arteriosclerosis is such an important factor in the former. Mackie, lxxii,
Thomas T.: 199.
Rheuma,tic
Felvor.
Amer.
Jour.
Med. Sci., 1926,
The basis of this study comprises 393 cases of rheumatic fever taken from the records of the Presbyterian Hospital in New York and comprise consecutive admissions over a period of nine years with the exception of scattered cases excluded because of incompleteness of
X;EVIEWS
AND
ABSTRACTS
111
history or work-up. The types of rheumatic fever include acute, subacute and chronic forms. L% group of 89 patients with chorea was studied at the same time. There is an approximately equal distribution between the two sexes of the rheumatic group. The chorea group, on the other hand, shows a marked predominance of females,-58 as compared to 31 males. Aye of Onset of Pirst Attack.-Hheumatic fever shows a somewhat irregular curve of the incidence, rising from 4.7 per cent under the age of five years to a peak of 20.8 per cent betyeen the ages of ten and fifteen years; thereafter it slowly but progressively falls to 1.5 per cent between the ages of fifty and fifty-five years. %‘he influence of chorea, however, is seen to be present during a much shorter period. Starting with an initial incidence of I.1 per cent, its curve rises steeply to a maximum of 58.4 per cent between the ages of five and ten years, falling rapidly then to an incidence ra,te of 7.8 per cent between the ages of fifteen and twenty years, after which period no initial attacks were found. Iwiderzce of Cardiac Involwmed ifn the liTir,si Atlack.-Of the 366 eases of rheumatic fever, 250, or 68.3 per cent, showed evidence of cardiac disease either a.t the time of admission to the hospital or during their stay in the wards. In 42 of 204 cases in the follow-up clinic the cardiac condition was definitely improved. On the other hand, 57 cases showed evidence of a progressive lesion and 103 cases were found to be essentially unchanged. Of 66 cases of chorea similarly analyzed, 34 had definite signs of cardiac involvement on admission or during their stay in the hospital. Forty of these individuals were subsequently seen in the follow-up clinic and 11 showed improvement in the cardiac condition, while 8 had progressing lesions. Twenty-one cases of this group were found to be unchanged.
The incidence curve of cardiac involvement in the first attack of rheumatic fever as found in this series approximately follows that of the age of onset of rheumatism. The I261e of Pocal Infection.-That focal infection plays #a role in the etiology seems apparent from the comparison of its occurrence in the rheumatic cases with a series of 400 nonrheumatic controls. In the former group it was found in 80 per cent of the individuals as against G6 per cent in the latter group. Tonsillar infection was found to be more than twice as prevalent in the rheumatic fever cases as in the controls. The complete removal of the tonsils and evidence of infection that was present, together with appropriate treatment of other foci of infection, seems to reduce but not to remove the incidence of recurrences of rheumatic fever.
112
TIE
AMERICAN
HEART
JOURNAL
Recz~rcnces of Rkeumckic Pever.---Two hunclred fifty-two cases were Seventy-one per cent available for analysis concerning this point. Age, too, has an irrespective of age had at least one recurrence. Of 87 eases important bearing upon the development of the disease. comprising the adult group, 58.6 per cent had recurrences. In the younger group of 165 individuals 78.2 per cent had at least one return of rheumatic fever. Those cases occurring between five and ten years of a.ge present the peak of the incidence rate of recurrence. Of 45 patients between these ages 93.4 per cent had a return of the acute phenomena. Aa attempt to ascertain the average time interval betwecn initial attack and first recurrence revealed the surprising fact that only 57 per cent had the first occurrence within four years after the primary episode. It would appear, therefore, that it is only after the lapse of three years of complete freedom from symptoms that an individua.1 has better than an even chance of escaping a further bout with a.cute rheumatic fever. The importance of prolonged and careful observation of pa,tients with rheumatic heart disease during periods of quiesence is not generally appreciated. The necessity for prolonged rest under medical care in suitable surroundings is not realized. A community which provides so well for the arrest of tuberculous disease and the rehabilitation of the patient offers no help to the victim of rheumatism until the late stages of the disease have supervened and the road to health and economic independence is closed. Further attacks upon the problem of rheuma.tic infection must be directed not only to the discovery of the etiology of the disease but to the education necessary to provide the means for its adequate and successful treatment.
