in connection with structural lesions, but without any relation of
cause and effect. Lesions affecting the valves or orifices of the heart
often exist without giving rise to any appreciable disturbance. They
are either innocuous or their effects do not occasion any inconvenience
of which notice is taken. How often is it that an examination of the
chest reveals the signs of cardiac lesions which had not been suspected
by either the patient or the physician! How often are applicants for
life insurance astonished when told that they are not insurable on
account of the signs of a cardiac affection! Now these persons are
liable to functional disorders of the heart from the causes which
produce them in those with perfectly sound organs, the cardiac lesions
having no part in the etiology, but perhaps contributing to render the
disorders more {751} intense. The problem of diagnosis in these cases
is to determine that the functional disorders are not dependent on the
lesions. Were they thereon dependent they might denote grave disease,
but if not thus dependent they have little or no gravity. This
diagnostic problem is to be solved, in the first place, by attention to
the inquiry whether the lesions are in proportion to the disturbance of
the heart's action. Valvular lesions, if the heart be but little or not
at all enlarged, are either innocuous or occasion small inconvenience.
This fact will often suffice for the solution of the problem. Moreover,
the physical signs may show that the lesions involve neither valvular
insufficiency nor obstruction, or, at all events, not in a degree
adequate to account for the disturbed action; in the second place, the
symptoms are to be considered with reference to the inquiry whether
they belong to the clinical history of structural affections or of
functional disorders; and, in the third place, the existence of any of
the well-known causes of functional disorders is to be taken into
consideration. The error is not uncommon of attributing functional
disorders to coexisting lesions when the connection is one of mere
coincidence. This error may be as unfortunate as that of supposing that
functional disorders denote structural affections when the latter are
entirely wanting.
Certain considerations, aside from the exclusion of organic affections
of the heart, apply particularly to the diagnosis of that variety of
functional disorder characterized by infrequency of the heart's action.
It is to be ascertained that the infrequency is not a normal
peculiarity, either congenital or acquired. Napoleon the Great was a
well-known instance of normal infrequency, the number of beats being 40
per minute. As a rule, if an intelligent adult person has habitually a
notably infrequent pulse he becomes acquainted with the fact, and
therefore if he be ignorant of such a peculiarity it may be inferred
that it is not normal.
There is a curious form of functional disorder which would lead to the
error of inferring infrequency of the heart's action from the pulse.
The disorder is characterized by the regular alternation of a
ventricular systole giving rise to a radial pulse, with one too feeble
to be appreciated at the wrist. Assuming the number of ventricular
systoles to be 70 per minute, in such a case the radial pulse would be
35 per minute. I have met with several examples of this form of
disorder in which, as may be said, there is a regular irregularity of
the heart's action. The carotid pulse in these cases represents each
ventricular systole, and on auscultation of the heart's sounds there
will be found to be four sounds to each radial pulse. This form of
disorder is liable to lead to the error of supposing reduplication of
both the first and the second sound of the heart. It is hardly
necessary to add that in cases of obstructive and regurgitant lesions
with feebleness of the heart's action the diminished quantity of blood
expelled from the left ventricle, with some of its contractions, may be
too small to produce an appreciable radial pulse. The existence of
these cardiac lesions is easily ascertained by auscultation.
Infrequency of the heart's action is a well-known symptom in cases of
injury of the skull and in certain intra-cranial affections. Cerebral
hemorrhage, embolism, and thrombosis are easily excluded by the absence
of paralysis, but the exclusion of subacute or chronic meningitis is
not so easy. But infrequency of the heart's action, when a symptom of
the latter affection, is accompanied by cerebral symptoms denoting
compression of the brain--symptoms which are wanting when the
infrequency is the characteristic of a functional disorder of the
heart's action. Moreover, the absence of fever, of increased
sensibility to light and sounds, and of the symptoms embraced in the
clinical history of cerebral meningitis, will render the exclusion of
that affection positive. The heart's action is abnormally infrequent in
some cases {752} of cholæmia and of uræmia, but these affections are
easily excluded. Certain drugs--namely, aconite, digitalis, and
veratrum viride--diminish the frequency of the heart's action. These
drugs, given to a person in health, produce, in fact, a transient
effect which is equivalent to the functional disorder of the heart
thereby characterized.
