Mechanical Treatment.—If the corset is adjusted before the patient rises, and fits reasonably snugly, but not too tight, the contents of the abdomen will all be kept in place, and the kidney will maintain its normal position. When the corset is not sufficient to retain the kidney in place, a simple pad, a towel or a napkin or, if there is much sensitiveness, something more elaborate, especially adapted to conditions, can be placed over the kidney, and when held firmly by the corset will keep the kidney in its place. At first the kidney is usually sensitive to this on account of having been pressed upon during the preceding weeks or months. The patient must bear some little inconvenience at first, must get accustomed to the new conditions in which the kidney is kept in place, and must not expect complete relief at once. Any improvement must be considered a step forward, and further amelioration can be confidently promised. As in all other cases of the use of apparatus or mechanical aids—spectacles, false teeth or crutches—the patient must be content to grow used to the new order of things, before expecting satisfying relief.

This is the palliative treatment. The natural treatment of many of these cases is to have the patient maintain such weight as will hold the kidney in place, because of the fat within the abdomen, without any necessity for external aids. This can be done more readily than is often thought to be possible. These patients insist that they lose their appetite when they settle down to work, but what they really lose is the habit of eating a definite amount at stated intervals. Very often it will be found that breakfast, which they took abundant time to eat during vacation, is rushed. The luncheon suffers in the same way and is small in quantity. They take only one good meal, and one good meal is not sufficient to maintain normal weight.

Question of Operation.—When a kidney is so movable as to deserve the adjective "floating," so that it moves considerably from its place and, perhaps, even sags and may be felt in the subumbilical region, it should be fastened up {309} by surgical means. There is a choice between two evils. The fastening of the kidney in the loin does not restore the normal condition, but puts it in an artificial condition. The kidney supports are of such a kind that it was evidently meant to be slightly movable. When it is fastened firmly in the loin, it is likely to feel every jar, and certain post-operative cases that I have seen, in which firm adhesions had supposedly taken place, complained considerably of the discomfort occasioned by this. In a certain number of cases, even after the operation, the kidney is still somewhat movable, because the adhesions yield and some of the old distress returns. All this must be realized before there is any question of an operation. There must be not merely a little discomfort, but enough of actual ache and of reflex disturbance that can be traced directly to the kidney to warrant the operation.

No floating kidney should be operated upon in a patient who has lost much in weight and has developed a sensitiveness of the kidney since the reduction of weight. Definite efforts should first be made to bring about increase in weight, so as to see whether this will not restore the previous condition of reasonable comfort. At times it is said that the disturbance of the stomach, that is reflex to such a floating kidney, prevents the patient from taking and assimilating enough food to restore normal weight. This will be true if attention has been called to the condition very seriously, and if the patient is persuaded that this is the reason why there is no appetite and poor digestion. Ordinary palliative measures, such as a binder, or a specially made corset, will be sufficient to prevent the kidney from producing reflex disturbance of the stomach, and will exert a strong suggestion to this effect under the influence of which the patient will usually gain in weight.

Intermittent Discomfort.—The discomfort that comes with a loose kidney may be quite intermittent. I have known patients to be bothered by it for months, and then quite free from it for several years, only to have their discomfort renewed so that they become quite worried. Some definite local or mechanical condition can generally be found for these variations in feeling.

In thin people a jolting ride over a rough road or stepping off a car will occasionally be the beginning of the trouble, and as this also is likely to cause a stone in the kidney to give its first manifestations, there may be serious suspicion of a more grave pathological condition than is really present. If this discomfort continues only the X-ray can absolutely decide the question.

Once the mechanical conditions which cause the discomfort are understood by the patient, the actual ache becomes much more easy to bear. Apprehension makes it almost intolerable. Attention exaggerates it, and makes diversion of mind difficult. Understanding helps all the conditions and lessens the pain, not actually but mentally, until after a time very little attention is paid to it.

