Some Difficulties in the Diag- 
nosis of Cardiac Diseases. 
BY 
FRANK W. JACKSON, M. D., 
Chief of Clinic and Instructor in Physical Diagnosis, 
Medical Division of the College of Physicians and 
Surgeons, New York ; Assistant Visiting 
Physician to Bellevue Hospital. 
REPRINTED PROM THE 
Neto Yorft Jttetncal Journal 
for April 28, 189/f.. Reprinted from the New Yorlc Medical Journal 
for April 28, 189 f 
SOME DIFFICULTIES IN 
THE DIAGNOSIS OF CARDIAC DISEASES.* 
By FRANK W. JACKSON, M. D., 
CHIEF OF CLINIC AND INSTRUCTOR IN PHYSICAL DIAGNOSIS, 
MEDICAL DIVISION OF THE COLLEGE OF PHYSICIANS AND SURGEONS, NEW YORK 
ASSISTANT VISITING PHYSICIAN TO BELLEVUE HOSPITAL. 
The diagnosis of most diseased conditions of the heart 
seems at the first glance comparatively easy, provided one has 
had the average training and experience in such conditions. 
A more careful study of the subject, however, reveals diffi- 
culties which are not commonly recognized or certainly are 
not recorded in the text-books, and which should be known 
to every practitioner. My notes upon cases of derange- 
ment of the heart observed during the past fourteen years 
are in many instances, to me at least, very interesting, and 
from these I have selected a few abstracts which, while 
only serving to indicate in a sketchy and imperfect manner 
some of the difficulties to be met with, may yet suffice to 
direct further attention to the subject. 
To the superficial observer the presence or absence of a 
cardiac murmur is sufficient to determine the abnormal or 
* Read before the New York Clinical Society, February 23, 1894. 
Copybight. 1894, by D. Appleton iSSgOrfsifriLA/i 2 
SOME DIFFICULTIES IN THE 
the normal condition of the heart, but it is well known that 
the presence or absence of a murmur is only one element in 
the diagnosis. It is not generally known, however, that 
a murmur may he evanescent. The common belief is that 
a murmur once developed must be present continuously as 
long as the morbid condition which gave rise to it persists. 
This is not the case. A murmur may, and frequently does, 
appear and disappear and return again within a very few 
hours. Such evanescent murmurs are most commonly due 
to functional derangements of the heart, hut they are also 
observed in connection with well-marked valvular lesions. 
This evanescent character of a valvular murmur was first 
brought to my notice in 1880, when I was an interne in 
the Roosevelt Hospital. A woman was admitted with a 
greatly dilated heart, hut no valvular murmur. The house 
staff made frequent examinations of her heart, and after 
several days a systolic apex murmur was detected. The 
attention of our attending physician, a gentleman of distin- 
guished ability in diagnosis, was directed to this murmur, 
hut he disconcerted us by stating that he did not hear it. 
It was one against three ; but it was one trained physician 
against three beginners, and we thought that we must have 
been mistaken. The examination of the patient’s heart, 
which was instituted the moment the attending physician 
had left us, failed to reveal a murmur, but the next day the 
murmur returned. Again our attending physician failed to 
hear it. Happily on the third day we caught the mur- 
mur at the right time and our attending physician con- 
firmed our diagnosis. A subsequent autopsy revealed a 
very marked insufficiency of the mitral valve. That case 
set me to thinking. Why was the murmur inconstant ? It 
could not be on account of the weakness of the cardiac 
muscle, for the heart was beating with equal strength both 
when the murmur was heard and when it was inaudible. I DIAGNOSIS OF CARDIAC DISEASES. 
3 
was inclined then to believe that the fault lay in our own 
ears, which at times were too dull to detect faint sounds ; 
but I have since become convinced that this is not the case. 
