Diagnosis And Prognosis In Heart Disease





The more carefully heart disease, and particularly individual patients

affected by various heart lesions, have been studied in recent years

the more it has come to be appreciated that the most important element

in the treatment of organic heart disease is the definite recognition

of the difficulty of exact diagnosis of most cardiac conditions and

the unfortunate tendency to make the prognosis worse than it really

is. Many heart affections are quite compatible with long life. In the

past both of these problems of diagnosis and prognosis have been only

too often solved unfavorably to the patient, to the serious detriment

of his power of physical reaction against the ailment. Many a patient

has been seriously disturbed and even his power of compensation

lessened by having a diagnosis of an organic affection of the heart

made with the usual prognosis, or at least strong suggestion of early

death that goes with it, when there was no justification for such an

unfavorable opinion.





Mental Attitude of Patient.--We do not pretend to cure tuberculosis,

but we do relieve its symptoms and bring about a remission in the

progress with a shutting in of the lesions. In heart disease something

of the same kind can very often be accomplished. This does not mean

that in advanced cases of heart disease much good can be accomplished

any more than in advanced cases of tuberculosis, though in both a

change of the mental attitude may lift the patient from what seems

almost a death-bed into renewed activity for a prolonged period.

Probably heart disease is more serious in its prognosis than

tuberculosis, yet undoubtedly the lives of many patients could be

prolonged nearly as much as in the pulmonary affection and a large

amount of suffering saved through mental influence. We do not hesitate

to change the occupation and the place of abode of the patient

suffering from tuberculosis. There is even greater reason for doing

this same thing when it seems advisable with patients suffering from

heart disease.



With regard to heart disease, the best authorities are now agreed that

it is better, as a rule, not to tell the patient himself unless it is

absolutely necessary to do so in order to get him to take the

precautions that will prevent further deterioration of his cardiac

condition. The depression incident to the knowledge that one has a

serious heart lesion is not reacted against, and especially not during

a threatening break in compensation, and a more favorable time must be

waited for to reveal his condition to him. The danger of sudden death

in valvular heart disease is much less than is popularly supposed.

Only sufferers from aortic heart disease are likely to die without

warning, and this form of the disease is comparatively rare. The death

of the patient suffering from mitral disease is likely to be

lingering. Mitral disease is the commonest form of heart disease, and

the prognosis of it in ordinary cases is by no means so grave as is

usually supposed. I have seen a patient still alive with a mitral

murmur who told the story of having had his affection originally

diagnosed as mitral regurgitation by Skoda, the distinguished Vienna

diagnostician, over forty years before. This patient at the time I saw

him was nearly seventy years of age, still had the mitral murmur, but

his apex beat was scarcely if at all displaced and there was neither

enlargement of the ventricle nor apparently any degeneration of the

auricle.





The Apex Beat and Heart Murmurs.--In this regard an expression of

Prof. Carl Gerhardt of Berlin deserves to be recalled. That

distinguished clinician used to say that if the apex beat was not

displaced there was no good reason for thinking that any heart

affection which might be present was serious enough to require active

treatment. Heart murmurs have been made entirely of too much

significance and any man of considerable experience is likely to have

seen a number of patients who, because they had a heart murmur, had

been seriously and needlessly disturbed by having a physician tell

them that they had heart disease, with an air of finality that seemed

to the patients to say that they might prepare for the worst very

soon. Patients suffering from diseased hearts have to care specially

for themselves, but not to the extent of living such maimed lives as

is likely to be the case if they are depressed by an unfortunate

exaggeration of the seriousness of their condition.



Our best authorities in* heart disease have at all times proclaimed

their uncertainty as to the diagnosis of heart conditions from

murmurs, while mediocre men of comparatively slight experience have

not hesitated to declare their certainty in this difficult matter. It

is not an unusual thing to hear of a supposed expert having declared

upon the witness stand and under oath that he could tell whether a man

had heart disease by listening to his heart, and some have even gone

the length of making their decisions in this matter while listening

for a few moments sometimes even above the clothing of the patient!

Needless to say, this is quite unjustifiable in our present knowledge

of the status of heart affections and only men of small experience and

over-confidence in themselves make any such declarations. The more

experience a physician has had in heart disease, the more careful he

is not to make positive declarations. One or two examinations may very

easily be deceptive unless there are signs quite apart from those in

the heart itself. Indeed, it is much more the state of the individual

than the state of the heart itself, or anything that can be found out

about it, except after a prolonged and repeated study, that enables us

to make definite decisions. Probably no one during the nineteenth

century had studied hearts more carefully than Prof. William Stokes,

whose books on the subject were so widely read. He wrote:







We read that a murmur with a first sound, under certain

circumstances, indicates lesion of the mitral valves. And again,

that a murmur with the second sound has this or that value. All this

may be very true, but is it always easy to determine which of the

sounds is the first, and which is the second? Every candid observer

must answer this question in the negative. In certain cases of

weakened hearts acting rapidly and irregularly, it is often scarcely

possible to determine the point. Again, even where the pulsations of

the heart are not much increased in rapidity, it sometimes, when a

loud murmur exists, becomes difficult to say with which sound the

murmur is associated. The murmur may mask not only the sound with

which it is properly synchronous, but also that with which it has no

connection, so that in some cases even of regularly acting hearts,

with a distinct systolic pulse, and the back stroke with the second

sound, nothing is to be heard but one loud murmur.