Hart,man, Renry, a,nd Levy, M. D.: Rupture of Aor& Aneurysm into the Superiojr Vena Cava: Report of Two Cases. South. &fed. Jour.,
1926, xix,
595.
The authors report two cases of sacular aneurysm with a rupture into the superior vena cava. In one there was present a syphilitic aortitis and valvulitis; the other showed chronic diffuse nephritis with pericarditis a+ pleurisy. Autopsy was obtained in both eases.
Lehman, W. : Clinical and Bacteriologicad observations carditis Lenta. Klin. Wchnschr., 1926, v, 2408.
upon Endo-
Lehmann, working in Schottmueller’s clinic, claims that the clinical picture of endocarditis lenta is sharply defined and due exclusively to the Streptococcus viridans. Though a variety of other organisms, staphylococcus, Influenza bacillus, Streptococcus hemolyticus, e.g., pneumococcus, diphtheroid bacillus, have been reported as etiological agents by other authors, none of these were found in Sehottmueller’ti
THE
AMERICA&’
HEART
JOURNAL
tination,
cross precipitation or cross: complement fixation among the isolated. It appears impossible to group these streptococci on the basis of their serological reactions. Lesions of the heart valves similar to those occurring in human beings can be produced experimentally in animals by injection of these organisms directly into the heart and intravenously. The cases reported were adults varying in age from twenty to fiftyeight years. One child of fifteen years is included. A history of rheumatic fever or tonsillitis was present in nearly every case. No description of the heart at autopsy is given. strains
Wood, J. Edwin, Jr., Jones, T. Duck&t, and Kimbrough,, Ray D.: The Etiology of Heart Dise#a,se: A Clinical Study of 623 Cases with Certain Observations on Ra,ce and Climates. Amer. Jour. Med. Sci., 1926, clxxii, 185. Two series of ca.ses of organic heart disease are presented for comparison. Series I included 300 cases admitted to the Medical Service of the University of Virginia Hospital from Oct. 1, 1925, to Jan. 1, 1926. Series II comprised 323 cases admitted to the Medical Service of the Massachusetts General Hospital from March 19, 1924, to Nov. I., 1924. From a study of the tables the authors conclude that heart disease is decidedly more common in the negro than in the white. It appears that the ratio is almost two times as frequent in the negro. It is interesting to note that hypertensive and syphilitic heart disease are in the main responsible for the increased incidence of heart disease in Males preponderate distinctly in the colored syphilitic this race. heart disease group. Rheumatic heart disease of all types is almost two times as common in Massachusetts as in Virginia, according to this study. The two series tend to show that rheumatic heart disease shows a gradual increase in occurrence from South to North in the Eastern part of the United States. Angina pectoris is.lcss common in the negro than in the white despite the fact that syphilitic arteriosclerosis is such an important factor in the former. Mackie, lxxii,
Thomas T.: 199.
Rheuma,tic
Felvor.
Amer.
Jour.
Med. Sci., 1926,
The basis of this study comprises 393 cases of rheumatic fever taken from the records of the Presbyterian Hospital in New York and comprise consecutive admissions over a period of nine years with the exception of scattered cases excluded because of incompleteness of
X;EVIEWS
AND
ABSTRACTS
111
history or work-up. The types of rheumatic fever include acute, subacute and chronic forms. L% group of 89 patients with chorea was studied at the same time. There is an approximately equal distribution between the two sexes of the rheumatic group. The chorea group, on the other hand, shows a marked predominance of females,-58 as compared to 31 males. Aye of Onset of Pirst Attack.-Hheumatic fever shows a somewhat irregular curve of the incidence, rising from 4.7 per cent under the age of five years to a peak of 20.8 per cent betyeen the ages of ten and fifteen years; thereafter it slowly but progressively falls to 1.5 per cent between the ages of fifty and fifty-five years. %‘he influence of chorea, however, is seen to be present during a much shorter period. Starting with an initial incidence of I.1 per cent, its curve rises steeply to a maximum of 58.4 per cent between the ages of five and ten years, falling rapidly then to an incidence ra,te of 7.8 per cent between the ages of fifteen and twenty years, after which period no initial attacks were found. Iwiderzce of Cardiac Involwmed ifn the liTir,si Atlack.-Of the 366 eases of rheumatic fever, 250, or 68.3 per cent, showed evidence of cardiac disease either a.t the time of admission to the hospital or during their stay in the wards. In 42 of 204 cases in the follow-up clinic the cardiac condition was definitely improved. On the other hand, 57 cases showed evidence of a progressive lesion and 103 cases were found to be essentially unchanged. Of 66 cases of chorea similarly analyzed, 34 had definite signs of cardiac involvement on admission or during their stay in the hospital. Forty of these individuals were subsequently seen in the follow-up clinic and 11 showed improvement in the cardiac condition, while 8 had progressing lesions. Twenty-one cases of this group were found to be unchanged.
