Myocarditis

“ Acute interstitial myocarditis occurs in connection with the infectious fevers, and also with pericarditis, more rarely endocarditis. It is characterized by the presence of numerous round cells in the interfibrillar tissue, multiplication of the corpuscles, and degeneration, granular or fatty, of the muscle-fibres. The coarse appearances are—a relaxed state of the cardiac walls, pale or turbid condition of substance, in extreme instances a sodden, soft friable state, so that the muscle readily tears on pressure. ”

“ FIBROUS Chronic myocarditis may develop on an acute myocarditis, but is generally a slowly progressive chronic process from the beginning; it occurs mostly in persons past middle life, and as a rule is not primarily associated with rheumatism or valvular disease of the heart. ”

“ Myocarditis and endocarditis occur frequently, and pericarditis occasionally. As in adults, rheumatism is the most common cause of inflammation of the structures of the heart, but rheumatism causes inflammation of the heart much more frequently in children than in adults. Besides this infection, the most frequent causes of inflammation of the heart in children are diphtheria, scarlet fever, typhoid fever, measles and influenza, with the frequency, perhaps, in the order named. Diphtheria frequently gives rise to myocarditis, which results in dilatation of the heart. ”

“ Perhaps generally the term "chronic myocarditis" is incorrect, as a real inflammatory condition is not present and has not been present; it is really a degenerative process with the development of connective tissue, a fibrosis and more or less hardening of the arterioles, a cardiosclerosis. In many instances this fibrosis is associated with fat deposits or fatty degeneration. The disease is often caused by a narrowing or obstruction or calcareous degeneration of the coronary arteries, thus diminishing the blood supply to the heart muscle. ”

“ Inflammation of the muscular structure of the heart occurs in limited, circumscribed areas, as evidenced by post-mortem examination, and it is probably always somewhat involved in connection with pericarditis and endocarditis. It may readily be inferred that if the whole organ were inflamed death would ensue immediately. Usually myocarditis results from the preexistence of blood poisoning or of some infectious febrile disease.
Symptoms.—The chief symptoms are those of heart weakness. The heart beat is fast, weak, and often irregular. Respiration is difficult and rapid. ”

“ No cardiac debilitating drug should be administered when myocarditis has been surmised or diagnosed. The safest hypnotic, if one is needed, is morphin in small doses. If there are weakening perspirations, atropin should be given, especially as it is also a circulatory stimulant. Calcium in almost any form seems to be of value in the majority of heart conditions. It is a sedative to the nervous system, and is certainly indicated in acute myocarditis. Calcium lactate is perhaps the best salt to administer, in doses of 0.25 gm. ”

“ Acute suppurative myocarditis is almost invariably associated with pyæmia or with malignant endocarditis, and in most instances may be regarded as embolic. In severe pyæmia from any cause foci of suppuration are not infrequently met with in the walls of the ventricles. There may be multiple abscesses or a single purulent collection varying in size from a pea to a walnut. Numerous miliary abscesses are not so often met with in ordinary pyæmia as in endocarditis. If large, the abscess may burst into the heart or into the pericardium and excite inflammation of this membrane ”

“ The heart muscle sometimes becomes inflamed as a complication or result of the existence of general or febrile and of infectious diseases. Severe influenza or infectious pneumonia is not infrequently followed by myocarditis. By extension of inflammation of the endocardium or pericardium the muscle of the heart may become involved. Overexertion or especially hard work continued for a long time may cause this muscle to become inflamed. ”

“ It may be taken for granted, however, that hardly any serious illness can long continue without cardiac muscle disturbance. If endocarditis is present, soft systolic murmurs soon appear. With the acute myocarditis developing, the apex beat is less positive, less accentuated, and later it becomes diffuse and even feeble. The closure of the aortic valve is less typically sharp, showing that the blood vessels are not so thoroughly filled. The peripheral circulation is not so active, the blood pressure falls, and the heart becomes more rapid, especially on the least exertion. ”

