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Phics of Egypt Differ from the Picture Writings Commonly Prevalent PRELIMINARY OBSERVATIONS ON ACQUIRED DISEASES OF THE HEART AND AORTA AS MET WITH IN bengXl* By UMA PRASANNA BASU, m.b., m.r.c.p. (Ire.), Teacher of Medicine, Calcutta Medical School. The: observations I have recorded in this paper are based upon a series of 446 cases examined by me during the course of hospital and private practice in this city, extending over a period of ten years. From the table containing the statis- tics of the different varieties of cases it will be * Being a paper read at. a meeting of the Medical Section of the Asiatic Society of Bengal oil the 11th of March, 1925. 308 THE INDIAN MEDICAL GAZETTE. [July, 1925. Tabi/?. Disorders of the Heart seen in Bengal from July 1915 to March 1925. 446 Cases. Different Varieties. Numbers. j Due to rheumatic fever .. .. .. .. .. .. 4 Pericarditis .. s As terminal event in nephritis .. .. .. .. .. 2 I Due to puerperal infection .. .. .. .. .. .. 1 Total .. 7 Extrasystoles .. .. .. .. .. 37 Paroxysmal tachycardia .. .. .. .. 6 Auricular flutter .. .. .. .. .. 4 ,, fibrillation .. .. .. .. 14 ( Arrhythmias Complete .. ?. .. 5 (of whom 2 suffered from Stokes- Adams' syn- Heart-block drome). 23 Typhoid 8 Dysentery 6 Influenza 4 (PneumoniaMalaria 2 Total .. 109 Disorders of the myocardium. f Due to coronary sclerosis .. .. .. .. 5 Angina .. ^ Exhaustion of heart muscles .. .. .. ..35 Total .. 40 to secondary anaemia of bleeding fibroid .. .. 20 :: :: :: :: :: '? {DuePure anxiety and worry ? ? .. .. .. 6 Total .. 47 Degeneration of the myocardium as the result of heat, poor diet and infections like cholera, dysentery, malaria and kala-azar .. .. .. .. 127 Due to rheumatic fever Influenza .. Acute Small-pox Measles Diphtheria .. .Typhoid fever Total 28 Endocarditis .. origin 17 Syphilitic origin 4 Degenerative type 8 iRhoumaticIdiopathic variety 6 Total 35 6 ? Malignant Bradycardia due to high arterial tension 4 f Heart of Graves' disease 4 Toxic heart .. < Tobacco heart 36 I Alcoholic heart 3 Total .. 43 evident that structural lesions of the heart and often observed here than in Europe. The aorta due to acquired diseases as met with in degenerative type of chronic endocarditis is also Bengal differ1 as widely from those that are seen seldom met with as the majority of the people in the different clinics of Europe as the hierogly- of Bengal hardly attain that age in which it is phics of Egypt differ from the picture writings commonly prevalent. In cases of rheumatic of Mexico. endocarditis seen in Europe the prognosis is very Chronic endocarditis, whether in the young or often grave because the infective process?like in the old, which is so frequently seen in Europe pneumococcal infections?has the morbid ten- is certainly less common in Bengal. Conse- dency to recur, and we are fortunate in this quently the familiar red faces of mitral disease country in this respect as recurrences are com- and the staring looks and pale appearance of paratively infrequent; yet in spite of this, chronic aortic regurgitation so common in the clinics of endocarditis?whatever may ;be its aetiology? Europe are conspicuously rare in Bengal; the very often runs a rapid course and compensa- former is rare because rheumatic fever which is, tion soon fails, which is just the converse of par excellcncc, a disease of the cold climate is what is generally seen in Europe. Another1 type a rare affection of the people of this province; of acquired chronic endocarditis which I observed the latter is less common because granular kid- in my series was the idiopathic variety which neys, alcoholism and athletic strain are much less affected chiefly the young males and sometimes July, 1925.] DISEASES OF THE HEART AND AORTA: BASU. 309 " the females, and which damaged either of the two very well be asked Is heart disease then un- orifices almost equally and in whom rheumatism common in Bengal?" No! The majority of and syphilis could be definitely excluded. the people of Bengal suffer from one of the most In the aetiology of acute endocarditis in Bengal serious types of heart lesion, namely, myocardial of the in my series of cases, influenza, small-pox, disease heart. We all know by this time measles, diphtheria, typhoid fever and sometimes that the endocardium constitutes anatomically a when of streptococcal infections?specially puer- very small portion of the heart, and that the prog- peral origin?ranked next to rheumatic fever in nosis of endocarditis depends largely on the con- their respective frequency in the order in which dition of the myocardium. It is this vital structure they have been mentioned. In the case of enteric that is the seat of disease in the overwhelming where acute endocarditis was present it could be majority of the cases seen in Bengal. It is not, attributed to the secondary streptococcic inva- strictly speaking, a myocarditis but a degenera- sion. tion of the myocardium absolutely independent of P'or obvious reasons rheumatic