Disease - Effects of strain on heart 303 ?

[RFT]

Am intrigued by this 17 year old recruit's state of health and his length of stay in hospital.  What precisely is it, how serious was his condition and was it common?

 

Table II - Admissions to Hospital.

Admitted to Hospital - 10/12/14

Discharged from Hospital - 28/1/15

Disease - Effects of strain on heart 303

Days in Hospital - 50

Remarks :- Came in with acute dilatation, which rest [most]? reduced but he fainted each time allowed up.  Recommended for discharge as unfit.

Signed Dr Haughton, Feb, 1915.

 

Army Form B.204

Discharge of a recruit as not likely to become an efficient soldier.

Suffering from the effects of strain of heart - Considered unfit by Dr Haughton under whose care he has been.

 

Rob

 

Edited 29 June , 2019 by RFT
corrected to read "dilatation"

[seaJane]

Are you sure about orbitation? I ask because the word does not appear in the Oxford English Dictionary.

[Ron Clifton]

I think that quite a few medical terms still have to make it into the OED. Even Dr Johnson left "sausage" out.  :lol:

 

Ron

Edited 28 June , 2019 by Ron Clifton

[RFT]

Thanks for the responses.

 

"Orbitation" - I too couldn't find the word in the dictionary but it certainly looks like "orbitation" in the notes.  

I assumed it was some form of dizziness or disorientation but clearly a somewhat serious condition given the 7 week stint in hospital?

 

Disease - "Effects of strain on heart 303."  (Presumably a reference to the use of a 303 rifle)?

 

Rob

 

 

[clive_hughes]

I wonder if the "303" was in fact a medical coding of some kind?  For example, one casualty I was researching was discharged suffering from dementia.  On his pension papers, it states "Disability 165 Dementia".  I'm sure I've seen similar instances of a number linked to an ailment, so perhaps there's a list of these somewhere?

 

 

[Robert Dunlop]

'strain on heart' was a catch-all medical term that related typically to some other condition, such as what is now often referred to as post-traumatic stress disorder or equivalent. The effects of stress were manifest in symptoms related to the effects of stress on the heart, such as palpitations (which may be the 'orbitations' referred to), dizziness, breathlessness, and atypical chest pain ('atypical' of pain arising from the heart directly). At the time, the term indicated that no evidence of primary heart disease was found.

 

Robert

[RFT]

9 hours ago, clive_hughes said:

I wonder if the "303" was in fact a medical coding of some kind?  For example, one casualty I was researching was discharged suffering from dementia.  On his pension papers, it states "Disability 165 Dementia". 

 

 

 

"303" - I certainly didn't give consideration to a possible medical coding!  Very much appreciate your comments.

 

Rob

[RFT]

2 hours ago, Robert Dunlop said:

'strain on heart' was a catch-all medical term that related typically to some other condition, such as what is now often referred to as post-traumatic stress disorder or equivalent. The effects of stress were manifest in symptoms related to the effects of stress on the heart, such as palpitations (which may be the 'orbitations' referred to), dizziness, breathlessness, and atypical chest pain ('atypical' of pain arising from the heart directly). At the time, the term indicated that no evidence of primary heart disease was found.

 

Thanks Robert.

 

"strain on heart" Do you know if this was a common occurrence?

The individual concerned was discharged in February 1915 and two years later, with seemingly no health issues, enrolled in the Royal Naval Air Service!

 

Rob

[johnboy]

Can you give a link to the docs you have quoted from? Sometimes other eyes read things differently.

[TEW]

A fair few of the MH106 A/D books have had a medical code number added post war. Plus there was a topic on forum way back about medical codes shown within service/pension files.

TEW

[RFT]

In response to johnboy and TEW -

 

Documents referred to :-

 

 

 

 

Would certainly welcome any alternative interpretation of the above document.

 

On reflection, part could read "which rest reduced"

 

Rob

Edited 29 June , 2019 by RFT
Additional info

[Bardess]

Aha, dilatation. Always good to see the original document

[RFT]

53 minutes ago, Bardess said:

Aha, dilatation. Always good to see the original document

 

Excellent. Many thanks Diane.

 

The next question - How serious a condition was/is it? 