Murmurs vary more than ears. The reason why they vary 
—except in those cases where there is temporary variation 
in the force of the heart’s action—is no more clear to me 
to-day than it was then. I have since met with many in- 
stances of cardiac disease in which a murmur could be 
heard at one examination and not at the next. It would 
seem that such variation in the cardiac murmur must occur 
only when the murmur is feeble in intensity ; but this is 
not so ; a loud murmur will often be observed to come and 
go. This noteworthy fact will frequently explain the dis- 
crepancy in the opinion of different physicians in regard to 
the same case. An interesting example of this difference 
of opinion occurred in connection with the application of 
one of my patients for life insurance five years ago. 
A gentleman, aged twenty-eight years, of nervous tempera- 
ment and slight physique, applied to one of the prominent life 
insurance companies of this city for a risk upon his life. He first 
came to me for a physical examination. As I had had an inti- 
mate medical knowledge of him for the previous three years, I 
assured him that he would have no difficulty in passing his ex- 
amination ; but to satisfy him I made a careful, not perfunctory, 
examination of his heart and lungs and of his urine. There 
was not the slightest evidence of anything abnormal, except 
that his pulse rate was a hundred. The heart sounds were clear 
and distinct and the heart was not enlarged. Knowing my pa- 
tient’s nervous temperament, I attributed his rapid heart action 
entirely to excitement, and I cautioned him to get the examiner 
to count his pulse before subjecting him to a general examina- 
tion. Three weeks later he came to me and said that his appli- 
cation had been refused. Three examiners had listened to his 
chest and then declined his risk on account of “ something 
wrong with his heart.” I was surprised, for I knew the gen- 4 
SOME DIFFICULTIES IN THE 
tleman had no organic disease, and I proceeded to examine his 
heart again. My ear had hardly touched the chest wall before I 
heard a particularly loud systolic apex murmur. After explaining 
to him that there was no cause for alarm I directed him to re- 
port to me for examination once a month. I found that this 
murmur was sometimes present and sometimes absent, some- 
times loud and sometimes very feeble. But up to a year ago, 
when he left Mew York, he never had a symptom of derange- 
ment of the heart, nor was there any increase in the size of the 
heart. 
During the past year I have had, and have still, under fre- 
quent observation a dispensary patient who, in addition to a 
well-marked aortic diastolic murmur, has a systolic apex mur- 
mur which is at times so loud as to be recognized by all my 
students, and yet on the following day it is frequently entirely 
inaudible. 
Last summer thege was admitted to the Roosevelt Hospital 
a man with unmistakable chronic fibrinous pericarditis. The 
characteristic “ to-and-fro ” murmur of pericarditis was so loud 
that it could be recognized at once either by the ear or the 
stethoscope. Yet that murmur would be found to disappear 
and reappear from day to day or even from hour to hour. In 
addition to this a blowing systolic endocardial like murmur 
would occasionally be heard to the left of the situation of the 
apex beat. 
Another source of error in the diagnosis of cardiac dis- 
ease is the curious fact which is, I believe, almost alto- 
gether overlooked, that some murmurs are heard only by 
the unaided ear and are inaudible to the stethoscope, while 
some are inaudible to the ear and are heard with great dis- 
tinctness by the stethoscope. This curious characteristic 
of murmurs may be noticed in any form of valvular disease, 
but it is most common in connection with the murmur of 
aortic regurgitation. This murmur, whether feeble or 
loud, is sometimes only heard by the ear and not by the 
stethoscope, while in other cases the murmur can not be DIAGNOSIS OF CARDIAC DISEASES. 
5 
detected by the ear alone, but is quite loud when heard 
through the stethoscope. I have no explanation to offer in 
regard to this peculiar phenomenon, but the fact is unmistak- 
able. It will readily be seen how important it is that this 
should be recognized, for if the heart be acting regularly 
and an examination be made with the stethoscope alone the 
heart sounds might appear absolutely normal and thus a 
most serious valvular disease would escape notice. I make 
it an invariable rule in cases which admit of the least doubt 
to listen both with my ear and with the stethoscope. If there 
seems to be every reason to believe that the heart is healthy, 
I think it better to listen with the ear alone than with the 
stethoscope alone. 
The fact that murmurs do not always confine them- 
selves to their regular areas is still another source of error. 
