Changing Concepts What Constitutes Heart Disease

Concepts about what constitutes heart disease have changed a great deal in the past century. For example, the corresponding section of a predecessor to this work, August Hirsch's Handbook of Geographical and Historical Pathology (1883-6) is entitled "Diseases of the Heart and Vessels," not diseases of the heart, and one of the main topics is hemorrhoids. Anatomic linkage of the heart and vessels into a single unit was common in the nineteenth century, as is shown by such titles as Diseases of the Heart and Aorta and Diseases of the Heart and Great Vessels. Around the end of the nineteenth century, however, the conceptualization of heart disease changed fundamentally. As Christopher Lawrence has pointed out, British physicians started to think about the heart in terms of its functional capacity rather than in terms of its anatomy. This led them to regard cardiac murmurs, such as would be detected by a stethoscope, as less important than physiological measurements of function.

This conceptual change was particularly apparent in discussions of a soldier's disease described at one time as "DaCosta's syndrome" and later, at the start of the First World War, as "soldier's heart." Afflicted by breathlessness, fatigue, and a feeling of impend ing doom, soldiers with this syndrome were initially treated by the British military with extended hospital bedrest. The presence of a cardiac murmur was taken as ipso facto evidence of heart disease. However, as the war continued, lasting far longer than originally anticipated, heart disease became a serious military, economic, and political problem. It was, in fact, the third most common reason for military discharge. Yet heart disease held out far more hope of treatment and return to service than did the most common cause of discharge, "wounds and injuries." Nonetheless, the long convalescence strained both the military hospitals and the political fortunes of England's leaders, who were forced to institute a military draft in 1916. Given these political exigencies, physicians working for the Medical Research Council reconceptualized the disease as the "effort syndrome." They decided that heart murmurs were important only insofar as they impaired the ability of the soldier to work, and then prescribed a series of graded exercises rather than hospitalization and bedrest. The result was that many soldiers previously declared "unfit for service" were reclassified as "fit." All of this demonstrates that some notions about what constitutes heart disease are informed by social needs.

Physicians' ideas have continued to be shaped by social context. Studies of the incidence of heart disease in black Americans early in the twentieth century were influenced by the cultural context in which they were written. Many investigators concluded that coronary artery disease was rare in black people, largely because black people were considered less likely to experience stress, owing to their assumed disinclination to hurry or worry about their lot in life, and because they were presumed to be less intellectually alert than the "refined, intellectual" classes.

In the late twentieth century, culture has continued to have an impact on our definitions of heart disease. For example, Lynn Payer has pointed out that failure to appreciate that the West German concept of heart disease differs from the U.S. concept could lead to the erroneous conclusion that death rates from ischemic heart disease are lower in West Germany than in the United States. In fact, the rates are approximately the same, but that type of heart disease is more likely to be called "ischemic heart disease" in the United States and "cardiac insufficiency" in West Germany.

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