THE DIAGNOSIS OF CHRONIC MYOCARDITIS SOREN P. REES, B. S., M. D.

Minneapolis

SYMPTOMS

Diminished heart power is the one constant condition in chronic myocarditis. It may give rise to no symptoms. In some cases of coronary sclerosis a sudden and immediately fatal blocking of a narrowed coronary artery is the first warning given of changed vessels and degenerated heart muscle. Many such deaths are diagnosed apoplexy. In myocarditis due to other causes, symptoms may be evident. only upon careful examination when the heart has been required to do additional work, and, when thus elicited, give rise in different cases, not to one, but to a variety of clinical pictures that easily draw the attention away from the heart, and obscure the true condition.

Breathlessness on slight exertion is the most common initial complaint, and may be the only complaint for years. Mrs. G, aged 63, had always been very active in home, social, charitable, and church work. She had always been healthy, and her family had been a strong and stout people. She had gained in flesh the last ten years until she weighed over 200 lb. She came under observation April, 1902, suffering from all the symptoms of advanced cardiac insufficiency due to degeneration of the heart muscle. For five years at least previous to this final breakdown, she had suffered from breathlessness on the least extra exertion, but being in good flesh and color, without any bronchial trouble and quite well when quiet, she had not been much alarmed over her condition. The struggle made by this resolute woman for nearly a year against death was one of the most pathetic pictures to be seen at the bedside.

A feeling of marked weakness upon slight exertion is an early complaint. The following case illustrates how frequently it is overlooked by the patient until much damage has been done:

Mrs. C, aged 60, had been always well except for an attack of the ague 32 years ago, and gastritis followed by dysentery 14 years ago. She had noticed for months that on waking mornings she felt strong and energetic, but the slight duties. of her home would by eleven o'clock forenoons use up her energy so completely that when the lunch hour came she had no strength or desire to eat. Upon sitting down, however, she would, before the meal with finished, feel much better, eat heartily, and, as her usual habit included a nap in the early afternoon, get through the rest of the day very well, only to experience the same fatigue the next day. She consoled herself with the thought that this tired feeling was natural to her age. One afternoon while preparing to go out and make a call with her sister, the exertion of dressing brought about a complete collapse of strength, and gave notice that something unusual was wrong. Examination, December, 1903, showed a slightly enlarged heart, without any murmurs, the sounds clear and weak, pulse 96 to 100 sitting, but on slight exertion 110 to 120; temperature normal; the chest clear; slight trace of albumen in the urine, but, on repeated examinations, no casts. The case has proven a typical, uncomplicated case of chronic myocarditis due to strain and over-exertion of mind and body.

Both of these women were of powerful build, physically and mentally. Both had lived very active lives, had experienced many cares, had been finally quite successful, and in later years acquired ease and wealth. In each case the cause of the disease must have been a constantly overworked and improperly nourished heart.

A sense of uneasiness over the heart region, especially after a full meal and most likely to come on after retiring, or a dull pain over the heart and palpitation on excitement or worry, are often present. A more or less continued dis

comfort in the chest, a slight harassing cough without coryza or temperature, or a persistent neuralgia may be the complaint for which the patient seeks relief. Later symptoms include marked dyspnea, substernal pressure, cough, hepatic stasis, dropsy, scanty urine, feeble and arythmic pulse, blood-tinged sputum, and all the other well known signs of a failing circulation. None of these symptoms are peculiar to myocardial disease. They may accompany a failing circulation due to any cause. Their presence when disease of the endocardium and pericardium, lung, blood, and kidneys can be excluded, should, especially in an elderly person, direct the serious attention to the heart muscle.

