DISEASES OF THE HEART AND CIRCULATION

The decision to institute treatment of a cardiac patient does not follow automatically on the diagnosis of heart disease. Not every victim of a valvular lesion or arrhythmia stands in need of drug therapy, though a majority require guidance and surveillance by the doctor. It is axiomatic in the management of cardiac patients, as- in medicine generally, that accurate diagnosis must precede treatment, and in cardiology this implies more than a bald anatomical diagnosis of such-and-such a valvular deformity, vascular lesion or muscular impairment. In valvular disease, for example, it is not sufficient to conclude that a certain valve is affected, but it is necessary to determine the etiology; to assess precisely the relative roles and degree of incompetence and stenosis; and to take account of the size of the heart, both overall and of individual chambers, of arrhythmias, of secondary pulmonary vascular effects, and above all of the state of the heart muscle. Such a complete four-fold diagnosis etiological, anatomical, physiological, and assessment of cardiac grade), on the lines long advocated by the American Heart Association, implies a full assessment of the individual patient, and its accuracy is reflected in rational treatment and prognosis. .
For example, the management of aortic valvular disease due to syphilis differs fundamentally from that due to rheumatism ; the management of a tight pure mitral stenosis differs from that of a minor grade of narrowing, and from that of incompetence : the size of the- heart is an index to prognosis, as are abnormal rhythms which may also demand treatment: and the exercise capacity of the individual has bearings on prognosis and on the need. for treatment. This last, for example, is crucial in the management of the pregnant cardiac patient,. Such a four-fold diagnosis is in no way cumbersome, and a simple dated entry on the patient's record card can summarize' in a line what would require a page of conventional history and signs.
Complete and accurate diagnosis of the type advocated is of two-fold value. The natural history of the various forms of heart disease is well known, and from considerations of the nature and severity of the lesion, the heart size and rhythm, the degree of disability and the occurrence of such episodes as embolism or acute pulmonary congestion, it is possible to pin-point the stage the patient has reached in the course of his disease, to estimate his prognosis and to guide him effectively in his affairs. Treatment based on such a complete appraisal is more rational and thus more effective than the simple prescription of sympto­matic remedies, such as nitroglycerin for angina or digitalis for heart failure.
It is to be emphasized that treatment poses an individual problem for each patient. There are general rules for guidance, but variations from one patient to the next in severity and stage of disease, in response to rest and reaction to drugs, are so wide that each case demands individual assessment.-' ,
It follows as a corollary that there is no " blanket " prescription for any type of cardiac disease. Medication must be prescribed on specific indications for a specific purpose. Digitalis is not required by every patient with a murmur; nor does the diagnosis of a cardiac lesion carry an automatic prohibition on activity or on child-bearing. Failure on the part of the doctor to carry the diagnosis beyond the stage of valvular disease or arrhythmia too often leads to misguided treatment, and on occasion to unwarranted invalidism and much avoidable suffering.