We naturally expect to find the murmurs of aortic valvular 
disease in the neighborhood of the second intercostal space 
to the right of the sternum, or over the upper portion of 
the sternum itself; but this is not always the case. The 
murmur of aortic regurgitation, particularly, is often heard 
only over the ensiform cartilage, and the examiner who 
forgets this possibility may readily be deceived by listening 
only over the upper portion of the sternum, and, if he there 
hears a clear second sound, he may readily make the mis- 
take of believing the aortic valves to be healthy. It must 
also be remembered that the murmur of aortic regurgita- 
tion may occasionally be heard at the apex of the heart 
only. A murmur heard in the neighborhood of the second 
intercostal space to the left of the sternum may indicate 
disease of the pulmonary valves or of the pulmonary artery ; 
but disease of the right heart is so rare in the adult that it 
is hazardous to make such a diagnosis. The true condition 
is usually disease of the aortic valves -or pressure upon the 
pulmonary artery. I ventured the diagnosis of disease of 6 
SOME DIFFICULTIES IN THE 
the pulmonary valves in a patient whom I saw this past 
summer at Bellevue Hospital, my reason for the diagnosis be- 
ing the fact that she had the symptoms of malignant endo- 
carditis, together with a loud, harsh systolic murmur, heard 
with greatest intensity over the situation of the pulmonary 
valves, while hardly any murmur could he heard over the 
aortic area. It is well known that malignant endocarditis, 
unlike rheumatic endocarditis, may attack the right heart 
in the adult. There seemed good reason to believe, there- 
fore, that the murmur was produced in the pulmonary ori- 
fice. The autopsy showed that I was mistaken. There 
was malignant endocarditis, hut the disease had involved 
the aortic valves, while the pulmonary valves were intact. 
In a like manner we may he embarrassed or deceived by the 
situation of the murmur of mitral stenosis. We are told 
that this should be heard only at the apex of the heart, but 
it is often inaudible at this point, and is only heard in the 
third intercostal space to the left of the sternum. I have 
also heard this murmur in the axillary region, considerably 
to the left of the apex beat, and nowhere else, and I have 
observed a harsh systolic murmur over the pulmonary ori- 
fice in a case which autopsy showed to be mitral stenosis. 
Five years ago I was very much puzzled by hearing a double 
murmur over tbe situation of the liver. A man applied to the 
Medical Clinic of the College of Physicians and Surgeons for 
relief from the ordinary symptoms of heart disease. The pe- 
culiarity of his case consisted in the absence of any signs of 
enlargement or disease of the left ventricle, while the area of 
cardiac dullness to the right of the sternum and between the 
fourth and sixth ribs was considerably increased. A distinct, 
but not loud, double murmur was heard over the same area, 
but with its maximum intensity in the fifth space and the nipple 
line, or seemingly over the liver. Dr. Delafield’s brilliant diag- 
nosis of a small aneurysmal sac having its origin just above the DIAGNOSIS OF CARDIAC DISEASES. 
7 
aortic valve and projecting downward was confirmed by autop- 
sy some two years later. 
The fact that the presence of a murmur does not neces- 
sarily indicate valvular disease is generally recognized; but 
ar too many physicians still regard a cardiac murmur 
and heart disease as synonymous terms. The subject is 
too extensive to be adequately dealt with within the limits 
of this paper; but it will be sufficient to call attention to 
the case, before mentioned, of the gentleman who applied 
for life insurance and was rejected on account of a mitral 
systolic murmur. During the five years since that murmur 
was discovered there has never been the first symptom of 
derangement of the heart’s action, and there has been no 
increase of the size of the heart or other sequelae of valvu- 
lar incompetence. It is not uncommon to discover cardiac 
murmurs in patients who have never experienced the slightest 
symptom of derangement of the heart’s action, and in many 
of whom no evidences of hypertrophy or other compensation 
can be found. The experience of examiners in life insur- 
ance will confirm this statement. A little leakage through 
a valve by no means destroys the efficiency of the valve, 
and, in the absence of evidence of progressive endocarditis, 
such cases should not be regarded as true heart disease. 