PATHOLOGY AND ETIOLOGY.--The neuroses of the heart are functional
disorders involving the relations of this organ to the nervous system.
The functional disorders of the heart's action affect the frequency,
the rhythm, and the force of the cardiac movements. The pathology of
these disorders would be more fully understood were our knowledge of
the physiology of the heart's movements more complete. We know that
contractions of the heart continue when it is separated from all its
nervous connections and after removal from the body, especially in
cold-blooded animals. The rhythm, frequency, and force of its normal
movements are evidently dependent on influences derived through the
sympathetic and pneumogastric nerves. Experiments show that the
movements continue, but with increased frequency and with irregularity,
after division of the pneumogastrics; hence this nerve is regarded as
exercising an inhibitory and regulating influence over the action of
the heart. Disorders of the heart's action from causes which pertain to
the brain doubtless involve especially this nerve. Other causes act
through the relations with the different organs of the body by means of
the sympathetic system of nerves.
Impoverishment of the blood occasions disorder, probably by affecting
the nutrition of the heart. Toxical agents in the blood enter into the
pathology in certain cases.
The etiology of functional disorders of the heart's action involves, as
an important factor, a predisposition inherent either in the organ or
in its nervous connections. A peculiar susceptibility to the causes
which induce disorder is an idiosyncrasy. Causes which produce disorder
in those who have this idiosyncrasy are inoperative upon others. Some
persons are liable to functional disorders of this organ all their
lives, whereas some appear to be exempt from any liability thereto. In
this respect the cardiac muscular fibres are analogous to those of the
pulmonary bronchi. A peculiar susceptibility of the latter is requisite
for the capability of having bronchial asthma. The susceptibility of
the heart-muscle varies in different persons, and a reasonable
supposition is that in proportion to the degree of this susceptibility
will the causes of functional disorder be more readily and actively
operative.
Clinical observation furnishes evidence of various causes giving rise
to functional disorders of the heart. The more prominent
are--over-exertion of the faculties of the mind, prolonged mental
anxiety, the use of tobacco, tea and coffee taken in excess, too great
indulgence in venery, the unnatural abuse of the sexual system,
dyspeptic ailments, uricæmia, and anæmia. These causes are often
combined in individual cases. With reference to effective treatment,
inquiries should be directed in every case to facts relating to these
several causes.
Long-continued violent muscular exertions are supposed to lead to
functional disorders of the heart. DaCosta has described cases
occurring among soldiers during the late Civil War in which the cardiac
disorder seemed to him referable to severe marches. He applied the name
irritable heart to the condition in these cases.[4] It is probable that
mental excitement had more or less to do with the causation. Albutt,
Seitz, and other observers have attributed functional disorders to
over-straining of the heart by occupations which call for severe
exercise of the muscles.
[Footnote 4: _Medical Memoirs of the United States Sanitary
Commission_, 1867. See _Address before the Philadelphia Medical
Society_, by A. Stillé, 1883, p. 18. See also _Diseases of the Heart
among Soldiers_, by A. B. R. Myers, London, 1870.]
{753} Paroxysmal disorder of the heart belongs among the multifarious
symptoms referable to the nervous system in cases of hysteria. It is
among the toxical manifestations embraced in the clinical history of
gout, being referable, when it occurs in this pathological connection,
to uricæmia. It may have this causation in cases in which the ordinary
gouty manifestations do not occur.
In the variety of disorder characterized by infrequency of the heart's
action it may be assumed that the causative agency is exerted through
the pneumogastrics. The inhibitory function of this nerve is affected
in the same way as by the galvanic current in the experimental
observations on animals in illustration of this function. This view is
corroborated by the frequent association of this variety of disorder
with notable cerebral disturbance.