“ Myocarditis is rarely accompanied with much or severe pain, while the anguish of violent pericarditis is often very great, and Maitland had suffered most atrociously. He was not now a strong man, not one with big reserves and powers of passive endurance, and in his agony he cried aloud for death. ”

“ If a child has had an attack of heart inflammation, a myocarditis or an endocarditis, greater care should be taken of him not only when he is well but especially when he becomes ill of any other disease. If the child has had a rheumatic inflammation of the heart, or has had rheumatism without such a complication, it is considered by some clinicians wise to give a week's treatment with salicylates at intervals of three or four months, for two or three years, perhaps. ”

“ Acute and chronic Bright's disease are often complicated by it. When an individual who is already the subject of valvular disease of the heart is attacked with acute rheumatism, the liability to endocarditis is much increased.
Even when rheumatism and chorea are absent, endocarditis is liable to occur when valvular disease exists. Some regard myocarditis, pericarditis, pleurisy, and pneumonia as capable of exciting endocarditis by the extension of the inflammatory process from the surface of the heart ”

“ Acute pericarditis occurring in rheumatism, in acute infections, and from simple injuries tends to recovery. In dry pericarditis with serious adhesions, or if adhesions occur as a sequence of acute pericarditis, the future prognosis is bad, as myocarditis may develop and sudden death or acute dilatation may occur. As stated above, if pericarditis develops during the progress of chronic disease, such as interstitial nephritis, or during sepsis, or from abscesses or growths in the region of the pericardium, the prognosis is bad. ”

“ The prognosis of a case diagnosed as chronic myocarditis or chronic degeneration of the heart is doubtful, as one cannot tell until several weeks or months of observation whether this particular heart also has fatty degeneration or not. If there is fatty degeneration, the prognosis is bad. If there is no serious fatty degeneration, the patient, with the modified life outlined, may live for a long time. Acute dilatation from any serious strain on the heart may occur, and if there is fatty degeneration it is liable to occur at any time. ”

“ In the milder grades of fibrous myocarditis, when only the apices of the papillæ and thin layers beneath the endocardium are involved, the heart does not appear to be seriously affected; but when of any extent the vigor and force of the contractions are impaired, and the ventricle is unable to do the work of a healthy muscle. ”

“ He had an attack of influenza on the previous Thursday. When Dr. Philpot got laid up and asked me to take his patients over he told me he had seen Mr. Giles and that he was in a bad way. The influenza made an extra call on the poor man’s heart which no doubt hastened his end, but the actual cause of death was myocarditis.”
“Does this disease leave any infallible signs after death? I mean, can a doctor say definitely from the mere inspection of the remains that death was due to it and to no other cause? ”

“ As long as the circulation in the heart itself is good and not impaired by coronary sclerosis, and as long as this slowly developing chronic myocarditis has not advanced far, cardiac symptoms will not be in evidence; but if these conditions occur, or if the blood pressure is so greatly increased as to damage the aortic valve or strain and dilate the left ventricle, symptoms rapidly appear, and the heart must be carefully watched. ”

“ Of the several forms of rheumatic cardiac inflammation, endocarditis is the most frequent, and in a large proportion of cases it may exist alone; pericarditis is also very often observed, but it seldom is found per se, being in the vast majority of cases combined with endo- and occasionally with myocarditis. It is generally the ordinary verrucose endocarditis that obtains. ”

“ There is always danger from rupture.
MYOCARDITIS.—This is an inflammation of the muscle substance of the heart. It may be acute or chronic.
Causes.—Endocarditis and pericarditis in the course of rheumatism; acute fevers like typhoid, etc.; clots lodging in the heart arteries, coming from diseases such as septicemia and pyemia.
Symptoms.—The heart is weak. The pulse is rapid, small and irregular, palpitation and fainty sensations come on suddenly during the course of diseases mentioned. The outlook is serious and life may end suddenly. ”

