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Physical Diagnosis

( Originally Published 1921 )

Reconstruction in heart disease must be founded primarily upon an accurate diagnosis. In no department of medicine has so great an advance been made as in heart disease during the last ten years. 1908 might be said to have been the first date in modern cardiology. A good deal of work had been done before that time, but it had not come to the notice of the profession at large until the publication of Sir James Mackenzie's book in 1908.

Mackenzie was the first man who thoroughly emphasized the fact that function was relatively of more importance than structure. Before Mackenzie's time the diagnosis of heart disease consisted in a successful mapping out of the organ, and the man who could predict the most closely what the heart would look like, if the person himself could see it, was considered the best diagnostician. When we found a heart that was irregular, we called it myocarditis and let it go at that, without giving time to the analysis of the irregularities. Great emphasis was laid upon the size of . the heart, and to this day, if you want to satisfy thoroughly the aver-age man that you havé made a wonderful diagnosis, tell him that his heart is enlarged. Then he feels that he has been told something definite.

The modern routine examination of a heart, where the facilities are complete, consists first in an orthodiagram, showing the exact outline of the heart. This gives a good deal of information, because hearts show a different outline according to the particular chamber that is in trouble. The heart with aortic lesion shows a relatively large hypertrophy of the left ventricle the left ventricle extending east and west, as it were, and lying down flat on the diaphragm. The heart with a mitral lesion, particularly mitral stenosis, has a relatively round outline, and the left auricle is quite a conspicuous element in the shadow. The poorly developed heart of the person with a weak heart is developed almost equally on the right and left sides, and it stands up in the middle of the chest much like an Indian club. The electrocardiogram in such a case shows that the right side of the heart is relatively more active than the left. With a little experience, one can make a shrewd diagnosis of the relative valvular and muscular condition of the heart by the orthodiagram.

The orthodiagram was originally made with a complicated instrument so constructed that the outline of the heart was drawn on a screen by a pencil that was passed around the shadow of the heart, while the X-ray tube was moved with the pencil so that the rays always passed the edge of the heart in a perfectly' perpendicular manner instead of radiating from one point. That has been entirely superseded by putting the source of light so far off and putting the plate so near to the heart that the divergence of the rays after they pass the edge of the heart becomes a negligible quantity. This is an advantage, because the use of the orthodiagraph always seemed to me to expose the operator to danger from damage from the X-ray. I never could see how a man could work all day long drawing these hearts without deterioration of health; in fact, he could not, for some of these operators did succumb to the effect of the X-ray.

By examining the heart with a fluoroscope, when you become thoroughly accustomed to it, you get the relative activity of the different chambers, and you get a general knowledge of the outline of the heart. Then you take your picture of the heart made with the X-ray tube six feet away and the plate quite near the heart, and it is a simple matter to draw on the X-ray plate, or on a print from it, an accurate outline of the heart, making a slight allowance for the shadow not more than a quarter of an inch.

The use of the fluoroscope has added tremendously to our familiarity with disordered hearts, and another thing which has helped us is the recent military draft. The medical profession has been compelled to give attention to all kinds of heart conditions during the last two years, and we have come to recognize certain groups which we hardly thought of before. We find that instead of a few people with congenital heart defects there are really many of them. Of course there has been much dispute as to the classification of these men, but they have fallen into definite groups in every army camp, and have been valuable as giving experience in exactly what I am talking about that is, reconstruction in heart disease.

It doesn't matter what you call this condition, it is something definite. Neurocirculatory asthenia is a long enough name, but I rather prefer to speak of the trouble as a poorly developed heart. Hence the foundation of reconstruction must be, primarily, a definite knowledge of the geography of the particular heart that you are dealing with. Secondarily, it must be a definite knowledge of the functional condition of that heart.

The modern cardiology is founded upon the use of the polygram. This recalls the inventor, Mackenzie. The story of Mackenzie's medical career is fascinating in its interest and in the surprising way in which it came about. Mackenzie, a practitioner in a small Scotch town, had no colleagues who were interested in the technicalities; he had no university, no hospital; but he became interested in the problem of the disorders of the heart. He made a complete study of the literature of the subject, talked to everybody he could, and finally came to the conelusion that the existent knowledge was unsatisfactory. He wisely decided that what was needed was a sufficient number of facts upon which to draw conclusions as to what was the meaning of irregular hearts. He found that the information obtained by taking tracings from the wrist was unsatisfactory. Then he took up a piece of knowledge which did not originate with him but had been entirely neglected that there is a pulse in the jugular vein. The pulse at the wrist comes from the left ventricle; the pulse in the jugular vein is a series of waves that come from the base of ;the heart. The venous blood is gathered at the base of the heart ready to go into the heart and to be pumped through the body, and forms a sort of pool there, and leading down to that pool is the jugular vein. Every movement of the heart makes a ripple in this blood, and that ripple or wave can be detected at the base of the neck. When any activity takes place in the heart, it sends a wave up through the jugular vein.

