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U. S. NAVAL MEDICAL BULLETIN

VOL. XIX.

NOVEMBER, 1923.

SPECIAL ARTICLES.

No. 5

AN ANALYSIS OF 360 CASES OF VALVULAR HEART DISEASE DISCHARGED FROM THE NAVAL SERVICE.

By W. A. BLOEDORN, Lieutenant Commander, and L. J. ROBERTS, Lieutenant, Medical Corps, United States Navy.

During the years 1921 and 1922 there were 360 cases of valvular disease, chronic cardiac, surveyed and discharged from the naval service. It appeared to us that an analysis of these cases might be of interest, and we have attempted to classify them in order that it might be possible to draw some conclusions regarding this interesting group.

Table 1 shows these patients classified according to time in service. Checking up the naval service of these patients, we find that 86, or 23.9 per cent, had less than one month of service, and that 167, or 46.5 per cent, had less than six months' service.

It is quite evident from these figures that almost half of these patients were probably enlisted with the same defect present that later caused their discharge from the service.

Table 2 shows these patients classified according to age. It appears that 145, or 43 per cent, were under 20 years of age, and that 337, or 95 per cent, were under 30 years of age. These figures bear out the preceding table and also tend to indicate that the majority of these cases were recruits.

Table 3 shows cases classified according to the station from which they were discharged. Approximately 60 per cent were discharged from naval hospitals and about 35 per cent from naval training

stations.

Table 4 shows these patients classified according to etiology. A careful search of the patients' records showed that 101, or 28 per cent, had a history of rheumatic fever, and that 59, or 16.4 per cent, gave a history of several attacks of tonsillitis.

In 184 cases, or 51 per cent, no etiologic factor was noted.

TABLE 2.—Showing cases classified according to age.

It appears from Table 4 that rheumatic fever heads the list, as is usual in valvular disease of the heart. This raises the rather interesting point as to whether a definite history of rheumatic fever should in itself constitute a cause for rejection for the naval service. It is probably true that from 40 to 50 per cent of all rheumaticfever patients develop endocarditis. In fact, it has been suggested that endocarditis is the primary lesion in all cases of rheumatic fever and that the joint involvement is secondary to such infection. The advocates of this viewpoint state that this would account for the large number of cases of valvular disease of the heart in which no etiologic factor can be demonstrated. They point out that in the absence of joint involvement the infection is limited to the endocardium and that it is only in cases in which the joints are affected secondarily that the symptoms of rheumatic fever develop.

This is a most interesting hypothesis, but at the present time is not generally accepted. Nevertheless, the great frequency with which heart disease accompanies or follows acute rheumatic fever would probably justify the recruiting officer in rejecting an applicant as unfit for naval service who gives a definite history of rheumatic fever. This procedure would no doubt safeguard the interests of the service and avoid conservatively from 25 to 35 per cent of all cases discharged for valvular disease, chronic cardiac.

Table 5 shows patients classified according to symptoms. The most common symptom complained of was dyspnea, which occurred in 141, or 39.1 per cent of cases. The next most common complaint was precordial pain, which occurred in 74, or 20.5 per cent of cases. In 171, or 47.5 per cent of cases, there was no mention of any symptoms of which patient complained.

TABLE 5.-Cases classified according to symptoms.

It appears to be true that the most prominent symptom in cardiac patients with beginning cardiac insufficiency is dyspnea, and this symptom in itself should call for an examination of the cardiovascular system. In other words, these patients first noticed their inability to carry on their ordinary routine duties with the same ease that they could formerly do their routine work. This, of course, is also the first symptom in many other diseases, as, for instance, chronic nephritis, hyperthyroidism, malignancy, and anemia. The fact that 171 or almost half of these patients had no symptoms whatever is good evidence that there was no insufficiency of the cardiac muscle. In fact, it is safe to assume that a fair percentage had no knowledge of any heart lesion being present. This raises another interesting point, to wit, should an individual already in the naval service be immediately surveyed and discharged when the diagnosis of a valvular lesion is made, even though there may be no evidence of any cardiac insufficiency whatever? Many of these patients could probably render years of service without any visable evidence of physical disability. This question is particularly pertinent in individuals who have completed one or more enlistments and who, in the course of routine examination, are considered to have valvular heart disease. It would appear reasonable in these cases to withhold medical survey or hospitalization until some defi nite indication for this procedure is manifest.

In the case of the recruit, however, the situation is somewhat dif ferent and it would probably serve the interests of the service better to immediately discharge a recruit rather than to continue through his period of preliminary training.