PHYSICAL SIGNS

Myocarditis developing gradually in a person about middle life, gives rise to no marked physical signs. General inspection usually reveals a strongly built man of powerful body and mind whose mental work has often exceeded his physical efforts, though both may have been heavily taxed. His appearance is usually that of a good eater and of the man who does things. Having always been strong and well, he scoffs at the idea that anything serious ails him in spite of some of the above symptoms. When finally he seeks medical advice his sturdy appearance and his apparent impatience at the thought that he may be ill or in need of careful examinations, often either deceives the physician or makes him yield to a hasty diagnosis of some minor ailment. Instead of getting a very exact and complete history of the man's ancestry, work, habits, and former health, which alone can show an etiological relation between his life and present condition, the few physical signs are passed over as unimportant, and the case allowed to drift on to a serious condition. If carefully scrutinized, these cases in spite of bulky frame and ruddy look give some signs of early decay. The eye lacks penetration, the skin is either dry on of that soft texture peculiar to the aged, the superficial capillaries prominent, the hair prematurely turned, and the very flesh, though bulky, of an ill-nourished appearance.

Inspection of the pericardium, unless the left ventricle. is much hypertrophied, reveals a weak apex beat, or, more often, because of a thick chest-wall and bulky lung, entirely fails to detect the weak cardiac impulse. Palpation may reveal the impulse when too feeble to be seen, and discover the superficial arteries, radial and temporal, stiffened, if not markedly sclerosed. The liver, generally somewhat enlarged, is smooth, has a sharp edge, and is slightly tender on pressure. Percussion shows some enlargement to the left and upwards giving to the deep cardiac dullness, as Dr. Babcock points out, a quadrilateral outline with rounded corners. In cases where the chest-wall is thick and the lungs bulky the fluoroscope may be of the greatest help in determining the cardiac outline, and often reveals to our surprise a much greater hypertrophy than we expected to find. Auscultation, which gives such brilliant evidence in valvular disease, is very disappointing in its negative testimony. The heart tones are clear, the first sound is soft and weak, the second sound accentuated, and over the aortic valves may have a distinctly ringing character. Later, when the left ventricle fails, the pulmonary may be the more pronounced. A soft mitral systolic murmur of relative insufficiency may later develop at the apex. The pulse is the most direct and trustworthy index to the heart's power. should be tested, not only with the patient at rest, but after exercise when an increase in its rate will be found out of all proportion to the exertion. The striking physical signs accompanying endocarditis and the decisive evidence gained by auscultation in valvular disease have made us neglect a critical study of the pulse. In myocarditis it is a small abrupt wave. At first strong, regular, and not rapid, except upon exertion, its most noticeable feature is the fact that the volume is not sustained, but the wave quickly recedes from the touch, giving at once the impression of lack of power behind it. As the heart becomes weaker the pulse. becomes more rapid, irregular in beat and volume, and intermittent. Some cases have a rapid pulse from the start. The writer has notes of a case in which the pulse at rest

It

was constantly between 160 and 180. She was a large, fleshy woman, apparently well except for shortness of breath on exertion and a consciousness of her heart action. A severe fright twelve years ago when seeing her child killed in a runaway was supposed to be the nervous shock that initiated the tachycardia. She was under observation for five years, and finally died from cancer of the breast, but her pulse, except when she was flat in bed, was invariably very rapid. In a study of the pulse the sphygmograph should give early and valuable information.

The urine may be normal. Usually a trace of albumen and a few hyaline or granular casts are found. On many occasions we have noticed that as the heart acted poorly, the urine would become scanty; albumen, many granular, a few hyaline casts, and much epithelial debris would appear, all of which would entirely disappear again for a time under successful cardiac stimulation.

The blood is often not much impoverished. Cases due to vascular changes or an interstitial nephritis are poor in hemoglobin. One case is remembered where free purgation and sweating having been used to overcome visceral engorgement and dropsy, the hemoglobin registered 105° (v. Fleischl).

The case history must at times decide the diagnosis. It should not only reveal the ordinary data, such as a family tendency towards early degeneration of important organs,. and record any former illness as to kind, duration, severity, and the nature of the recovery, and give an exact statement of the symptoms, how and in what way they appeared and to what extent troublesome, but it should go minutely into the daily habits and routine life of the patient. How and what and when he eats and drinks, when and how hard he works, how much recreation, of what nature and where taken (whether outdoors or in a stuffy and smoky clubroom), are fit subjects for investigation. Just how much tobacco is used and in what form, whether anxiety or mental worry is or has been present, what excesses, if any, have been indulged in-these are all questions that must not be passed over.