The difficulty of diagnosis in cases of cardiac disease 
without a murmur is much greater. This applies particu- 
larly to disease of the aortic valves, or of the aorta just 
above the valves. The diagnosis of the dilated heart, or of 
cardiac weakness, is comparatively simple, since in these cases 
we have direct evidence of the failure of the cardiac mus- 
cle, and the presence or absence of a murmur signifies but 
little. Well-marked stenosis of the mitral orifice or of the 
aortic orifice, though often unattended by its characteristic 
murmur, is usually recognized without much difficulty. 
The class of cases of which I wish to speak particularly is 8 
SOME DIFFICULTIES IN TIIE 
that in which there is either atheroma or thickening of the 
aortic valve with atheroma of the aorta, or there is athe- 
roma of the aorta in the neighborhood of the orifices of 
the coronary arteries without involvement of the aortic 
valves. The difficulties in the diagnosis of some of these 
cases is very great indeed, and yet they should be recog- 
nized if possible, since the prognosis is of the utmost 
gravity. It is a condition which occurs in New York 
more commonly than is generally known, and more espe- 
cially among the upper classes. Most of my cases have 
been men of middle age, who have been in active business 
for many years, and who have worried over their business. 
These men complain for a considerable length of time of 
“ dyspepsia ” ; then they have painful sensations about the 
heart, then palpitation of the heart, and, finally, dyspnoea 
on exertion. They are liable to sudden death, usually with 
symptoms of angina pectoris. In some cases the diagnosis 
is comparatively easy, but in others it is very difficult in- 
deed. Two years ago two gentlemen put themselves under 
my care at about the same time and with very similar 
symptoms. 
Each was over fifty years of age, and each was in active 
business. The first patient had suffered for several years from 
palpitation of the heart and flatulence, and these symptoms had 
distressed him so that he had lived for a year on a diet of hot 
water and chopped beef, but without material benefit. At the 
time he came to me he was building a house, and he found 
when he ascended the steep temporary stairs that he was short 
of breath, and that, as he expressed it, “there was a devil un- 
der his breast bone.” Careful physical examination revealed an 
intermittent but strongly acting heart, a clear first sound at the 
apex, while no aortic valve sound could be heard. There wei-e 
no murmurs. The apex beat was in its normal position, but 
auscultatory percussion showed the heart to be unquestionably 
enlarged. There was no increase of arterial tension and no DIAGNOSIS OF CARDIAC DISEASES. 
9 
renal disease. Several subsequent examinations showed that 
the aortic valve sound was persistently absent. There never 
was a murmur. Here, the enlargement of the heart and the 
absence of the aortic valve sound, the attacks of pain and 
dyspnoea on exertion, and the location of the pain under the 
sternum, rendered the diagnosis of disease of the aortic valve 
and of the aorta very probable, and the bad prognosis was con- 
firmed by his sudden death with symptoms of angina pectoris a 
year later. 
The second patient had suffered for a long time from flaut- 
lent dyspepsia and an intermittent heart. For about a year 
previous to the time that he consulted me he had suffered from 
attacks of asthma and bronchitis. He was very nervous about 
himself, and especially in regard to his heart. He had taken 
many drugs. 
Examination of his chest showed that he had moderate em- 
physema of the lungs. His heart was intermittent but fairly 
strong; all the valve sounds were normal, and auscultatory 
percussion showed no increase in the size of the heart; the apex 
beat could not be felt. There were no murmurs. Subsequent 
examinations revealed no change in these signs. There was no 
increase of arterial tension and no renal disease. This case I 
regarded as just the opposite of the former one. I considered 
his cardiac symptoms to be entirely functional, and I believed that 
his attacks of asthma were due to his emphysema superinduced 
by reflex conditions from his stomach. I gave an absolutely 
good prognosis. I stopped all medicine except some iodide of 
potassium and told him to go back to his business instead of 
spending his time in bed, as he had been doing. Within two 
weeks he improved wonderfully, and after about six weeks he 
came into my office one day to tell me how well he felt. His 
heart was regular; he had had no asthma for some time, and 
only complained of some shortness of breath on active exertion. 