Could it have been brought about by strenuous activity/training?  (Note 303 is mentioned and the recruit was at a training camp).

Am still taken aback at the 50 day stint in hospital!

 

Rob

Edited 29 June , 2019 by RFT
Modified questions.

[Bardess]

A question for our two resident medical marvels

@Robert Dunlop

@Dai Bach y Sowldiwr

[Dai Bach y Sowldiwr]

Dilatation is suggestive of 'Acute Dilatation of the Heart' which is an objective finding, meaning the diameter of the heart is larger than it should be, usually suggestive of organic disease.

And not something that any neurosis would usually cause.

Not physical stress per se, but maybe if the heart was already weak or damaged  due to things like cardiac failure due to rheumatic heart disease (acute or chronic), or other infective cause.

Or idiopathic heart failure , or HF due to anaemia, or cardiomyopathy etc etc.

[RFT]

3 hours ago, Dai Bach y Sowldiwr said:

Dilatation is suggestive of 'Acute Dilatation of the Heart' which is an objective finding, meaning the diameter of the heart is larger than it should be, usually suggestive of organic disease.

And not something that any neurosis would usually cause.

Not physical stress per se, but maybe if the heart was already weak or damaged  due to things like cardiac failure due to rheumatic heart disease (acute or chronic), or other infective cause.

Or idiopathic heart failure , or HF due to anaemia, or cardiomyopathy etc etc.

 

May I thank you very much indeed for this comprehensive explanation.  I truly appreciate it.

 

The recruit in question was in fact, my grandfather (whose photograph appears in my profile). 

 

Following discharge from the army he enrolled in the RNAS before transferring to the newly formed  RAF (1st April 1918).

 

Rob

[Robert Dunlop]

Thank you very much for posting a copy of the original entry. Although the 'd' is different from 'discharge', the fourth letter is 'i', and there appear to be 4 dots suggesting 'i's, 'dilitation' [sic] is very likely. At the time when the entry was made, the concept of 'acute dilatation' of the heart was somewhat different from what we consider today. There were two very different perspectives. One related to the actual size of the heart - more specifically to the size of the internal chambers within the heart. The size of the heart as a whole reflects two major components: the chambers (right and left atria; right and left ventricules); and the heart muscle that surrounds the ventricular chambers (the atria have very thin walls with almost no muscle compared to the ventricles, which have to pump the blood through the lungs and the body). If the heart muscle becomes much thicker then the heart size may increase but the affected chamber/s will actually be restricted in volume, not dilated. Dilatation therefore refers to a situation where one or more chambers become bigger, ie the volume within the chamber/s is increased, which increases the overall size of the heart.

 

Back in the day, it was much harder for doctors to determine if the chambers of the heart were dilated. The definitive answer would be provided by a post-mortem examination. Before death, however, doctors were reliant on examination of the outside of the chest wall, plus chest x-ray (if available - even then, chest x-rays are notoriously unreliable for determining if one or more chambers are dilated). Most of the published studies that I have read on Disordered Action of the Heart (DAH) and Soldier's Heart, which diagnoses covered 'strain on heart' and the likes), did not use chest x-rays to determine heart size. Doctors usually relied on two ways to estimate the size of the heart when examining the chest: palpation; and percussion. With palpation, the doctor places a hand on the front left of the chest and feels for the tapping sensation where the apex of the left ventricle (which pumps the blood around the body) strikes the inside of the chest wall. This tapping sensation is known as the apex beat and is usually felt between a line down the middle of the sternum (breast bone) and an imaginary line drawn from the mid-point of the left clavicle (collar bone). The latter line is called, not surprisingly, the mid-clavicular line or MCL. If the apex beat is felt further out on the chest wall beyond the MCL then this suggests (but is not diagnostic of) an enlarged heart.

 

Percussion is the process of tapping on the chest wall and listening for the dullness over the heart versus the characteristic sound over the air-filled lungs. If you start in the middle of the chest and tap across the chest wall towards the side of the chest then you can usually detect where the dullness stops. This point is also compared to the MCL.

 

It is important to understand, however, that examination findings only tell you the point/s at which the apex beat and/or the edge of dullness on percussion are detected. You may infer things from these findings, such as the fact that the overall size of the heart may be enlarged, but you cannot be absolutely certain.

