Part 17 (2/2)
The position of the patient with true angina pectoris is characteristic. He stops still wherever he is, stands perfectly erect or bends his body backward, raises his chin, supports himself with one hand, leans against anything that is near him, and places his other hand over his heart, although he exercises very little pressure with this hand. The position a.s.sumed is that which will give the left chest the greatest unhampered expansion, as though he would relieve all pressure on the heart.
Besides the feeling of constriction, even to some spasm, perhaps, of the intercostal muscles, respiration is slowed or very shallow, because of the reflex desire of the patient not to add to the pain by breathing. The face is pale, the eyes show fear, and the whole expression is almost typical of cardiac anxiety. The patient feels that he is about to die. The pulse is generally slowed, may be irregular, and may not be felt at the wrist. The blood pressure has been found at times to be increased. It could of course be taken only in those cases in which there were more or less continued anginal pains; the true typical acute angina pectoris attack is over, or the patient is dead, before any blood pressure determination could be made. When there is more or less constant ache or frequent slight attacks of pain, the blood pressure may be raised by the causative disease, arteriosclerosis. During the acute attack with inefficient cardiac action and a diminished force and frequency of the beat, the peripheral blood pressure can only be lowered.
The duration of an acute attack, that is, the acute pain, is generally but a few seconds, sometimes a few minutes, and rarely has lasted for several hours. In the latter cases some obstruction to an artery has been found at necropsy, but not sufficient to stop the circulation at a vital point. Repeated slight attacks, more or less severe, may occur frequently throughout one or more days, or even perhaps a series of days, caused by the least exertion, even that of turning in bed.
While most cases of sudden death with cardiac pain are due to a local disease in or around the heart, it is quite probable that some disturbance in the medulla oblongata may cause acute inhibitory stoppage of the heart through the pneumogastric (vagi) nerves. The power of the pneumogastric reflex to inhibit the action of the heart is, of course, easily demonstrated pharmacologically. Clinically reflexes down these nerves interfering with the heart's action cause faintness and serious prostration, if not actual shock, and perhaps, at times, death. The most frequent cause of such a reflex is abdominal pain, perhaps due to some serious condition in the stomach, to gastralgia, to an intestinal twist, to intussusception or other obstruction, or to hepatic or renal colic. A severe nerve injury anywhere may cause such a heart reflex. Hence serious nerve pain must always be stopped almost immediately, else cardiac and vasomotor shock will occur. In serious pain morphin becomes a life saver.
MANAGEMENT
While a number of causes of true cardiac pain may be eliminated by improvement in any loss of compensation, by improvement of the heart tone, by more or less recovery from myocardial or endocardial inflammation, and by the withdrawal of nicotin, which may cause cardiac pains, still, true angina pectoris once occurring is likely to be caused by a progressive, incurable condition, and the attacks will become more frequent until the final one. It is possible that a true angina may be due to a coronary artery disease or obstruction, and that a collateral circulation may become established and repair the deficiency. While this probably can take place, it must be rare.
Occasionally when the intense pain has ceased, the patient may be nauseated and actually vomit, or he may soon pa.s.s a large amount of urine of low specific gravity, or have a copious movement of the bowels.
The first attack, and subsequent ones more and more readily, are precipitated by any exertion which increases the work of the heart, as walking up hill, walking against the wind, going upstairs, physical strains, as suddenly getting out of bed, leaning over to put on the shoes, straining at stool, or even mental excitement.
Exertion directly after eating a large meal is especially liable to precipitate an attack. Food which does not readily digest, or food which causes gastric flatulence may precipitate attacks. Any indiscretion in the use of coffee, tea, alcohol or tobacco may be the cause of the attack.
For treatment of the immediate pain, if the physician arrives soon enough, anything may be given which quickly relieves local or general arterial spasm and spasm of the muscles. The moment that the heart and its arterioles relax, the attack is often over. The most quickly acting drug for this purpose is amyl nitrite, inhaled. If amyl nitrite is not at hand, or has been found previously to cause considerable disturbance of the head or a feeling of prolonged faintness, nitroglycerin is the next most rapidly acting drug. It may be given hypodermically, or a tablet may be dissolved on the tongue. The amyl nitrite should be in the emergency case of the physician in the form of ampules, or may be carried by the patient after he has had one or more attacks. The ampules now come made of very thin gla.s.s with an absorbent and silk covering ready for crus.h.i.+ng with the fingers, and are thus immediately ready for inhalation. One of these is generally all that it is necessary to use at any one time. Nitroglycerin, if given hypodermically, should be in dose of 1/100 grain. If given by mouth the dose should be the same, repeated in ten minutes if the pain has not stopped.