SECTION VII

CARDIOTHERAPY


CHAPTER I

THE HEART AND MENTAL INFLUENCE

The heart is an organ so vitally important that we might expect it to be carefully protected by nature from any interference with its action through mental influence, emotional conditions, or voluntary or involuntary feelings. As a matter of fact, it is extremely susceptible to mental influence, stimulant or depressive, and to emotions of all kinds. Psychotherapy, that is, the removal of inhibiting influences originating in the mind, and the suggestion of favorable mental influences, is probably more important for the heart than for any other organ in the body. The law of reserve energy has its most noteworthy applications with regard to it. When we are apparently so completely fatigued that we cannot do anything more, a purely mental stimulus may so enliven the heart as to give the body a new supply of strength and energy. A man wandering through a desert, or swimming for his life at sea, may be so exhausted as to be quite ready to give up entirely, and be brought to the conviction that he has absolutely no strength left for further effort, when a flash in the distance, or a sound that indicates that help is near, or some other mental incitement, will give renewed energy. It is probably through the heart that there comes to us most of our power to accomplish things when we are already so tired as to seem exhausted. On the other hand, it is the failure of circulation in muscles, because of a slacking heart, that produces the sense of exhaustion. Muscular work is easy or even pleasant when we are in good spirits, while, whenever exertion is undertaken in the midst of discouragement, we cannot accomplish nearly so much as when conditions are so framed as to give stimulus and encouragement.

If a perfectly normal heart can be so affected by mental conditions and emotions as to be seriously disturbed in its work on the one hand, or greatly stimulated into new activity on the other, it is to be expected that a heart affected by disease will be similarly affected and probably even to a greater degree. It is clear, then, that our cardiac patients have to be guarded against unfavorable mental conditions, and have to have all their reserve energy called out for them by encouragement and by the best possible prognosis for their reflection. This is especially true as regards the removal of the many unfavorable suggestions which, because of ignorance, have in the past gathered round most forms of heart disease.

Emotion and the Heart.—The mental and emotional influence over the heart's action was the truth that lay at the basis of the old fallacy with regard to the physiology of the heart. The literature of all countries testifies that the heart was long supposed to be the seat and origin of the emotions. Every one has experienced how the heart jumps when something unexpected happens. People have fainted from excess of joy as well as of grief. The physical side of emotion is so generally associated with some modification of the heart beat that it is no wonder that emotions were directly connected with the organ. When people are in depressed states the heart is apt to beat more slowly than usual, while when in states of exhilaration, even those dependent merely on mental factors, the pulse is more rapid. Melancholic states have occasionally been attributed to the slowness of the pulse, but the slow pulse seems to be a symptom connected with the mental condition rather than a causative factor. In the maniacal conditions, the rapidity of the pulse, which is sometimes quite marked, must probably be explained in the same way, as due to the mental excitement under which the patient is laboring.

The Heart and the Nervous System.—Prof. Von Leyden ten years ago recalled attention to the fact that the heart is literally the primum movens in man, and that before the central nervous system is laid down, or there is any possible question of impulses flowing from center to periphery, the heart, or at least its embryonic representative, is beating as constantly, regularly, rhythmically, as it is to do during all the subsequent life of the individual. Oliver Wendell Holmes has expressed it poetically by stating that the angel of life sets this heart pendulum going and only the angel of death can break into the case and stop it.

Primitive Heart Action.—The original beating of the heart is entirely automatic, and quite apart from any nervous initiative or stimulus. The original bend in the primal blood vessel, which is to represent the heart in the course of development, begins to pulsate very early in the chick and evidently does the same thing in all other living things. Notwithstanding this fact that the heart is thus easily demonstrated to be the primum movens, the first exhibitor of vitality, and might thus seem to be one of the organs or indeed the one which should be safe from any nervous interference, later on powerful connections with the nervous system are made, and heart acceleration and inhibition become familiar phenomena. Every emotion, as we have said, has its influence on the heart and even a certain amount of voluntary control may be acquired. Indian fakirs are said to be able to cause the heart to slow and almost to stop. The curious phenomenon of suspended animation which they sometimes exhibit is said to be due to this. Certain of the well-developed muscular subjects who exhibit themselves at medical clinics are able to cause their hearts to miss a beat, but this is said to be rather a result of will-power over other muscles compressing the thorax, and interfering with the heart, than direct influence upon the heart itself.

