DIAGNOSIS

The diagnosis is therefore not made upon any one symptom or physical sign, but upon a careful study of the case as a whole viewed in the light of a full and minute case history. The broad principles of physiological pathology must determine our conclusions, and not, what is often more easy and now more common, the identification of the presence of a certain bacterium. Of special value in arriving at a conclusion are the following:

I. The age is a factor so important that it can be truly stated that at or after middle life the greatest number of people who suffer from heart trouble are not victims of valvular, but of myocardial, disease.

2. The sex includes more males on account of the habits and hardships peculiar to men.

3. The social condition reveals more men of affairs who are high livers and lead sedentary lives. If these formerly lived an active out-of-door life the influence of the later sedentary habits seem all the more injurious.

4. Of habits the constant use of alcohol, tobacco, and rich food are conspicuous. The evil effect of alcohol on the heart muscle is evident when we recall how often in a chronic alcoholic, apparently strong, a slight illness, such as a mild bronchitis, pleurisy, influenza, or rheumatism, brings the patient shortly into a very serious condition. It is strikingly illustrated by the statement of a careful physician who recently said that of all the cases of pneumonia in alcoholics that had come under his care at the City Hospital he remembered only a single case that had recovered. An excess of tobacco or the habit of eating too much rich food is second only to alcohol in its injurious effects.

5. The occupation may reveal a life of special hardships or of great physical exertions, or show the patient exposed to some specific poison peculiarly injurious to the heart.

6. Some former illness may be responsible for the state of the heart muscle. A severe simple anemia, even in a young girl, may bring about a serious fatty change in the

cardiac muscle fibres. Any acute infection, typhoid, pneumonia, smallpox, diphtheria, scarlet fever, measles, may by its toxines so affect the heart muscle that unless sufficient opportunity is given for complete repair a chronic degenerative change takes place later. Pericarditis has, in the writer's experience, been a grave cause. A fatal case seen last September made a deep impression. The man was about 35, of medium weight and build, and a Scandinavian. He complained of weakness and difficult breathing, a severe harassing cough, and much thick, tenacious expectoration. The pulse was very irregular, intermittent, and at times weak. Cardiac and bronchial stimulants were given with confidence of getting prompt benefit, for the lungs were not consolidated, the heart apparently free from valvular disease or great dilatation, and there was no fever. In spite of good care extending over two weeks, the patient made no improvement, and quite unexpectedly sank away on account of heart weakness. This man gave a history of pleuropneumonia and pericarditis with effusion some weeks previously from which he had apparently recovered, but with a heart muscle so crippled that repair was impossible.

The diagnosis to be complete should thus include, as far as possible, the probable cause of the change. It is impossible to often accurately determine the character or extent of the anatomical changes except in cases where a loose and corpulent body suggests a fatty degeneration, or a general hardening of the arteries with shrinking kidneys and mental symptoms point to a fibroid condition in the heart. Clinically, however, it should be possible to group cases in one of a few divisions according to the etiological factor as determined by the case history, and thus ascertain whether an acute infection, a specific poison, a change in the vascular system, mental strain and worry, or some other factor is the cause of the myocardial change. In such a way only will the diagnosis be effectual in pointing out the prognosis and determining the treatment.

FOR DISCUSSION SEE PAGE 151

PROGNOSIS AND TREATMENT OF CHRONIC MYOCARDITIS

J. W. BELL, M. D.

Minneapolis

Chronic myocarditis is a disease insidious in its onset, latent in its evolution, and erratic in its clinical course, causing sooner or later the death of the patient.

PROGNOSIS

The prognosis in a given case, as to duration of life, will depend on the cause of the disease, and the state of the heart muscle, influenced favorably or unfavorably by the age, habits, temperament, and general nutrition of the patient. The question of the probable duration of the disease, equivalent in this instance to the duration of life, is one the medical attendant is in every case obliged to answer or attempt to answer. While the disease is progressive in its course, and invariably fatal, much may be accomplished by judicious management to prolong life and defer the evil day.