Almost coincidently with the administration of nitroglycerin or the amyl nitrite, a hypodermic injection of 1/8 or 1/6 grain of morphin sulphate should be given without atropin, as full relaxation is desired without any stimulation of atropin.
Alcohol is also a valuable treatment of this pain, when the drugs mentioned are not at hand. The dose should be large; whisky or brandy is best, and should be administered in hot or at least warm water. The physiologic action of alcohol, which dulls or benumbs the nervous system and dilates the peripheral blood vessels, is exactly in line with the clinical indications.
If a patient is home and at rest at the time of an attack, a hot- water bag but slightly filled, or a pad electrically heated, may be placed over the heart some times with marked advantage and relief from pain. Occasionally even such gentle applications are not tolerated.
After the attack is over, absolute rest for some hours, at least, is positively necessary. If the attack was severe, the patient should rest several days, as there seems to be a great tendency for such attacks to come in groups, the cause being acutely present for at least some time. But little food should be given; nothing very hot or very cold, and no large amount of liquids; gentle catharsis may be induced on the following day, if deemed advisable; no stimulating drugs should be administered, and nothing which would raise the blood pressure.
The question often arises as to whether or not the patient shall be told of the seriousness of his condition. It is hardly wise to withhold this knowledge from him, and generally is not necessary.
The ordinary alert patient knows how serious the condition is by his own feelings, and will even reprove or joke with his physician for minimizing the danger. It is best that the whole subject be discussed carefully with him and his life regulated and ordered, and emergency drugs prepared and given him with proper instructions, to the family, so that he may possibly prevent other attacks and, if they occur, may have the best immediate treatment.
The acute symptoms being over, a careful a.n.a.lysis of the probable cause of the anginal attack should be made. If it is a general sclerosis, the treatment should be directed to that condition. If it is a myocarditis, a fatty degeneration of the heart or a fatty heart, this should be properly treated as previously described. If it is due to a toxemia from intestinal disturbance, that may readily be remedied. If due to nicotin, it need not again occur from that reason, and perhaps the damage caused by the nicotin may be removed.
Any organic kidney trouble must, of course, be managed according to its seriousness, and if there is hypertension without any serious lesion, the treatment should be directed toward its relief.
Not infrequently, whether a patient is suffering from real angina pectoris or a pseudo-angina pectoris, the absorption of toxins irons the intestines, due to indigestion and fermentation, adds to these cardiac pains, and may even be a cause of them. Consequently, eliminative treatment and a temporary rigid diet, and various treatments to prevent intestinal indigestion, are of great value in angina pectoris.
It may be even advisable for twenty-four hours or so to give nothing but water, and then perhaps a skimmed milk diet for a few days. This treatment, combined with almost absolute rest, and later graded exercise, with other measures to lower the blood pressure, and with the absence of tobacco, sometimes is very successful treatment.
PSEUDO-ANGINA
While this name is more or less unfortunate, it has long been in vogue as a designation for pains and disturbances referred by a patient to his heart. Therefore with the distinct understanding that if the diagnosis is correct the name is a misnomer, it may be allowable to discuss under this heading some of the attacks which may simulate an angina and must be separated from a true angina.
To decide whether pain in the region of the heart or irregularity of its action is due to organic disease, to functional disturbance, or to referred causes is often extremely difficult. Some of the most disturbing sensations in the region of the heart are not due to any organic trouble, and yet the patient is fearful that such sensations mean some kind of heart disease, and therefore becomes exceedingly anxious and watches and mentally records every sensation in the left chest. This is unfortunate, as the patient may learn to note, if he does not actually count, his heart beats, while normally he should sense nothing of his heart's activity. On the other hand, as just stated, it may be almost impossible to decide that this disturbance of the heart is not due to an organic cause, but is entirely functional, or due to some extraneous reason.
It seems justifiable in every case of irregular heart action to a.s.sure the patient that the condition can be improved, which in most instances is the truth. There can be no question of such urgent a.s.surance, if it is decided that the cause is not in the heart itself, or at least is not organic. Irregularities in the heart's action will be discussed later. At this time discussion will be limited to pain which is not true angina pectoris, but which is in the region of the heart or is referred to it.
Intercostal neuralgia is more likely to occur on the left side of the chest than on the right. This is particularly unfortunate, as tending to cause these pains to be referred to the heart. The localization of tender spots along the course of a nerve with demonstration of these to the patient and the diagnosis stated is all the a.s.surance that he requires.
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