treatment of heart-clot is useless (Bucquoy). Others, more sanguine,
repose confidence in the internal use of alkalies, even when a
fibrinous deposit in the cavities of the heart has commenced to form. A
third class of observers, whilst they doubt the efficacy of any
treatment under these circumstances in causing the disaggregation or
absorption of an intra-cardiac coagulum, nevertheless believe we can
limit the rapidity and size of its formation, and also retard the fatal
termination, by giving time sufficient for adhesions to form with the
cardiac walls. Richardson has proposed the administration of minim x
doses of liquor ammoniæ at short intervals in an ounce of water, in
order to dissolve existing coagula, and reports favorably upon its use.
Gerhardt[98] counts upon better results from the use of a saline spray
of bicarbonate of sodium of the strength of ½° to 1½°. This spray
should be frequently inhaled, and in this manner, he believes, the
heart is reached more directly and effectually. Successes are claimed
by the use of this method of treatment. According to Flint,[99] the
idea of giving any remedies with a view to dissolve solidified fibrin
is absurd, whereas as a preventive treatment it is legitimate in
circumstances where this state is likely to occur, and may even become
an important therapeutic object.
[Footnote 98: _Deutsches Archiv für klinische Medicin_, vol. v. p. 207,
summarized in the _Dublin Quarterly Journal of Medical Sciences_, May,
1869, p. 421, quoted by Walshe.]
[Footnote 99: _Diseases of the Heart_, p. 285.]
Alkaline remedies are said to have the power of holding the fibrin of
the blood in solution. If this be true, they are certainly indicated to
prevent coagulation. Moreover, if the fibrin in normal blood be held in
solution owing to the presence of ammonia, it must be evident that this
remedy is specially indicated in carrying out a secondary object of the
prophylactic treatment. Bartholow[100] still maintains, however, that
frequent small doses of ammonium carbonate afford the best chances of
relief even when the coagulum is already formed. The latter
distinguished author advises in cases which are most imminent
intravenous injections of ammonia. The proportions should be one part
of ammonia to three of water. The vein selected must be the jugular,
and special precautions taken to avoid the entrance of air or a foreign
body into the circulation. With attention to this formal indication
there is little or no danger from these injections, as has been many
times proven experimentally. Walshe[101] regards the use of carbonate
of ammonium, combined with bicarbonate of potassium, in five-grain
doses, repeated three times daily, as a mere prophylactic, but as the
best, after all, we possess, and recognizes from its use the only
practical outcome from the enormous sacrifices of canine life made by
Magendie in his experiments to illustrate his lectures on the blood. In
spite of the numerous attempts to fluidify the blood, these efforts
have always remained unsuccessful (Raynaud), and Legroux, who first
proposed it, in his later writings abandoned the alkaline treatment as
useless. The most he affirms that can be done is to combat with energy
cardiac inflammations.
[Footnote 100: _Practice of Medicine_, New York, 1880, p. 285.]
[Footnote 101: _Diseases of the Heart_, 4th ed., London, 1873.]
There is, however, a palliative medication which is indicated by the
presence of the obstacles to the circulation within the heart. The
general condition must be kept in view in carrying out treatment rather
than the local signs. A properly combined therapeutic method in which
the derivatives and counter-irritants play an important rôle offers, in
Legroux's estimation, the best solacing means to oppose to the
developed accidents. We must, however, maintain the patient in a quiet
attitude and administer drugs which {746} shall tranquillize pain and
diminish anxiety. The counsel to keep the patient absolutely at rest is
of primary importance in view of the sudden fatal accidents which have
frequently occurred either in getting into bed after descending from
it, or in sitting up and reaching for something the patient needs. The
patient should be placed in bed in a semi-recumbent position, properly
supported, and arrangements must be made so that all fatigue of eating
and drinking or attending to his excrementitial functions are provided
against. Of course we should treat a case of cardiac thrombosis
complicating a frank inflammatory condition, such as acute
endocarditis, certain forms of pleurisy or pneumonia, very differently
from a case in which the state is one of relative feebleness or
adynamia, as in the advanced stages of diphtheria, or after profuse
uterine hemorrhage during or after confinement. In the first category
of cases it may be in a few rare instances that local depletion of the
blood by means of leeches or venesection is still indicated, especially
if the patient be one of more than usual vigorous frame. In any example
of this sort it is obvious that the internal use of the alkalies, the
employment of revulsives (_i.e._ dry cups), and counter-irritants over
the chest (as previously mentioned), adjoined, perhaps, to the action
on the emunctories by diluent drinks, are the means which offer us the
best guarantee of success. But how shall we act with our second class
of cases? Certainly, we ought not for one moment, with our actual
physiological knowledge, to consider the propriety of taking blood from
a patient thus affected. May we use the alkaline treatment with
reasonable hopes of benefit in a curative way? Yes, if we employ
certain of the stimulating salts, like carbonate of ammonium, or even
this salt combined with moderate doses of bicarbonate of potassium. We
should remember, however, that these drugs are intended particularly to
combat the pathological condition of the blood which apparently
underlies the formation of fibrinous concretions in the heart.