The next day, while ascending the stairs of the elevated road, 
he complained of pain under his sternum, and then almost faint- 
ed. He was assisted to a neighboring drug store. When he 
sat for a moment, a small quantity of blood gushed from his 
mouth and he died. I could not obtain an autopsy, but I be- 10 
SOME DIFFICULTIES IN THE 
lieved that all his symptoms were due to an aneurysm of the 
arch of the aorta. 
I liad been misled by the nervous character of the in- 
dividual, which had induced me to underestimate the sever- 
ity of his symptoms, and since to this was added a heart 
normal in size and strength and with absolutely no change 
in the valve sounds, I was completely deceived as to his 
true condition. The following is a typical case : 
Last spring a gentleman was sent to me by his son, who is a 
physician, for advice as to the condition of his heart. He was 
sixty years of age; he had always been remarkably healthy, and 
he was a very active and hard worker. His only discomfort 
was an occasional attack of “biliousness.” He considered him- 
self perfectly well at this time, and he had only come to me to 
please his son. In 1892 his son noticed that there was an ex- 
aggerated heart action, and about the same time it was noticed 
•that there was some little difficulty in breathing on ascending 
many stairs. Just before I saw him he had applied for an in- 
crease of life insurance, which was denied him, because, he 
said, his pulse rate was ninety to the minute. He denied to me 
that he ever felt ill except for some dyspeptic symptoms, and 
occasional attacks of slight pain running down the left arm. I 
found distinct hypertrophy of the heart, a very feeble aortic 
valve sound, and no cardiac murmurs. At that time there was 
no increase of arterial tension, but there was some thickening 
of the radial artery. The pulse was slightly intermittent. 
There was no renal disease. The age of the gentleman, the en- 
largement of the heart, and the feeble aortic valve sound, to- 
gether with the pain running down the arm and the thickened 
radial arteries, led me to give a very unfavorable prognosis. 
Subsequent examinations both by his son and myself failed to 
reveal a cardiac murmur, but after three months a moderate in- 
crease of arterial tension developed, and he complained of dysp- 
noea and discomfort after eating, which was relieved by eructa- 
tions of gas. He continued at his business and insisted that he was 
perfectly well. On the evening of December I7tb he suffered DIAGNOSIS OF CARDIAC DISEASES. 
11 
from dyspnoea on exertion, having to rest four times in walking 
half a mile, and he reached home exhausted. After a few min- 
utes’rest he ate heartily and his symptoms disappeared. He re- 
tired to bed at 11.30 p. m. About 1 a. m. he complained of 
dyspnoea and pain in the region of the heart; there was eructa- 
tion of gas and there was profuse perspiration. The pain and 
oppression became intense, and he died at 1.30 a. m. 
It will be seen that these cases do not resemble angina 
pectoris except at their termination, and that for a consid- 
erable period before death the symptoms are slight or ob- 
scure. It seems to me that the most significant signs of 
this condition are enlargement of the heart and an absence 
of the aortic valve sound, or a feeble aortic valve sound, 
though both these signs may be absent. 