Mental Influence over Diseased Hearts.—Worry produces much more serious symptoms in heart patients than in others. Anxiety about the heart itself is often a source of serious detriment to a heart patient. Most people have such a terror of having anything the matter with their hearts that the haunting thought of such calamity is likely to have a definite influence in preventing the development of such compensation as will enable the heart to {312} do its work to the best advantage. It used to be the custom to refrain from telling patients suffering from tuberculosis that they had the disease. On the other hand, people with heart disease were usually informed of that fact. The reason given for the latter course was that heart disease may in many cases be the forerunner of sudden death, and the warning knowledge was supposed to enable a man to get his affairs in order. No worse policy for either disease could well have been imagined. The pulmonary patient should be told at once, the heart patient should, as far as possible, be saved the depressing knowledge of his condition.

Dr. MacKenzie, whose practically illuminating studies of heart disease give him a right to express opinions with regard to it (and when those opinions concern the influence of the mind they are doubly valuable because of the absolute objectivity of his studies), has some rather strong expressions with regard to the importance of modifying the mental state in heart cases. He says:

The consciousness of heart trouble has often a depressing effect on people, whether the trouble be slight or serious. When such people become convinced that the trouble is curable or not serious, their condition at once becomes greatly improved. Cures by faith, whether in drugs, baths, elaborate methods or religion, act by playing upon the mental condition. But our employment of this element in treatment should not be the outcome of blind unreasoning faith in some rite or ceremony, bath or drug, but in the intelligent perception of the nature of the symptoms. The reassurance of the patient of the harmless nature of the complaint goes a great way in curing him. The reassurance that with reasonable care no danger need be feared is extremely helpful. Even in serious cases when there is reasonable hope of recovery or a certain degree of recovery, the encouragement of the patient may and does help forward his improvement.

Heart Remedies and Suggestion.—Probably the best evidence we have for the influence of the mind over the heart in diseased conditions, that is, when there is definite organic change in the heart valves or muscle, is to be found in the history of the many remedies that have come and gone in heart therapeutics during the past generation. Strophanthus, for instance, was very popular a quarter of a century ago, and it seems as though in many cases it not only replaced, but was more efficient than digitalis. How few there are who use it now with confidence, and how general is the impression that it does not affect the heart to any extent! The confidence with which the remedy was given by the physician was conveyed to the patient and he "took heart," as the expression is, and proceeded to get better. Even more striking is the evidence afforded by other remedies. For a while it seemed that cactus provided a heart stimulant and regulator of value. Convalaria also gained a reputation as a heart remedy. Both are now practically abandoned. Here, once more, the real remedy, when these substances were employed, was, undoubtedly, the suggestion to the patient in connection with the regulation of his habits of life, so that his heart got a chance to catch up with its work. There are other remedies with which we had similar experiences.

Even digitalis has had phases of confidence and distrust in it, that are interesting to study in the light of what we now know with regard to the influence of the psyche on the heart. One hears at medical society meetings reports of the favorable action of digitalis within a few hours of its administration. These are not examples of digitalis action, but of mental influence. {313} Any heart patient after the first visit of a physician in whom he has confidence is sure to brighten up at once, heart action is ever so much better and symptoms of mental depression, and even of circulatory disturbance, disappear. It is this that has made the study of even the efficiency of digitalis so difficult. There were times when most physicians employed it in rather large quantities for all forms of heart disease. In some heart cases it is absolutely contra-indicated. Fortunately many of the preparations of digitalis used in the past were quite inert, and so no harm was done. The results obtained were psychotherapeutic.

Cardiac Inhibition.—The importance of the role of the nervous system and of the mental influences which control it in all functions is well illustrated by what we have learned during the last half century with regard to inhibition in the animal organism. We used to think that while the nervous system sent down positive impulses—that is, nervous stimuli which brought about the accomplishment of certain activities—it had nothing to do with the stoppage of those activities. Such interference was supposed always to be due to external influences of various kinds, potent for the time, in the organism. We have learned, however, that inhibition is one of the important functions of the nervous system. The idea has now become so familiar that sometimes we are apt to forget how great is its significance. Lauder Brunton, in his article on "Inhibition," set forth its role as we have come to know it.