Against the possible fatty degeneration of the cardiac muscular fibre,
or the functional or organic affection of the pneumogastrics, which
predispose to or accompany the production of cardiac coagula, we must
make use of digitalis in small, repeated doses, and nux vomica or some
other preparation containing strychnine. I have on more than one
occasion seen these agents do evident good,[102] and on this account am
encouraged to urge their exhibition. With Hertz, we are not disposed to
believe that digitalis, when given with a little precaution, and
especially in urgent cases, is contraindicated by the danger feared by
Gerhardt and Penzoldt, that it favors thrombosis of the right side of
the heart and gives rise to new emboli.[103]
[Footnote 102: _Loc. cit._, p. 68.]
[Footnote 103: _Ziemssen's Cyclopædia_, vol. v. p. 326.]
It is almost needless to add that under like circumstances we should
insist upon the frequent use of stimulants, like alcohol, chloroform,
and ether, in the form of brandy, whiskey, spiritus chloroformi, or
spiritus ætheris, or repeated doses of strong black coffee with one of
the preceding preparations added to it. In regard to the prophylactic
use of alkaline treatment continued during several days and in large or
frequently-repeated doses, we advise against it for the reasons, first,
that we do not know, in advance, the precise conditions in which
fibrinous intra-cardiac coagula will form; and second, because though
the alkalies have a well-known antiplastic action, they act as
depressants to the general economy when employed in the manner
mentioned, which is the sole method in which their internal use would
be of some practical advantage.
Whenever we have in diphtheria a case in which there is at the same
time obstruction of the glottis by a false membrane and clogging of the
heart by a fibrinous coagulum, we should abstain from performing
tracheotomy on account of its evident uselessness.[104]
[Footnote 104: _Medical Times_, vol. ii. p. 617.]
{747}
NEUROSES OF THE HEART.
FUNCTIONAL DISORDERS OF THE HEART'S ACTION; ANGINA PECTORIS;
EXOPHTHALMIC GOITRE.
BY AUSTIN FLINT, M.D.
The neuroses of the heart are those affections relating to this organ
which do not necessarily involve either inflammation or structural
lesion of any of its component parts. The larger proportion of these
affections may be grouped under the name functional disorders of the
heart's action. The affection called angina pectoris is characterized
by pain more or less intense. It is generally associated with
disordered action of the heart, and also with cardiac lesions. It may,
however, exist without either disordered action or lesion, and hence it
is with propriety included among the neuroses of the heart.
Exophthalmic goitre is invariably associated with disordered action of
the heart, but it has other very marked symptomatic traits which give
to it a distinctive character. The name of the affection refers to
these. The cardiac disorder is, however, the most constant, and,
pathologically, the most important, and therefore the affection may be
considered as one of the neuroses of the heart. In this article the
functional disorders of the heart's action, irrespective of angina
pectoris and exophthalmic goitre, will be first considered, and
afterward these two affections will receive separate consideration.
Functional Disorders of the Heart's Action.
The disorders of the heart's action which agree in respect of their
functional character present marked variations as regards the manner in
which the action is disordered. An account of these will be given under
the name Varieties, together with the symptomatology.
VARIETIES AND SYMPTOMATOLOGY.--The term palpitation denotes a violent
or tumultuous action of the heart. A type of this variety of disorder
is afforded when the heart is much excited by fear or some other
intense mental emotion. The fact that emotional excitement will produce
in some persons notable palpitation, and in others little or no
disturbance of the heart's action, illustrates differences inherent in
the organ itself as regards susceptibility to disorder. These innate
differences are exemplified in cases of disease. In certain persons the
heart readily takes on a morbid functional disorder from causes which
in other persons do not produce this effect. A peculiar susceptibility
to disorder is expressed by the term irritable heart, a term introduced
by DaCosta. Instead of the violence which characterizes palpitation,
there may be irregularity, with notable feebleness of the heart's
action. The patient often describes this variety of disorder as a
fluttering of the heart. The consciousness of the disorder is less
distinct than when the {748} disordered action is violent. With
irregularity are generally associated increased frequency of the
heart's action and præcordial distress. The degree of disorder as
respects either violence or feebleness and irregularity of action
differs in different cases within wide limits. Intermittence is another
variety of disorder. The intermission may extend over a period of one,
two, three, or more beats. It is sometimes preceded or followed by
increased frequency of action, and it sometimes occurs without any
other rhythmical disturbance. The patient is usually conscious of the
intermittence, and it is apt to occasion great alarm, especially before
the mind has become accustomed to it. The intermissions occur more or
less frequently in different cases and at different periods in the same
case. In the cases of palpitation in which the heart acts with violence
it is not probable that the power of the heart's action is increased.