pericarditis was coronary sclerosis, and this degeneration is res- death of rare, and when present very often co-existed with ponsible for the early its people. It a cases itself in the myo- and endocarditis. In few of nephri- symptomatically manifests lack of tis it was seen as a terminal event. physical endurance so well known amongst the In the heart-kidney complex met with in Bengalis that it hardly merits a detailed des- Bengal the heart is responsible for the kidney cription. Clinically it attracts the notice of the disease in many cases, which is just the opposite physician by a rapid rate of the heart, the pulse of what is commonly seen in Europe. very often ranging between 80 to 90 per minute If we define angina as coronary sclerosis then, at rest. Some degree of hyperesthesia over the of course, such anginas are seldom met with in precordium was present in many cases. The this soil as it very often consorts with arterio- apex beat was very often difficult to localise, sclerosis which is comparatively rare. If on the X-ray examinations seldom revealed dilatation, contrary, as I pointed out a few years ago, we On auscultation the first sound was very often as was look upon the symptom-complex as an expression muffled and tonicity murmurs, pointed of exhaustion of the heart muscle then such out by me some time ago, indicating a toneless anginas?for reasons given below?are by no flabby myocardium could often be heard, as also means uncommon. the basal systolic murmurs. In a limited num- The extra-systoles observed in my series of ber of cases the pulmonary second sound was cases were to a great extent of reflex vagal origin. also accentuated. Such patients very often exhi- The eccentric heart manifesting such arrhythmias bited effort syndrome. as paroxysmal tachycardia, auricular flutter and It is thus evident that there is a fundamental auricular fibrillation was rare compared with difference between the types of heart disease those seen in Europe. A notable feature in prevalent among the inhabitants of the countries some cases of auricular fibrillation that came under in question. And what constitutes this differ- was absolute of ence ? my observation regularity the pulse in striking contrast with the occasionally The cardinal factor responsible for this irregular pulse very often seen in such arrhyth- difference is the climate. This was very mias. And from what I have seen of these ably pointed out as long ago as the year irregularities I can definitely say, from the poly- 1910 by Lieutenant-Colonel J. W. D. Megaw, graphic tracings I took of some of them, that i.M.S., in an excellent paper on this subject such could often be linked in one contributed him to the Indian Mcdical irregularities by " chain. The dififerent types were but manifesta- Gazette for March. He said debilitating tions of different grades of one and the same climatic conditions are distinctly calculated disorder which was very often an eccentric focus to bring about early enfeeblement of the heart "; of irritation within the heart muscle. When that the reference was to Anglo-Indians and domiciled focus was mild it produced extra-systoles; when Europeans. There could be no gainsaying that moderate, paroxysmal tachycardia; when severe, high air temperatures produced vasodilatation auricular flutter; and when serious, fibrillation. which threw- greater work upon the heart and Real cases of complete heart-block and thus drew largely upon the cardiac reserve. It Stokes-Adams' disease were very, rare, and for made the people lazy and lethargic, the majority the former malady?when present?syphilis was of whom consequently did not take proper exer- mainly responsible. Partial heart-block as the cise and thus rendered the ill-nourished heart? result of such infections as pneumonia, typhoid like the arm in a sling?to waste from want of fever, bacillary dysentery and very rarely malaria proper blood supply. The factor next of import- ance in the was certainly not uncommon. Bradycardia purely production of a degenerated myo- common a is due to high arterial tension?so feature cardium the poverty of the masses from dearth in the European clinics?was seldom seen. of industrial developments in this country. As The poisoned heart of Graves' disease was '? m?tter ?f the chief disease of Bengal is that the inanition. very occasional. Seeing principal types Poverty demoralises the myocardium of diseases of the heart prevalent in Europe chiefly in two ways, the first of which is the were uncommon in my series of cases, it might inferior quality of the food that is consumed. 310 THE INDIAN MEDICAL GAZETTE. [Jui,y, 1925. While I do not concur with Lieutenant-Colonel D. disaster. The Bengalis thus die prematurely as that the McCay nitrogen-poor diet markedly the result of such infections as compared with affects the of the of physical growth people the Europeans who, as a rule, stand infection for the reason the Bengal simple biological that better and attain to a much older age.
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