The recognition of the part inhibition plays in vital phenomena is undoubtedly one of the most important discoveries which have been made in physiology since Harvey discovered the circulation of the blood. It throws light upon an immense number of phenomena previously inexplicable and enables us to form theories of a satisfactory nature about many vital problems. It offers an explanation of the nature of hypnotic states, which is at least as satisfactory as that we have of the action of many drugs.

The nervous mechanism of the heart affords the best and most commonly cited example of inhibitory action, and here it was first studied by Weber and Claude Bernard in 1848. The cardiac ganglia derived from the sympathetic preside over the movements of the organ, and in response to the stimulus of the intra-ventricular blood-pressure cause rhythmical contraction of the cavities. Their action is, however, controlled by the pneumogastric nerve, through which impulses of an inhibitory nature are constantly traveling and acting as a restraining force.

As noted by Lauder Brunton, the late Professor Czermak had a small glandular tumor in close contact with the right pneumogastric nerve and he was able by pressure on this to compress the nerve to any extent he wished, and either "to completely stop the heart or simply retard it." He often performed this experiment so that it is not nearly so dangerous as might be thought. We have some instances, apparently too well authenticated to be doubted, in which the power of the human will to inhibit heart action has been as strikingly manifested as this mechanical disturbance of Professor Czermak. Sometimes these stories of cardiac inhibition through the will are dismissed as unworthy of credence, and doubtless many of them are mere fiction, or have been exaggerated for sensational purposes, but some of them are very suggestive examples of the power of the will over the heart. If only a modicum of such power were to be employed, it would seriously hamper heart action, and it must be the aim of psychotherapy to prevent such inhibition.

At least one instance of voluntary heart inhibition was observed by thoroughly trained and properly accredited scientists. A report of it has been published. As a bit of documentary evidence, on a subject that is usually considered so vague as to be scarcely worth considering, Dr. Cheyne's description of the remarkable power of Colonel Tonshend over his heart should be in the hands of those who wish to influence hearts through minds and wills.

He could die or expire when he pleased, and yet by an effort, or somehow, he could come to life again. . . . We all three felt his pulse first: it was distinct, though small and thready, and his heart had its usual beating. He composed himself upon his back and lay in a still posture for some time. While I held his right hand. Dr. Baynard laid his hand upon his heart, and Mr. Skrine held a clean looking-glass to his mouth. I found his pulse sink gradually till at last I could not feel any, by the most exact and nice touch; Dr. Baynard could not feel the least motion in the heart, nor Mr. Skrine discern the least soil of breath on the bright mirror. Then each of us by turns examined his arm, heart and breath, but could not by the nicest scrutiny, discover the least symptom of life in him. We reasoned a long time about this odd appearance, and finding he still continued in that position, we began to conclude that he had indeed carried the experiment too far; and at last we were satisfied that he was already dead, and were just ready to leave him. This continued about half an hour. . . . As we were going away we perceived some motion about the body, and, upon examination, found his pulse and the motion of his heart gradually returning; he began to breathe heavily and speak softly.

Nor must it be thought that the inhibitory faculty can act only in slowing the heart. Normally a certain amount of inhibition is exercised over the heart's action. If by any chance this should be decreased then acceleration of cardiac activity may take place. Lauder Brunton called attention to that in discussing another phase of pneumogastric function. He said:

Paralysis of the pneumogastric, of course, does away with its action. And hence we have among other symptoms of this condition increased rapidity of the contractions of the heart from withdrawal of the inhibitory influence.

If slowing of the heart action can be produced through the mind by this mechanism of inhibition, so also under other circumstances may acceleration occur.