The systolic ventricular movements are quick and have a spasmodic
violence, without actual increase of force. The first sound of the
heart over the apex under these circumstances is short and its quality
valvular. The valvular element of this sound is predominant and
intensified in consequence of the quickness of the systolic movements
and the small quantity of blood in the ventricles when the ventricular
systole takes place. Owing to the latter physical condition the range
of movement of the auriculo-ventricular valves is greater and the
valvular sound proportionately increased. The systolic movements of the
apex against the chest-wall sometimes give rise to a ringing or
metallic sound (cliquetis métallique).
A rare variety of functional disorder which has received but little
attention is notable infrequency of the heart's action. The revolutions
of the organ were reduced to sixteen per minute in a case reported by
Thornton.[1] In 1876, I reported 5 cases, the reduction in frequency
varying from 26 to 40 per minute.[2] In one of these cases there was
marked intermittency, and in another case the action of the heart was
irregular. With these exceptions the rhythm was regular. I have met
with a few additional instances since these cases were reported. In
this variety the disorder continues for several successive days, and it
may be for a much longer period. A persistent infrequency sometimes
remains as a sequel, recovery in other respects being complete. In one
of my reported cases the revolutions were 36 for several weeks after
recovery. In these instances the infrequency of the heart's action,
which is sometimes a congenital peculiarity, is acquired. Hewan has
reported his own case as an illustration of this fact. His normal
frequency had been 72, but after a period of intense study the
frequency gradually decreased, and finally remained at from 28 to 32
per minute.[3] This variety of disorder will claim distinct
consideration with reference to diagnosis and etiology. It may or may
not be accompanied by præcordial distress.
[Footnote 1: _Trans. Clinical Society of London_, vol. viii., 1875.]
[Footnote 2: _American Practitioner_, January, 1876.]
[Footnote 3: _London Med. Times and Gazette_, March, 1875.]
The more frequent varieties of disorder of the heart's action occur in
most instances in paroxysms. The paroxysms differ widely in duration as
well as in their intensity. They may last for an instant only or for
many continuous days. Exceptionally the duration is much longer. I have
known a persistent and very great increase of frequency of the heart's
action with irregularity, and such a degree of weakness that the pulse
could with difficulty be counted, to continue for several weeks,
leading to oedema of the lower limbs, prostration, and pallor, so that
the patient's appearance was that of one moribund. In this case before
the attack and after recovery there was no evidence of any other
affection than functional disorder of the heart, and to this the
patient had long been subject. In another case an extremely irregular
action of the heart continued unceasingly for more than two months,
there {749} being no signs of either an inflammatory or a structural
affection of the organ, and the functional disorder at length ceasing.
As a rule, an attack of functional disorder of the heart implies a
liability thereto; other attacks occur after variable intervals. This
fact involves a peculiar susceptibility, or, in other words, an
irritable heart.
The symptoms referable to the heart may be combined with those of
coexisting affections. Disturbances of digestion are frequently
associated. Paroxysms of disordered action of the heart are often
accompanied by gastric flatulence, and gaseous eructations afford
relief. Patients are apt to endeavor to eructate by voluntary efforts.
Other evidences of indigestion are not infrequent. The mind is much
disturbed, especially if previous paroxysms have not occurred. The
facial expression shows anxiety. The apprehension is of organic disease
of the heart and of sudden death. This apprehension is excited in a
marked degree by intermittence of the heart's action. It is often
extremely difficult to convince patients of the absence of immediate
danger. They require to be assured of this fact over and over again,
and whenever a paroxysm occurs. This statement applies even to medical
men who suffer from functional disorders of the heart's action. The
surface is usually cool or cold. It is sometimes bathed in
perspiration--a symptom probably due, in a great measure, to the
condition of mind. Exclusive of angina pectoris, paroxysms of
functional disorder are not attended by præcordial pain. The paroxysms
may cease either suddenly or after a gradual improvement. The cessation
is abrupt in the instances in which the paroxysms last but an instant
or but a few moments, and not infrequently when the paroxysms are of
much longer duration the normal rhythmical action is at once resumed.