Still another source of error in the diagnosis of heart 
affections is to be found in the estimation of the size of 
the heart. Many hearts have undoubtedly been regarded as 
diseased which were absolutely healthy, simply because the 
apex beat was farther from the median line than is com- 
monly the case, or because percussion revealed a larger 
area of cardiac dullness than the books would lead us to ex- 
pect. In the beginning of my experiments in auscultatory 
percussion I believed that I had discovered a number of 
enlarged hearts, and I was disposed to criticise those gentle- 
men under whose care the patients were for not observing 
the enlargement of the heart, or for not discovering the 
nephritis or other cause of the enlargement. Further in- 
vestigation showed me that these hearts were only of nor- 
mal size, and that I must modify my preconceived ideas of 
the size of the heart as revealed by percussion. The left 
border of the heart is, in the healthy individual, much far- 
ther to the left than is usually supposed. It is commonly 
regarded as being about a quarter of an inch to the right 
of the left male nipple, and it is believed that much in- 12 
SOME DIFFICULTIES IN THE 
crease of the area of dullness beyond that point indicates 
enlargement of the heart. As a matter of fact the line of 
the left border of the heart usually runs through the areola 
of the male nipple and often to the left of the areola of the 
nipple. Repeated examinations of the size of the heart by 
percussion and by palpation of the apex heat have con- 
vinced me that the latter is the more reliable method of 
estimating moderate increase in the size of the heart; hut 
even here the opportunities for error are numerous. The 
general rule is that the apex beat in the healthy adult heart 
is to be found an inch to the inner side and two inches be- 
low the left nipple, and that an apex beat below that point 
or further to the left indicates that the heart is either en- 
larged or displaced. This is, however, a very poor rule, 
for, in the. first place, even the male nipple is subject to great 
variations in its position, both vertically and as regards the 
midsternal line ; and, in the second place, the heart itself 
is movable in the chest and the apex may occupy different 
positions at different times, depending upon the position of 
the body. I have frequently felt my own apex beat, while 
lying upon my back, within the nipple line, and then, upon 
turning upon my left side, I have felt it half an inch to the 
left of the nipple line. It is better to estimate the distance 
of the apex beat to the left of the midsternal line than to 
compare its position with the nipple. Such apex beats 
may be found in the healthy adult male in the erect posi- 
tion—from two inches and a quarter to four inches and a 
quarter to the left of the midsternal line, depending upon 
the size of the individual and the degree of development of 
the chest. When the apex beat is found to be four or 
more inches to the left of the sternum it might be outside 
of the nipple line, and if the heart’s action were excited it 
might easily be mistaken for a hypertrophied heart. The 
knowledge that the heart’s apex may normally he found DIAGNOSIS OF CARDIAC DISEASES. 
13 
beating to the left of the nipple line should save us from 
the error of a hasty diagnosis of cardiac disease in the ab- 
sence of distinct symptoms of cardiac derangement. 
In many cases the question as to whether a heart is to 
be regarded as enlarged or not is by no means a simple 
problem, and its solution must be sought through a process 
of rational deduction, rather than by the direct evidence of 
physical examination. 
I have observed in a few autopsies an error much more 
difficult to eliminate—namely, decided hypertrophy and 
some dilatation of the heart, without any displacement of the 
apex beat to the left or downward, and without increase of 
the area of cardiac dullness. Such cases are those in which 
the hypertrophy has developed especially in an antero- 
posterior direction, and, though the heart is enlarged, such 
enlargement does not reveal itself upon the surface of the 
chest. The obvious lesson from these cases is that in con- 
nection with well-marked symptoms of heart disease, either 
with or without murmurs, the apparently normal size of the 
heart should not affect our diagnosis. It should also be 
borne in mind that we may have marked valvular disease 
without enlargement of the heart. 
Attacks of palpitation or of intermittent heart action 
are commonly regarded by the laity, and sometimes by 
the physician, as indicative of heart disease; but it is well 
known that most of these cases are merely functional dis- 
turbance of the organ, and that in the absence of signs of 
enlargement of the heart, or of failure of the heart mus- 
cle, together with the presence of normal heart sounds, we 
can almost always make the correct diagnosis. But that 
such is not always the case is shown by the history of the 
gentleman cited above, who died suddenly from the exer- 
tion of ascending the elevated railroad stairs. In condi- 
tions of mitral stenosis especially, we are liable to fall into 14 
SOME DIFFICULTIES IN THE 
the error of regarding the palpitation of the heart and the 
irregular pulse as due to functional causes alone, since in 
connection with grave obstructive lesions of the mitral 
valve there is frequently no obvious enlargement of the 
heart and no murmur. In cases of doubt we must delaj7 a 
positive diagnosis until we can assure ourselves of the pres- 
ence or absence of signs of venous congestion or other evi- 
dence of failure of the normal circulation. Cases of func- 
tional derangement of the heart often assume startling and 
serious forms, and yet the prognosis is almost invariably 
good. 
