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 [{317}] 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 [{319}] 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.