PROGNOSIS.--A purely functional disorder of the heart's action may be
said to be devoid of danger to life. This is a remarkable fact, taking
into view the importance of the organ, together with the degree and the
duration of disordered action in some cases. Of many thousand cases
which have come under my observation, I am not aware of having met with
a single instance in which death was fairly attributable to an
uncomplicated functional disorder. It is readily understood that
functional disorders superadded to, albeit not dependent upon, organic
affections of the heart may contribute to a fatal termination. But the
tolerance of functional disorders under these circumstances is often
very remarkable.
The assurance of the absence of all danger frequently lifts from the
minds of patients a heavy load of anxiety and apprehension. To be able
to give such an assurance is one of the delights of medical practice.
Patients often find it difficult to believe that the disorder from
which they suffer can take place while the heart is organically sound.
Many require very positive and repeated assurances in order to secure
their belief. The question is many times asked, "How is it possible
that I should suffer so much, and yet the heart be free from disease?"
Another question which is apt to be asked is, "How can you ascertain so
quickly that there is no disease?" In anticipation of the latter
question, in order to ensure the desirable moral effect, it is
sometimes good policy to prolong the examination, inasmuch as for the
exclusion of all the physical signs of organic disease a few moments
only are required. Another question, still, is, "Will not organic
disease be likely to be produced by the functional disorders?" The
physician is fully warranted in giving a negative answer. Exclusive of
the cases of exophthalmic goitre, functional disorders of the heart do
not involve liability to either inflammatory or structural affections.
Recurrences of functional disorders of the heart constitute the rule
rather than the exception. Their frequency will depend much on the
degree of the predisposition, but of course more or less on the causes
therewith associated. The mental anxiety and apprehensions which they
at first occasion after a time wear away, and they are at length
reckoned as belonging among those annoyances of life to which may be
applied the common expression, "What cannot be cured must be endured."
TREATMENT.--Prompt relief or palliation of suffering is often the
immediate object of treatment when cases first come under observation.
The medicinal remedies for this object are the ethereal or alcoholic
stimulants, the different antispasmodics, and opium. Chloric ether and
the compound spirit of ether (Hoffman's anodyne) often act efficiently.
An eligible prescription is the combination of one of these with an
equal part of the compound tincture of lavender, of which a
teaspoonful, properly diluted, may be given after short intervals.
Brandy, whiskey, or some other form of spirit in many cases will afford
prompt relief. It should be given not much diluted. These remedies
{754} are especially indicated in paroxysms of irregular or
intermittent and enfeebled action of the heart. They are less adapted
to cases in which the heart's action is violent. Of antispasmodics,
valerian, the valerianate of ammonia, camphor, and asafoetida are
appropriate. Some one of the preparations of opium is to be employed if
the disorder be not relieved by other remedies. Of the different forms
of opiate, codeia is the least objectionable, and perhaps as efficient
as any other. With a view to promptness of relief in certain cases of
severity, morphia may be administered hypodermically. Other palliative
measures are a sinapism to the præcordia, and, if the extremities be
cold, a mustard pediluvium. Of the efficacy of the ice-bag applied over
the heart, which is recommended by German writers, I cannot speak from
personal observation. The testimony in behalf of its usefulness is, to
say the least, sufficient for resorting to it without apprehension of
doing harm. In some cases of obstinate persistence of disorder the
opportunity is afforded for trying in succession the various remedies
which have been named. Digitalis is sometimes useful. Concomitant
disorders which may have originated or which tend to keep up the
disordered action of the heart are to be appropriately treated.
Flatulence and other ailments referable to indigestion and constipation
not infrequently are in this category. Paroxysms may be sometimes
arrested by certain mechanical means, such as pressure upon the
abdomen, holding the breath after a deep inspiration, and compression
of the vagus and sympathetic nerves in the neck.