The incidence curve of cardiac involvement in the first attack of rheumatic fever as found in this series approximately follows that of the age of onset of rheumatism. The I261e of Pocal Infection.-That focal infection plays #a role in the etiology seems apparent from the comparison of its occurrence in the rheumatic cases with a series of 400 nonrheumatic controls. In the former group it was found in 80 per cent of the individuals as against G6 per cent in the latter group. Tonsillar infection was found to be more than twice as prevalent in the rheumatic fever cases as in the controls. The complete removal of the tonsils and evidence of infection that was present, together with appropriate treatment of other foci of infection, seems to reduce but not to remove the incidence of recurrences of rheumatic fever.
112
TIE
AMERICAN
HEART
JOURNAL
Recz~rcnces of Rkeumckic Pever.---Two hunclred fifty-two cases were Seventy-one per cent available for analysis concerning this point. Age, too, has an irrespective of age had at least one recurrence. Of 87 eases important bearing upon the development of the disease. comprising the adult group, 58.6 per cent had recurrences. In the younger group of 165 individuals 78.2 per cent had at least one return of rheumatic fever. Those cases occurring between five and ten years of a.ge present the peak of the incidence rate of recurrence. Of 45 patients between these ages 93.4 per cent had a return of the acute phenomena. Aa attempt to ascertain the average time interval betwecn initial attack and first recurrence revealed the surprising fact that only 57 per cent had the first occurrence within four years after the primary episode. It would appear, therefore, that it is only after the lapse of three years of complete freedom from symptoms that an individua.1 has better than an even chance of escaping a further bout with a.cute rheumatic fever. The importance of prolonged and careful observation of pa,tients with rheumatic heart disease during periods of quiesence is not generally appreciated. The necessity for prolonged rest under medical care in suitable surroundings is not realized. A community which provides so well for the arrest of tuberculous disease and the rehabilitation of the patient offers no help to the victim of rheumatism until the late stages of the disease have supervened and the road to health and economic independence is closed. Further attacks upon the problem of rheuma.tic infection must be directed not only to the discovery of the etiology of the disease but to the education necessary to provide the means for its adequate and successful treatment.
Hart,man, Renry, a,nd Levy, M. D.: Rupture of Aor& Aneurysm into the Superiojr Vena Cava: Report of Two Cases. South. &fed. Jour.,
1926, xix,
595.
The authors report two cases of sacular aneurysm with a rupture into the superior vena cava. In one there was present a syphilitic aortitis and valvulitis; the other showed chronic diffuse nephritis with pericarditis a+ pleurisy. Autopsy was obtained in both eases.
Lehman, W. : Clinical and Bacteriologicad observations carditis Lenta. Klin. Wchnschr., 1926, v, 2408.
upon Endo-
Lehmann, working in Schottmueller’s clinic, claims that the clinical picture of endocarditis lenta is sharply defined and due exclusively to the Streptococcus viridans. Though a variety of other organisms, staphylococcus, Influenza bacillus, Streptococcus hemolyticus, e.g., pneumococcus, diphtheroid bacillus, have been reported as etiological agents by other authors, none of these were found in Sehottmueller’ti