Mackenzie took this obscure piece of knowledge which nobody had thought much about, and decided that if he were to know what was going on in the heart he would have to find some way of detecting and recording the waves in this pool of blood in which the heart was moving. He called in to his help the village watchmaker and constructed a little metal cup which he placed over the point where these waves could be detected. He connected this cup with a tube containing air to a recording chamber, and to this recording chamber attached a pen. Every little ripple that the heart made when it moved, whether it was the auricle, the ventricle, or some other part, was conveyed through this tube from the cup to the recording pen. He caused the pen to be moistened in ink, and arranged paper to pass under the pen. In that way he got an autograph of the activities of the base of the heart. At the same time, on the same piece of paper, he obtained the record of the radial artery.

So he got the two pens, one recording the action of the ventricle, and the other recording the action of the auricle and whatever else took place at the base of the heart. His idea was that if he got records of all the irregular hearts, he would have something to begin with, something to study. For he said, "It doesn't matter whether I can interpret these things or not. I may not live long enough, but here I have them." He made five thousand copies of these records from irregular hearts.

Every heart patient who knew Mackenzie went to him and he made these pictures. When he had a number made, he sorted them out into groups. There were fifty cases that looked exactly alike, and he concluded that they must represent some disease. Another group represented another disease, and so on. And then he commenced to name these diseases.

The first disease he described was what we now call auricular fibrillation. Here is a group of cases, he said, in which the auricle and the ventricle seem to act at the same time. I can find no trace of independent action of the auricle. So, he said, the auricle and ventricle must be acting at the same time, and to act at the same time the impulse of the heart must start somewhere between the two and spread to both at the same time. He said they represent a class of people whose hearts are rapid and irregular, people who suffer from dropsy and are seriously, ill, and they also represent a disease that is most benefited by digitalis. Nobody else in the history of the world had ever thought of putting these people in a definite group. Later on it was learned from electrocardiographic records that the auricle was paralysed.

The affection had been called myocarditis. No medical term has ever held back the knowledge of medicine more than that term. But Mackensie pointed out that functional disorder might be distinct from extensive inflammation. Then he modestly said he did not know what it was, in which he showed himself really great. He knew considerable about it but did not know what it was. Mackenzie was not credited with the discovery of this disease (auricular fibrillation) in part because another man invented the electrocardiogram, which tells the whole story in plain language, and so obtained the credit for the discovery. Of the unfairness Mackenzie never complained; he was too big a man.

The case is similar with all the other irregularities. Mackenzie gradually explained them. One of the greatest things he did was his teaching concerning sinus arrhythmia. This is the irregular heart that is normal in very young children and disappears as people grow older. Mackenzie pointed out that this was innocent, and that it ought not to cause concern; in doing so he liberated thousands of children from the burden of invalidism and sent them to play out of doors and be like other children. I remember many children who were supposed to have heart disease and were kept still because their hearts were irregular, Mackenzie, after pointing out that this was physiologic in children, showed the true nature of the intermittent pulse. In fact he did away with the idea of missed beats, because this is a very rare thing. He said that it was innocent simply a premature contraction; that when the pulse intermits, ordinarily it means that the ventricle is a little irritable and gives a slight beat independent of the auricle, and that takes the place of the regular big beat. The succeeding beat following this small one is usually a large one.

After that he showed the true nature of heart block. He showed that it consists of an interruption of the muscular action between the auricle and the ventricle, and that the auricle is beating in its regular rhythm and the ventricle in its regular rhythm, but not in unison. Similarly he described, in a measure, the nature of the different palpitations, paroxysmal tachycardia, and so on. He pointed out that palpitation might be traced to a number of different causes, and that the treatment of the different kinds was to be varied accordingly.

Reconstruction in heart disease must, then, be founded on definite physiological diagnosis. When we find that the irregularity has its origin in the ventricle, we know that it is comparatively innocent, and that we can give abundant liberty to the individual, in spite of his irregular heart.

Ventricular premature contraction for some reason or another is a common affliction among physicians. If I should pick out, in my collection of irregular hearts, the twenty most striking examples that I have of irritable ventricles, at least ten of them would be found to belong to physicians. I recently received a bunch of flowers from a Long Island physician's wife, and this is what she wrote on it. "May this touch of spring brighten your thoughts as you have brightened my life in your kind and sympathetic care of the doctor." The doctor had been working hard during the influenza epidemic and he was having premature ventricular contractions about four or five or six times to the minute. By a patient and thorough examination I convinced the doctor that I knew all about his heart. That examination was an important part of the reconstruction in that case. Then I succeeded in reassuring him and sending him back to his practise, and with certain limitations and care of himself he has improved, and hasn't lost a day since. I call that an example of reconstruction in a heart disorder. When armed with a definite diagnosis, you can reassure the patient.

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