 

'Dilatation' was most often used to describe the fact that the apex beat and/or the percussion finding was displaced. As such, this term must be considered a finding and not a diagnosis. In patients who are very anxious, a normal size heart will beat more vigorously and produce a wider area of apex beat. This may mimic an increase in the size of the heart but is not associated with underlying heart disease.

 

Very rarely, the literature of the time refers to 'acute dilatation [of the heart]' as a rapidly progressive, usually fatal, condition in which the heart muscle becomes affected by something that causes severe weakness of the muscle, eg a virus or toxin. Today, we refer to this as an acute cardiomyopathy - this was definitely not the case here.

 

In this context, it is highly likely that 'acute dilatation' referred to a finding that the edge of the heart seemed to be displaced. It may have been a finding that was recorded by someone else and recorded in the letter that the hospital received or it may have been something that was discovered on admission. The discharge diagnosis of 'effects of strain on heart' strongly suggests that there were no other significant findings, such as heart murmurs, signs of heart failure, or other indications of underlying heart disease. This would fit with the subsequent history of enrolling in the RNAS and being medically fit to transfer to the RAF as well.

 

It is hard to be sure about the incidence and prevalence of DAH/'heart' strain but in one series published during the war by a major hospital back in England, about 60% of cases admitted for heart disease were deemed to not have any disease of the heart. Without doubt, the diagnostic tools of today would pick up some cases of sub-clinical heart disease in that 60% but it still gives a good approximation for the proportion of the chronic/difficult cases that reach a major hospital, given that rheumatic heart disease, for example, was much more common then than now.

 

Robert

[RFT]

Hello Robert,

 

Has there ever been a more in depth response to a member's posting on the Great War Forum!  To say I am taken aback by your detailed analysis would be a gross understatement on my part.  The time taken in its compilation, let alone the content, is worthy of much praise.  I have before me a printed copy so that I may read and reread (and digest) all that you have written.

 

To supplement what I mentioned in my last posting - My grandfather enrolled in the RNAS, July 1917, transferring to the RAF 1st April, 1918.  He went on to serve with with 47 "A" Squadron RAF, south Russia (1919/1920).  In March, 1920, while serving (in Russia) he contracted Pulmonary Tuberculosis, was evacuated to Feneraki, Constantinople, thereafter to Cambridge Military Hospital, Aldershot.  Honourably Discharged from the RAF, Aug 1920,  his state of health post-Russian war service was never good and he passed away in 1948, aged 51.

 

As a consequence of your reply, my grandfather's file can now be brought to a close.  

 

I am very much indebted to you and cannot thank you enough. 

 

Best regards,

 

Rob

Edited 30 June , 2019 by RFT
Additional info

[Bardess]

Came in with acute dilatation, which rest reduced, but he fainted each time allowed up. Recommended for discharge as unfit

[Madmeg]

I was going to suggest cardiac hypertrophy- but Roberts wonderful explanation up there probably rules it out. 

But FWIW- cardiac hypertrophy is the enlargement of the muscle of the heart. This can be due to a genetic condition or can be exercise induced- the heart is working harder so the muscle becomes stronger- bigger. This however, leads to the internal chamber becoming smaller (not dilating as explained above), in extreme cases this can mean that blood can no longer flow through the heart and can be fatal. It can lead to collapse of otherwise fit (often very fit) individuals but if exercise induced rest would allow the heart to return to a normal size again.

 

"faints on getting up"- indicates orthostatic hypotension- ie not enough blood pressure to keep the brain perfused- lying down his heart could cope but standing up would cause gravitational flow of blood to his feet and the heart wasn't able to compensate. This could be caused by a number of factors- blood loss/shock, low blood pressure, some medications,- but in his case would be related to his heart not working effectively. The heart could have been- working too slowly (bradycardic) so the blood wasn;t getting around fast enough (could be a factor in an enlarged heart as the flow would be impeded through the heart or dilated as the heart is pumping poorly), there wasn;t enough blood getting around (again factor of an enlarged heart ), flow was very weak (dilated heart not getting an atrial kick from the enlarged chambers)

 

It obviously wasnt anything genetic as he recovered.