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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

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

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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