So great is the difficulty in some cases, that we cannot resist

altering our opinions from day to day as to which is the first and

which the second sound.



To the inexperienced the detailed descriptions of such phenomena as

the intensification of the sounds of the pulmonary valves; of

constrictive murmurs as distinguished from non-constrictive; of

associations of different murmurs at the opposite sides of the

heart; of pre-systolic and post-systolic, pre-diastolic and

post-diastolic murmurs, act injuriously--first, by conveying the

idea that the separate existence of these phenomena is certain, and

that their diagnostic value is established; and secondly, by

diverting attention from the great object, which--it cannot be too

often repeated--is to ascertain if the murmur proceeds from an

organic cause; and again, to determine the vital and physical state

of the cavities of the heart. . . .



There are too many cases in which murmurs have no such serious

significance as was often attributed to them when first studied, and

yet it used to be almost a universal custom among physicians, and the

custom still obtains with many, to tell a patient rather emphatically

whenever a heart murmur was present, that he had heart disease. Above

all, too much significance has been ascribed to murmurs in initial

cases of heart disease and these are just the cases that should not be

disturbed by unfavorable suggestion. The louder the murmur the less

likelihood there is of there being heart disease in the ordinarily

accepted sense of the term, that is, that the heart is so affected as

to be incapable of doing its work properly, for where loud murmurs are

present this is almost never the case. A murmur that may be heard a

foot distant is usually associated with perfect compensation.



If this were remembered by those who examine hearts generally, there

would be much less disturbance of heart action by unfavorable mental

influence. A great many more who are suffering from certain

symptomatic conditions of the heart not surely or necessarily

dependent on organic lesions, are plunged into depression by

unfortunate, premature or exaggerated expressions on the part of their

physicians. It is almost a rule to have men and even women patients

say that it makes no difference to them, that they should be told the

exact truth as to what their condition is. The future has been

mercifully hidden from us in most things and there is no doubt that

this plan is the better for human comfort and accomplishment

generally.



The truth is not easy to find and oftener in these cases lies on the

side of favorable prognosis and refusal to think the worst than the

opposite. In this there has been a great difference between the German

and the Irish schools of medicine. The three great Irish physicians,

Graves, Stokes and Corrigan, insisted on the place of the individual

and upon how much depends upon the general conditions in pulmonary and

cardiac disease. Our teaching in America in this matter has come

not from the conservative British schools of medicine, but from the

German school, and that has had a notable tendency to exaggerate the

significance of heart signs over the general condition.



What a great distinction there is between this mode of looking at

these diseases and the German method was pointed out by Prof. Lindwurm

of Munich, when he translated Prof. Stokes' work on the heart into

German. Prof. Lindwurm said:



Thus our modern German works are to a greater or lesser extent only

treatises on the physical diagnosis of organic affections of the

heart. Stokes, on the contrary, resists this one-sided tendency

which bases the diagnosis solely on physical signs and disregards

the all-important vital phenomena; he lays less weight on the

differential diagnosis of lesions on the several valves and on the

situation of a sound than on the condition of the heart in general,

and especially on the question as to whether a murmur is organic or

inorganic, and whether the disease itself is organic or functional.





Broadbent on Cardiac Diagnosis.--What Stokes taught the

English-speaking world so emphatically in the first half of the

nineteenth century Sir William Broadbent was just as insistent about

in the latter half. It is evident, then, that clinical experience has

not changed its viewpoint in these matters in spite of all our study

of the heart in the interval. In his paper on "The Conduct of the

Heart in the Face of Difficulties" he has many suggestions that will

prevent the physician of less experience from taking too pessimistic a

view of heart symptoms. He said:



Moreover, the heart has very special relations with the nervous

system; it reflects every emotion, beats high with courage, is

palsied by fear, throbs rapidly and violently with excitement, and

acts feebly under nervous depression; but it is not only through the

cerebro-spinal system that the heart is influenced, it is in

immediate relation with the vasomotor nervous apparatus, and in a

scarcely less degree with the sympathetic system generally.

Normally, afferent impulses are constantly flowing from the viscera

to the central nervous system and by this reflex process their blood

supply is regulated, and their functional activity is governed.

These afferent impulses when perverted by functional derangement or

disease may become serious disturbing influences.



The nervous system in a large and increasing proportion of people is

unduly sensitive and excessively mobile, and the reactions to

influences of every kind are exaggerated. In some a little emotional

excitement gives rise to palpitation, and a piece of bad news or the

bang of a door seems to stop the heart altogether. There is in such

subjects no form or degree of cardiac disease which may not he

simulated. [Italics ours.] Add a touch of hysteria on the lookout

for symptoms and for someone to give ear to the narration of the

unparalleled agonies of the sufferer, and the difficulties of the

heart, and it may be added of dealing with them, are complete.