The variety of disorder characterized by diminished frequency of the
heart's action is often associated with cerebral disturbance. In 2
cases cited in my paper there were severe epileptiform seizures,
together with frequent epileptoid attacks; in 2 cases there was mental
excitability amounting to delirium; and in 1 case there was great
mental and physical prostration with gastric irritability, the latter
due apparently to cerebral disturbance. In 1 case only there was no
evidence of disorder of the brain. Of 3 cases which have fallen under
observation since the publication of my paper, in 1 there was notable
mental disturbance, the mind remaining intact in the other 2 cases.
DIAGNOSIS.--Certain facts pertaining to functional disorders of the
heart's action in their ordinary paroxysmal forms render the diagnosis
probable. One of these is the occurrence in paroxysms, the action of
the heart being normal in the intervals. Another fact is the occurrence
of the paroxysms at night oftener than in the daytime. The ability of
the patient to take active exercise without exciting a paroxysm and
without discomfort is evidence that the paroxysmal affection is
functional. A diagnostic feature of a purely functional disorder is
great apprehension connected with the disordered action of the heart.
The patient is apt to feel that there is imminent danger of sudden
death. So strong is this apprehension that it is sometimes difficult to
overcome it by positive assertions of the absence of danger. On the
other hand, disordered action of the heart, when incident to structural
affections, occasions comparatively little mental disturbance; the
patient suffers chiefly or exclusively from the physical ailments. In a
purely functional affection the patient generally is vividly conscious
of the disordered action, whereas the action in structural affections
may be greatly disordered and the patient take no cognizance of it. The
existence of certain causes to be mentioned under the head of the
Etiology bears upon the diagnosis. The liability to functional
disorders, as evidenced by previous attacks, is also to be taken into
account. These facts, however, are not fully adequate for the exclusion
of {750} structural affections of the heart. Moreover, the persistence
in some cases of notable disorder for days, weeks, or even months,
would seem to render highly probable the existence of some structural
affection. The basis of a positive diagnosis is the exclusion, by the
absence of their physical signs, of inflammatory affections and lesions
of structure.
The physician who undertakes to diagnosticate functional disorders of
the heart by symptoms alone--that is, without physical
exploration--must often be in doubt, and if not prudently distrustful
of his ability as a diagnostician, he is liable to commit errors which
are sometimes extremely unfortunate. I was requested to see a young
woman who was represented as suffering from a disease of the heart from
which she might die at any moment. It was stated to me that her
situation was perfectly understood by herself and her family, and that
the object of my visit was simply to satisfy some of her friends. I
found her in a dark room, with every arrangement to prevent the least
mental excitement and physical exertion. Fearing that my questions and
the examination of the chest might occasion disturbance which would
prove fatal, it was proposed that one of her family be made the medium
of the former, and that the latter be dispensed with. This was of
course objected to on my part. My questions she answered in a feeble
whisper. The examination of the chest showed the absence of all
physical signs of disease. The affection was purely functional and
wholly devoid of danger. I could cite from cases which have come under
my observation not a few in which the error of imputing functional
disorders to organic lesions has occasioned the loss of years as
regards the duties and pleasures of life, together with the unhappiness
incident to living in daily expectation of sudden death. With a degree
of practical knowledge of auscultation and percussion sufficient to
recognize the signs of inflammatory and structural diseases, and
self-confidence sufficient to decide upon the absence of these signs,
there is but little liability to error in the diagnosis of functional
disorders.
If the apex-beat be in its normal situation, and the areas of the
superficial and deep cardiac regions be not extended, the heart is not
enlarged; and if there be no endocardial murmur it may be inferred that
the valves and orifices are normal. The exclusion of structural lesions
under these circumstances is almost positive. It is open only to the
exception that certain occult lesions may exist, such as fatty
degeneration and obstruction of the coronary arteries. Aside from the
infrequency of these, the history and symptoms may render their
existence extremely improbable. A hæmic murmur at the aortic or the
pulmonic orifices or at both orifices is not uncommon. That the murmur
is inorganic may generally be determined by other evidences of anæmia,
by an arterial murmur in the neck, and by the venous hum. With the
results of physical exploration as just stated, whatever may be the
form of disorder, whatever may be its intensity, whatever may be its
duration, and whatever may be the associated symptoms, it may be
declared to be purely functional.