I have had under my care for the past twelve years a lady, 
now well on in years, who has suffered for over twenty years 
with attacks of very grave intermittence of the heart, often at- 
tended with syncope, but to-day she is without a sign of en- 
largement of the heart or murmur, or any evidence of failure of 
the heart muscle. 
A young married lady had had several attacks of rheuma- 
tism, and following her first attack, ten years ago, she became 
subject to attacks of palpitation of the heart and syncope. She 
was told by two physicians that she had heart disease, and she 
was very apprehensive of her condition. She came under my 
professional care three years ago. I had known her for many 
years, and I always understood that she had heart disease, but 
I also knew her to be of a very active, emotional temperament. 
The knowledge of this latter fact, combined with the result of 
repeated examinations, which revealed a heart normal in size 
and action, with clear heart sounds, normal in every respect 
except for a slight prolongation of the first sound at the apex 
(which was undoubtedly due to the rubbing of the apex against 
the chest wall), and the fact that she had gone for ten years 
without dropsy or other signs of venous engorgement, enabled 
me to disregard the rheumatic history, and to express the posi- 
tive opinion that there was no organic disease of the heart. The 
result has thus far justified the diagnosis, for she has given up 
the idea that she is an invalid, and for the last two years DIAGNOSIS OF CARDIAC DISEASES. 
15 
she has been entirely free from symptoms of cardiac derange- 
ment. 
Some cases which are regarded as merely functional 
palpitation of the heart are undoubtedly examples of adher- 
ent pericardium, since this latter condition is perhaps the 
most difficult to recognize of all diseased conditions of the 
heart. Adhesions between the two layers of the pericar- 
dium are frequently discovered at autopsy, although they 
had not even been suspected during life. 
It would seem that the secondary congestions resulting 
from a dilated or weak heart would invariably be referred 
to their proper source; but it is easier to overlook this than 
one would at first suppose. Cases of acute dilatation of 
the heart without endocarditis are those which are most 
liable to lead one into error. Here the symptoms of inter- 
ference of the functions of the stomach and liver may as- 
sume such prominence as to entirely overshadow the 
breathlessness and palpitation which would otherwise di- 
rect our attention at once to the heart, and even though the 
heart be examined the absence of a murmur and the ab- 
sence of a rheumatic history may entrap the unwary. 
My attention was once directed by a physician of ability to 
a man who had suffered from jaundice for over a year and in 
whom the liver was found to be considerably enlarged. The 
history which had been obtained was purely one of derange- 
ment of the functions of the liver and stomach. A physical 
examination of his chest revealed a dilated and hypertrophied 
heart without evidence of endocarditis, and a few questions de- 
veloped the fact that he had been taken with breathlessness 
at the same time that the jaundice appeared, and that some six 
months before dyspnoea and palpitation became so severe that 
he could not work or undertake any active exertion. Tie had, 
however, not thought much of these symptoms, but was much 
distressed by his jaundice and dyspnoea. Calomel and alkalies 16 
SOME DIFFICULTIES IN THE 
had failed to relieve, but rest in bed and cardiac tonics reduced 
the size of the congested liver and relieved all his symptoms. 
The cases of atheroma of the aorta before referred to 
are often attended by symptoms of flatulence and other 
disturbances of the stomach, and so are liable jto mislead us. 
In some cases the symptoms are almost purely those of 
disease of the lungs, and we may be led into error by the 
absence of anything directly pointing to disease of the 
heart or aorta. This is particularly so in connection with 
a small aneurysm of the first portion of the aorta, which, 
giving no symptoms or physical signs in itself,- may by 
pressure upon a bronchus produce cough and attacks of 
asthma. It is only by a complete system of exclusion that 
the correct diagnosis can be inferred, and then it is, of 
course, an inference only, and not a certainty. 
