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Rheumatic heart disease in Philadelphia hospitals. A study of 4,653 cases of rheumatic heart disease, rheumatic fever, Sydenham's chorea, and subacute bacterial endocarditis, involving 5,921 admissions to Philadelphia hospitals from January 1, 1930, to December 31, 1934. II. Age, race, and sex distribution and interrelation of rheumatic fever, Sydenham's chorea, rheumatic heart disease, and subacute bacterial endocarditis. III. Fatal rheumatic heart disease and subacute bacterial endoc



Rheumatic heart disease in Philadelphia hospitals. A study of 4,653 cases of rheumatic heart disease, rheumatic fever, Sydenham's chorea, and subacute bacterial endocarditis, involving 5,921 admissions to Philadelphia hospitals from January 1, 1930, to December 31, 1934. II. Age, race, and sex distribution and interrelation of rheumatic fever, Sydenham's chorea, rheumatic heart disease, and subacute bacterial endocarditis. III. Fatal rheumatic heart disease and subacute bacterial endoc



Publ Health Repts 55(37-38-40): 1647-1691, 1707-1740, 1809-1831



II. The literature has been reviewed and tables prepd. showing the association of rheumatic fever (r.f.) and clinical manifestations of rheumatic heart disease (r.h.d.), the age at onset of rheumatic infections, the % of Sydenham's chorea (S.c.) presenting clinical evidence of r.h.d., the % of r.h.d. with histories of r.f. and S.c, and the % of sub-acute bacterial endocarditis (s.b.e.) superimposed on r.h.d. The importance of r.h.d. as a problem of childhood and youth is emphasized: the onset of 76.4% of r.f., 98.2% of chorea, and 69.1% of r.h.d. occurred before age 20. The mode of the age of onset of r.f. was 8.7 yrs., of S.c. 9.3 yrs., and of r.h.d. 8.9 yrs. Of the initial admissions during the period under study (not necessarily the first admissions for these conditions), 59.6% of r.f., 97.1% of S.c, and 47.8% of r.h.d. occurred among persons of < 20 yrs. Though this is the first large-scale study of the major rheumatic manifestations at all ages, the peak of onset of r.f., S.c, and r.h.d. occurred in the 5- to 9-yr. age period. The expression "juvenile rheumatism" is deemed inappropriate for a disease which, though usually beginning during childhood, is characterized by chronicity, exacerbations, and recurrences throughout adult life. Although essentially a problem of childhood and youth, attacks of r.f. may occur at almost any age; but in only 2.7% of cases of r.f. and 5.7% of cases of r.h.d. did the onset occur after age 40, and r.h.d. is infrequent among hospital patients over age 60. Ri., S.c, and rJi.d. are not common under age 5. Few cases of r.f. under age 2 were admitted, and comparatively few previous histories indicated the onset of rheumatic infection in infancy. Approx. the same number of oo as oo were admitted for ri.; slightly more oo than oo gave histories of r.f. The distribution of r.h.d. according to sex indicated a slightly greater % of oo. S.c. was nearly twice as common among oo.[long dash]R.f. and r.h.d. were less common among Negroes than might be expected, considering their unfavorable economic circumstances as a result of which they are more likely to be hospitalized. A considerably greater % of first attacks of r.f. was indicated among colored persons in the 20- to 39-yr. age period. S.c. was uncommon among Negroes. It may be that r.h.d. is more likely to develop in association with S.c. among colored persons.[long dash]The clinical records of 63.3% of 1,324 cases of r.f. indicated diagnoses of r.h.d. The % of r.f. with heart disease was greatest among persons under age 20. Of the 3,654 cases of r.h.d., 61.5% gave histories or exhibited clinical manifestations of r.f. S.c, with or without ri., was indicated in 15.2% of r.h.d. Excluding the cases of chorea which also gave histories or presented clinical evidence of ri., 11.4% of the cases of r.h.d. gave histories of having had chorea without frank attacks of ri.; altogether, 72.7% of r.h.d. gave histories or exhibited clinical manifestations of ri., S.c, or both. Diagnoses of r.h.d. were indicated in 42.1% of S.c; this % would probably have been higher had these cases been followed after discharge from hospital. These and other studies indicate that a child with almost any form of S.c. stands a much greater chance of developing r.h.d. than a child who has never had any form of S.c. This, together with the fact that 10-15% of cases of r.h.d. give histories of chorea, many without frank attacks of r.f., suggests that S.c, should continue to be regarded as a manifestation of the rheumatic state. The importance of activity of rheumatic infection is suggested by the fact that 56.4% of 3,446 cases of r.h.d. uncomplicated by s.b.e. were regarded as presenting signs of rheumatic activity. This is probably an underestimate. Over 80% of cases under age 20 were considered as having active rheumatic infection. Of the 3,654 cases of r.h.d., including s.b.e. when occurring as a complication, 22.9% presented clinical manifestations of rheumatic arthritis. The % of r.h.d. with r.f. was greater among cases under age 20. Among 324 cases of s.b.e., 64.5% were regarded as superimposed on r.h.d. Comment is made upon the discrepancy in the age distribution of clinical diagnoses of r.f. in hospitals, most of which are either approved for interneship by the Amer. Med. Assoc. or are accredited children's hospitals, and the age distribution of deaths attributed by physicians to r.f., as indicated by mortality statistics obtained from the local office of vital statistics: this suggests the inadvisability of making r.f. at all ages a notifiable disease; measures directed toward combating this problem should be concentrated on persons under age 20, the period in which most cases develop.[long dash]III. Of the 5,921 admissions involving r.h.d., r.f. S.c, and s.b.e. to Philadelphia hospitals from Jan. 1, 1930, to Dec. 31, 1934, 17.2% are known to have terminated fatally during the period under study or during an admission begun prior to Jan. 1, 1935. Excludin g s.b.e. apparently not superimposed on r.h.d., death occurred in 15.8%, of 5,801 admissions for rheumatic conditions. Of 4.653 cases, in contradistinction to admissions, of rheumatic conditions and s.b.e., 21.9% died. Excluding s.b.e. apparently not superimposed on r.h.d., 20.2% of 4.538 cases resulted fatally. Of the 916 fatal cases of r.h.d., 94% were admitted primarily for rheumatic conditions or s.b.e. superimposed on r.h.d. The cause of death of only 1.6% of 916 fatal clinical cases of r.h.d. appeared to be attributable directly to causes other than r.h.d. or s.b.e. as a complication; had this study been made on the basis of postmortem examinations rather than clinical cases of r.h.d., this % would probably have been substantially increased. With one possible exception the cause of 916 deaths involving rheumatic conditions, including s.b.e. as a complicating factor, was r.h.d.; in no instance was death attributable to the arthritic manifestations of r.f. or the cerebral man

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