Typical Case.--We are prone to think that after the age of seventy the

existence of definite heart murmurs with some tendency to blueness of

the lips and of the fingers, with coldness of the hands, surely

indicates the presence of a serious heart lesion. It is in old people,

however, that such symptoms may be most deceptive. The outcome may

prove that physical signs ordinarily presumed to be surely indicative

of organic disease may be only signs of functional disorder, or at

most may represent certain organic affections for which even the old

heart is thoroughly capable of compensation. One such instance in my

own experience is so striking that I venture to give it in detail.







This was the case of an old physician friend of some eighty years of

age. His son had a summer lodge in the Adirondacks. Though for some

sixty years the father had been living at the sea level in New York

almost constantly, he went up to visit the son and be with his

grandchildren at an elevation of nearly 2,500 feet. His heart began to

bother him almost at once and he could not go up or down stairs or

take any exercise without considerable discomfort, marked shortness of

breath and a tendency to palpitation that was almost alarming. He

continued his stay for several months in the hope that he would get

used to the altitude, though there were always difficulties of

circulation manifested by blue lips and finger nails. He returned to

New York and placed himself under the care of a heart specialist who

found what appeared to be evident signs of heart deterioration of

muscular character complicated by valvular lesions. He consoled, the

old gentleman by the reflection that a heart that had served his

purposes so well for eighty years could not really be complained of if

now it should show some signs of deterioration. He also insisted that

any mental work would be almost sure to be injurious because of the

calls upon the circulation that it would make.



The old gentleman was ordered South for the following winter with an

absolute prohibition of any mental work. He had planned to revise an

historical work on which he had been engaged for many years and which

had served to keep him in good health perhaps more than anything else.

This was put away entirely and he proceeded to try to get well doing

nothing. Almost needless to say with nothing to do he did not get

well. He had been an extremely busy man all his life, had worked at

least twelve to fourteen hours a day for most of the preceding fifty

years, and for him to do nothing would be quite as impossible as for a

child to be kept in utter physical inactivity. His heart palpitation

continued and grew worse. He was waked up at night by starts that

seriously disturbed him and usually kept him from sleep for hours. As

he said himself, after he had read the morning paper and gone to

stool, there was nothing else for him to do all day except eat and

sleep, and these incidents had never occupied any of his attention in

the past. In spite of the doctor's orders he had his manuscript sent

to him and proceeded to work. At once he began to grow better. At the

end of three months he was feeling better than he had felt for several

years. When I saw him, about his eighty-first birthday, he was looking

better than he had for some time.



As he said himself in describing his case, his own experience had

taught him that the more fuss a heart made the less likelihood was

there of its having anything serious the matter with it, at least of

such a character as would terminate life suddenly or unexpectedly. The

serious heart lesions are those which give no symptoms, or but very

slight ones, and the sudden deaths in heart disease usually come from

the development of insidious symptoms that do not betray themselves to

the patient until the fatal termination is on them. The more the

patient himself has been disturbed by his heart, the less likelihood

is there of its giving out suddenly. The subjective symptoms are

usually due to the fact that the heart is actively overcoming external

interference, or resenting over-attention to it in its work. Certain

it is, that the neglect of it, so far as that is consonant with

reasonably regular life, is the very best thing and the most important

part of any prescription given for symptomatic heart disease, whether

organic or functional, is to forget it just as far as possible.







Heart Symptoms in the Young.--In young people particularly it is

important not to suggest the possibility of heart disease until there

are definite signs in the circulation apart from the heart which place

the diagnosis beyond all doubt. The psychotherapeutics of organic

heart disease that is most important is that of prophylaxis. Patients'

minds must be guarded as far as possible against disturbance from the

thought that they have heart disease, for this of itself adds a new

factor which tends to disturb compensation and adds to the heart's

labor because worry interferes with the vasomotor mechanism. In this

matter it seems advisable to repeat once more that there must be a

complete reversal of the customs that have existed until now with

regard to tuberculosis and heart disease. Consumptives have from the

very nature of their disease a tendency to hopefulness which soon

brings about a favorable reaction against the bad news, but heart

patients derive no advantage from the announcement and, indeed, if

they are of the nervous, worrying kind, the effect of it is likely to

be cumulative. A week after being told the worst a consumptive has

reacted vigorously and hopefully, and if he has a fair share of

immunity, the scare will do good by making him take the precautions

necessary to increase his resistive vitality. At the end of the same

time a heart patient will be just realizing all the significance of

the unfavorable diagnosis and prognosis of his case.



It may be urged that heart patients by knowing their condition will be

preserved better from injuring themselves by over-exertion, but what

we have said elsewhere about the value of exercise in the treatment of

heart cases shows how much patients may be injured by having their

exercise too much reduced and their activity inhibited by the dread

consequent upon the announcement made to them. It is perfectly easy to

insist with them that they shall not do sudden things, or take violent

exercise, or overdo activity, without disturbing them by the dread

words "heart disease."





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