In forming a prognosis the following facts should be carefully considered: age, habits, temperament, general nutrition, condition of the vessels, kidneys, and heart, especially the condition of the latter as indicated by the location, extent, and character of the palpable impulse, area of deep cardiac dullness, and character of heart sounds. We should also carefully consider the condition of the pulse, presence and extent of dropsy, frequency and severity of attacks of palpitation and dyspnea, presence of precordial distress, and, lastly, evidence of interference with the blood supply to the heart as indicated by one or more attacks of angina pectoris.

The younger the patient the more exemplary his habits,

and the better his general nutrition, the more favorable the prognosis; on the other hand, the farther the individual is beyond the equator of life, the more questionable his habits, and the more faulty his digestive system, the more unfavorable the prognosis. As long as the heart muscle receives sufficient nourishment it remains in position to continue the unequal contest, but the moment its blood supply is impaired through coronary disease, that moment life becomes uncertain. Briefly, prognosis depends upon the relation existing between the demands made upon the heart and its ability to meet them; hence it is largely a question of myocardial nutrition.

TREATMENT

For the purpose of treatment we divide the clinical course of the disease into two periods or stages: (1) the period of progressive and often slow development of myocardial weakness, accompanied by breathlessness, precordial distress, irregular pulse, and occasional attacks of palpitation, and (2) the period of advanced myocardial weakness, accompanied by symptoms of pronounced cardiac insufficiency, such as constant precordial distress, dyspnea, cardiac asthma, Cheyne-Stokes breathing, frequent attacks of palpitation, marked irregularity of pulse, angina, tachycardia, bradycardia, Stokes-Adams quartet of symptoms, and later all the symptoms of general venous engorgement.

Each individual case must be carefully studied as regards the existence of any constitutional vice, the exact state of the heart and arteries, the character of the pulse, and the digestive powers. Having then a clear conception. or the patient's condition it should be carefully and frankly explained to him, unless there be some special reason to the contrary, when it should be explained to a friend or relative.

If called to treat a case in the first period or stage our first endeavor should be to discover and remove every possible cause of cardiac irritation and embarrassment. Our second endeavor should be to so regulate the diet, exercise, and habits of the individual as to bring the general nutrition, as well as that of the heart muscle, up to the highest point,

and to maintain it. For this purpose, in addition to hygienic and dietetic measures, general tonic treatment, consisting, according to indications, of strychnia, arsenic, and iron, is indicated. The question of exercise must be carefully considered in relation to each individual case, and with special reference to the condition of the myocardium. In early cases where the pathologic changes are not far advanced, especially in obese persons where fatty infiltration, rather than degeneration, is the rule, graduated exercise is especially beneficial. However, in the large majority of cases of chronic myocarditis absolute rest in the recumbent position will be found necessary for a few weeks at least. The patient's habits should be carefully regulated; tobacco, alcohol, coffee, and tea should be interdicted. He should be urged to lead a quiet, orderly, and temperate life, as free from worry and excitement as is compatible with our modern civilization. The diet must be adapted to the digestive powers and the wants of the system. All rich, bulky foods, especially those inclined to induce flatulence, should be excluded. The patient should be advised to sleep and eat regularly, using three meals daily, composed of concentrated, non-fermentative, nutritious food suited to the requirements of his special case; the midday meal should always be the principal one; no solid food between meals; little or no fluid with meals. Patients should be urged to sleep at least ten hours out of every twenty-four, with a midday rest of at least one or two hours following the midday meal, in order to minimize the daily labor of the heart, the latter injunction should be rigidly followed the remainder of the patient's life. It is attention to the little things of eating, sleeping, drinking, and doing that makes success possible in dealing with this condition.

In order to intelligently advise and treat an individual suffering from chronic myocarditis, we must inquire carefully into his heredity, as well as his past and present condition, also have clearly in mind the etiological factors responsible for the varied pathologic changes present m chronic myocarditis. The fat, flabby man of sedentary