“ If the left ventricle becomes sufficiently weakened or dilated, the same damming back of the blood through the lungs and right heart occurs, and more or less serious signs of broken compensation develop. The main danger, however, with a heart with this lesion, occurring coincidently with arteriosclerosis, is a progressive chronic myocarditis. ”

“ The diseases affecting the pericardium by continuity or contiguity of texture are chiefly myocarditis, tubercle of the lung and mediastinal glands, cancer of the same structures, pleurisy, pneumonia, and cancer of the oesophagus. On fibroid disease of the heart pericarditis is a frequent attendant.3 The diseases affecting the pericardium by a special election, and which are remote from the membrane, are, principally, acute articular rheumatism, Bright's disease, inflammation and other diseases of the liver, phlebitis, typhus, typhoid and eruptive fevers, scurvy, and acute alcoholism. ”

“ This is usually regarded as an extension from a chronic endocarditis. More rarely the fibrosis extends from a thickened pericardium, but cases are on record of the conversion of the outer layers of the muscular fibres into a firm, hard tissue. We frequently meet with scattered areas of fibrosis in septum and ventricular walls without any implication of peri- or endocardium. During foetal life an endo-myocarditis may occur in the conus of the right ventricle, less frequently in the left, and produce very great narrowing by the gradual contraction of the newly-formed tissue. ”

“ LAXATIVES If the bowels are known to be in excellent condition and not loaded with fecal matters, brisk catharsis is not needed simply because endocarditis has developed. If the bowels have been neglected, a small dose of calomel, aided by a compound aloin tablet, is necessary and good treatment. Subsequent movements of the bowels should be daily obtained by vegetable laxatives with occasional enemas, as needed. With all inflammation of the heart and the possibility of myocarditis developing or being actually present, it is not advisable to use salines freely or often. ”

“ In a few cases there is direct extension from the pericardium. Rheumatism is in this way indirectly responsible; possibly some of the cases are directly traceable to acute interstitial myocarditis occurring in this disease. Chronic alcoholism, syphilis, and gout are prominent factors in the etiology. Some of the most marked cases give no clue in the history or habits of any conditions which we could reasonably connect with the disease. Males are more often affected than females. The tendency to arterio-sclerosis seems to run in some families. ”

“ Friction phenomena are not perceived. There are as symptoms dizziness and faintness, drowsiness, difficulty of breathing, sense of præcordial oppression, weak pulse, and, when myocarditis exists, pain in the heart. The prognosis generally is unfavorable. Death, if not the direct result of the causes producing hæmopericardium, is due to the hemorrhage or to failure of the heart.
The TREATMENT consists in absolute rest, in giving readily-digested food, and in supporting the action of the heart; for this purpose stimulants may be required, unless something in the history of the case forbid. ”

“ But if an altitude of from four thousand to five thousand feet above the sea level puts a certain amount of strain on a normal heart and by a rise of the blood-pressure indirectly also on the small peripheral arteries, must not this action be multiplied in the case of a heart suffering from even an early stage of myocarditis or in the case of arteries with thickened or even calcified walls? ”

“ Some have a rapid heart action after the least exertion without any cardiac lesion or assignable excuse for such rapidity. Others have a rapid heart with mental activity and excessive excitement. Therefore in deciding that a heart is abnormally rapid one must individualize the patient.
During or after illness many patients are said to have palpitation when the real cause is an unhealed myocarditis. Tuberculosis almost invariably causes increased heart action, even when there is no fever. All high fever increases the heart's action, but not so markedly in typhoid fever as in other fevers ”

“ In acute pericarditis grave implication of the myocardium may be suspected when the pulse gets small and rapid, dyspnoea urgent, and the cardiac pain is increased. Such symptoms, in the absence of copious effusion, would appear to indicate extension of the inflammation to the heart-muscle. Even the occurrence of suppuration has no distinctive symptoms, as it almost invariably occurs as part of a pyæmic process, and the cardiac weakness which supervenes may be regarded as an outcome of the septic or febrile condition. ”