In some cases of functional disorder there is a persistent increase of
the frequency of the heart's action without irregularity in rhythm. The
action of the heart in these cases is the same as in cases of
exophthalmic goitre, the enlargement of the thyroid body and the
prominence of the eyeballs which characterize the latter affection
being wanting. In these cases aconite in small doses is to be
recommended. From one minim to three minims of the tincture of the root
may be given, repeated after intervals of four or six hours and
continued indefinitely. In cases the opposite to the foregoing--namely,
those in which the disorder is characterized by infrequency of the
heart's action--a rational indication is to give remedies with a view
to excite the heart. In the cases which have come under my observation
alcoholics have had but little effect upon the heart, although
apparently useful as regards the nervous symptoms which are apt to
accompany this variety of cardiac disorder. As this disorder does not,
as a rule, occasion distress, the patient perhaps not being conscious
of any disturbances of the heart's action, and as the infrequency does
not appear to involve danger, the treatment may be directed to
fulfilling other symptomatic indications.
Positive assurances of the absence of danger have often a potential
influence in relieving paroxysms of functional disorder. The disorder
is not infrequently increased and kept up by mental apprehension, and
these assurances therefore do away with an active causative agency.
They are also useful in the way of preventing the recurrence of
paroxysms. It is evident that in order to exert this moral influence
the physician must be competent to decide that the disorder is purely
functional. He can so decide only if he have confidence in his ability
to exclude inflammatory and structural affections or to determine that
the disorder is not dependent on lesions which may coexist. If he have
not sufficient confidence in his opinion, he will naturally and
properly not give positive assurances, and a lack of positiveness will
be likely to lead the patient to infer that the disorder is not devoid
of danger. The good effect of certain measures of treatment is in part
attributable to a mental influence. This is legitimately a therapeutic
object here as in other affections.
The more important part of the treatment in the majority of the cases
of functional disorders of the heart's action is that which relates to
prevention. {755} The preventive treatment, in addition to the moral
influences already referred to, consists chiefly in removing as far as
practicable the causes of the disorder. The predisposition cannot be
removed, but the causes which are auxiliary thereto in producing
disorder are, to a greater or less extent, controllable.
Prolonged mental anxiety is often inseparable from the events of life.
"Therein the patient must minister unto himself" The voluntary exercise
of the mental faculties, however, can be restrained within
physiological limits. Tobacco can be abstained from, and, as a rule,
total abstinence is easier than moderate indulgence. Tea and coffee can
be used moderately if at all. Dyspeptic ailments are amenable to
appropriate dietetic and medicinal treatment. On no account should the
diet be reduced below the requirements for ample nutrition. Anæmia,
which exists in a large proportion of cases, especially in women, calls
for chalybeate tonics, to be continued persistently as long as the
blood remains impoverished. It is needless to add that in these cases
the causes of the anæmia are, if possible, to be removed, and that
chalybeates are to be supplemented by proper dietetic and regiminal
treatment. Sexual excess and abuses are to receive adequate attention.
There can be no question as to unnatural sexual excitation. But a
question often arises in individual cases concerning the physiological
limitations of natural indulgence. These limitations probably differ
widely in different persons. They are, however, always exceeded if the
indulgence exceed the instinctive demand--that is, if its increase be
made an object for voluntary efforts. Long-continued and violent
muscular exertions should be interdicted. Uricæmia or the gouty
diathesis claims appropriate remedies and hygienic regulations.
Several of the various causes just recapitulated are frequently
combined, so that the preventive treatment is by no means always
limited to the removal of a single cause. The treatment will prove
successful in proportion as the efforts to remove the causes are
effectual.
Angina Pectoris.
The name angina pectoris was introduced by Heberden in 1768 to
designate a group of symptoms which from that date has been regarded as
constituting an individual affection. The word angina, signifying
strangulation, has but little pertinency in this application of it, and
various other names have been proposed in its stead. For the most part
these are based on pathological views which are either erroneous or
hypothetical, and at the present time the name angina pectoris is
generally adopted in all countries.