Four years ago I saw in the wards at Roosevelt Hospital a 
man whose symptoms were those of emphysema o„f the lungs 
and a very intense general bronchitis." lie had frequent :md 
severe attacks of asthmatic breathing, which I at first attrib- 
uted to the severity of the bronchitis, but tliough the bronchitis 
cleared up the attacks of asthma continued, and even-increased 
in severity, and I therefore suspected aqd looked for signs of 
an aneurysm of the arch of the aorta, Rut I 
had him under observation for nearly two. months’, Jyrit could 
find no definite explanation of his asthmatic attacks The at- 
tending physician who followed me also-suspected1aneurysm, 
but could find no definite signs of this condition, xfie patient 
died suddenly and an autopsy revealed an aneurysm of the as- 
cending arch of the aorta and pressing upon the right bronchus. 
In this connection the society will remember the case 
which I reported a year ago of the man in whom, without 
symptoms characteristic of anything in particular, phys- 
ical signs of fluid in the left pleural cavity were found, and 
when the chest was aspirated a large quantity of bloody DIAGNOSIS OF CARDIAC DISEASES. 
17 
serum was withdrawn. It will be remembered that no ex- 
planation could be found for the presence of blood in his 
pleural cavity, or even for the presence of a pleurisy. His 
sudden death made what was before very obscure per- 
fectly plain. The autopsy revealed an aneurysm of the de- 
scending arch of the aorta and an old rupture through the 
lung into the pleural cavity. This rupture had become 
filled up by fibrine and the leakage stopped, till rupture oc- 
curred at another point and he died. In this case there was 
nothing upon which to base even a suspicion of aneurysm. 
His only symptoms were those of pleurisy with a bloody 
effusion. 
Finally, cardiac disease may he overshadowed by acute 
disease of the lungs or by general diseases. This applies 
particularly to malignant endocarditis. Here the fever and 
erratic chills are liable to be referred to ether sources than 
the heart, and that organ is overlooked, or the disease is 
mistaken for malarial poisoning. The presence of a car- 
diac murmur and the purpuric eruption, or other evidences 
of haemorrhage, will usually direct attention to the true 
nature of the disease, hut these signs may he absent. I 
had a case at the Roosevelt Hospital last summer which 
illustrates this point. 
A patient was admitted with sigus of consolidation of the 
lower lohe of the right lung. It was then noted that there was 
a soft systolic apex murmur, but there was nothing else to indi- 
cate disease of the heart and the murmur was disregarded. 
When I saw him he had been under observation a month or 
more, and the signs of consolidation of the lung had not dimin- 
ished. Three weeks previously he had begun to have very 
great fluctuations of temperature ; the temperature would rise 
to 105° or 106° in the evening and then fall nearly to normal in 
the morning. There was also considerable sweating. I heard 
no cardiac murmur, and in the presence of distinct evidence of 
involvement of the lung the idea of disease of the heart never 18 
THE DIAGNOSIS OF CARDIAC DISEASES. 
occurred to me. The diagnosis seemed to me to lie between an 
empyema, an abscess of the lung, and acute tuberculosis of 
the lung. Several deep explorations of the lung with an aspi- 
rating needle failed to discover pus, and the examination of the 
sputum failed to reveal the presence of tubercle bacilli. He 
died one week later, and the autopsy revealed an unresolved 
pneumonia and very marked malignant endocarditis, with vege- 
tations upon the tricuspid, mitral, and aortic valves—a condi- 
tion which would seem impossible to occur without the pres- 
ence of loud murmurs. 
I believe that such murmurs must have been audible 
most of the time, and that had I examined the heart subse- 
quently to my initial examination I must have heard them. 
An analysis of a number of cases of heart disease occurring 
in the wards of Roosevelt Hospital in which vegetations 
upon the aortic and mitral valves were shown to be present 
by post-mortem examination demonstrates, however, that 
in many cases no murmurs were heard, and I derive con- 
siderable comfort from this circumstance. The case is, 
however, an interesting and instructive one as showing- 
how completely disease of the lung may overshadow the 
more serious disease of the heart. The New York Medical Journal. 
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