Shock and the Heart.—How large a role emotion plays in disturbing the action of a heart that is already diseased, is illustrated by the story told in serious histories, on what seems good authority, of the dwarf of the French king, who was frightened to death by what he thought were the arrangements for his execution. While we take great pains as a rule to impress upon sufferers from organic heart disease the necessity for their avoiding every kind of over-exertion, or sudden movement of any kind, we do not always impress upon them the even greater necessity for the avoidance of shock and fright, and profound emotions. It must not be thought that emotional shocks have a deleterious effect only in advanced cases of heart trouble. Almost any physician will readily recall examples where emotion had much to do with the break in compensation which indicates that the heart has for a time been overworked.

A case in my own experience illustrates this: The patient, a student, had suffered from severe so-called growing pains, undoubtedly rheumatic, when he was about fourteen, and probably had acquired a heart lesion at that time. {315} It did not, however, disturb him in the slightest degree. The patient had never noticed any fatigue on running up stairs; he had no shortness of breath; there were no symptoms pointing to his heart. One summer while his family were in the country he came into town for the day, and missing the last train out, he went to the family home to sleep, though it had been closed up for the summer. He let himself in without difficulty and was preparing to go to bed when he resolved to get a glass of water. There being no tumbler nearer than the dining-room, he went there. As he entered the dining-room he struck a match. With the flash of the light he found himself looking into the barrel of a revolver and a hoarse voice said, "Hands up!" His hands went up. The next minute he was in the hands of two "plain clothes" policemen who had been watching the neighborhood because of recent burglaries. Noticing the light upstairs, they had made their way in for the purpose of catching what they thought a burglar at work.

The young fellow, who had never before fainted, collapsed almost at once, and was unconscious for some minutes. The next day he was rather prostrated and tired on movement. By resting a good deal for the next week this passed off to a considerable degree, but then his physician found that he was suffering from a serious heart lesion, with a decided break in compensation. I saw him several months later. His heart had never regained its old power, and his mitral valve was quite unable to fulfill its function. Just what the mechanism of the almost sudden break in compensation was after he had been for so long quite immune from any effects of the rheumatism, is hard to say, but the lesson of the case is easy to understand.

Place of Psychotherapy in Treatment.—The role of psychotherapy, then, in heart cases consists in the recognition of the part that the mind, the will and the emotions play in their influence over this important organ. These psychic factors may produce disturbed conditions of various kinds. The more experience the physician has with cardiac cases of all kinds, organic as well as functional, the more powerful does he recognize the influence of the mind over the heart to be. The expression that a man is living on his will is no mere figure of speech. Some cases we have cited seem to show that a favorable attitude of mind keeps up heart action, where an unfavorable attitude would almost surely allow the heart to fail. It is this very potent influence then that must be used to as great advantage as possible in the psychotherapy of cardiac patients.

Undoubtedly the most important phase of it is in prophylaxis. As far as possible we must save our heart patients from emotions. The effect of emotion on the heart is known. When that organ is already crippled, emotion may produce a serious strain on it. It is as important to save heart patients from joyful emotions as from those of contrary nature. Many a son who, after years of absence, thought to surprise a dear old mother by suddenly presenting himself to her, has learned to his cost that an old heart may break from joy, almost as easily as from sorrow, and may be as unfavorably affected by the glad emotions as by terror or fright. We must also save heart patients from the unfavorable influence of a bad prognosis, and of too serious a diagnosis, both of which may be quite unjustified, for the rule is that the longer a man has been studying the heart, the less likely is he to be confident in his diagnosis, or unfavorable in his prognosis.

The curative place of psychotherapy is in the obtaining, as far as possible, of placid easy lives for these patients. This does not mean that they are to give up their occupations, for very often the internal emotional life, which develops when they have nothing to do but think about themselves, will be more serious in its effect upon the heart than the ordinary vocation. Exciting incidents in life work must, however, be avoided. If men are in occupations that require exposure to excitement, then it may be advisable to change their occupations. Brokers, speculators, actors, sometimes public speakers, on whom appearances in public in spite of apparent placidity are often a severe strain, may have to be guided into quieter paths of life. In general, in every attempt to treat heart disease, and the neurotic symptoms which develop in connection with it, the patient's mind must be considered as one of the most important therapeutic factors.

CHAPTER II

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 {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.

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."