The affection may be defined as a paroxysmal neuralgia, the pain of
which is seated within or near the præcordia, shooting thence in most
cases into the left shoulder, and extending downward to a greater or
less extent into the left upper extremity, the right upper extremity
being sometimes similarly affected. In some instances the pain extends
to the lower limbs; the paroxysms often accompanied by a feeling of
anguish and of impending death, the affection in the great majority of
cases being incident to organic disease of either the heart or the
aorta and involving liability to sudden death.
SYMPTOMATOLOGY.--The foregoing definition embraces the prominent traits
of a severe paroxysm. The pain may extend into situations other than
those mentioned--namely, in different directions throughout the chest,
into the neck, the jaws, and the temples, the abdomen, and the groin.
In describing the pain patients use such terms as constricting,
tearing, burning, etc. Perhaps in its most severe form there is no
disease attended with more intense suffering. It is related that the
description of the affection by Heberden led to a communication to him
from an unknown correspondent who gave an account of his own case, and
bequeathed to Heberden his body to be {756} examined after death. The
examination was made by John Hunter, who himself fell a victim to the
affection. An analogous instance occurred in my own experience. A
patient was led by the intensity of his sufferings to request that I
should make a post-mortem examination in his case, with the hope that
something might be thereby ascertained which would prove useful to
others. This request was complied with. Associated with the pain in
severe paroxysms is what has been called a breast-pang, giving rise to
a sensation as if death were at hand. A choking sensation, which is
implied in the name angina, is an occasional symptom, resembling the
globus hystericus. Respiration is not obstructed, but the patient may
voluntarily restrain the respiratory movements lest they increase the
suffering. Dyspnoea, if present, is thereby produced. During the
continuance of the paroxysm the patient refrains from movements of the
body or limbs, keeping a fixed position and grasping some firm support
in order better to remain motionless while the pain lasts. A sensation
of numbness in the affected limbs accompanies the pain. The circulation
is usually more or less disturbed. There is sometimes increased and
sometimes diminished frequency of the pulse. The action of the heart is
often intermittent and otherwise irregular. It may be strong, but
oftener it is weak. At the beginning the arterial tension has been
found to be increased, but later is diminished. The face is generally
pallid, but sometimes livid. The disturbances of the circulation are
often modified by coexisting organic disease of the heart, but
superadded are those of functional disorder incident to the paroxysm.
The countenance is haggard and anxious. The surface of the body is
cold, and may be bathed in perspiration. The mind remains unaffected.
The paroxysms usually commence suddenly, and, as a rule, so end.
Eructations of gas are apt to follow their cessation, together with a
free discharge of limpid urine. The duration of a paroxysm may be but a
few seconds; it is rarely longer than a few minutes. When it appears to
be protracted for a considerable period, there is generally a series of
attacks occurring in quick succession, instead of one continuous
paroxysm.
There is much variation in different cases as regards the severity of
the paroxysms, and the mildest offer a striking contrast to the
severest, the essential symptomatic characters of the affection,
however, being preserved. In mild paroxysms the pain is comparatively
slight, the anguish or heart-pang is less, and the heart's action may
be but little or not at all disturbed. Such paroxysms occasion
annoyance without great suffering. Different cases, and the same case
at different times, exemplify varying degrees of severity.
Recurrences of angina take place as a rule, to which there are but few
exceptions. The intervals between the paroxysms vary in different
cases, and often in the same case. Their recurrence is not governed by
any law of periodicity. Generally, they are at first infrequent, and
their frequency increases slowly. With increase in frequency their
severity is apt to be increased. At first, and for a certain length of
time, they are occasioned by some apparent exciting cause. A common
cause is the exertion of walking, especially against a current of wind.
Often for a considerable period patients are exempt whenever they are
at rest. Sooner or later, in most cases, attacks are produced by other
causes, such as a fit of anger or other mental emotion, and finally
without any appreciable existing cause. I have known attacks to be
caused by the act of swallowing solid food, so that eating became a
source of terror to the patient. They occur in some cases during sleep.
Occurring after intervals of a few moments, the affection in this
respect resembling certain cases of tic douloureux, it doubtless would
be difficult by any description to convey an adequate idea of the
lamentable condition of the patient.