With high blood pressure to the point of beginning endarteritis, a gradually increasing force of the apex beat occurs, the aortic closure is accentuated as just described, the pulse is slow, the tensity of the arteries depends on the stage of the disease, and when the disease is actually present, the palpable arteries do not collapse on pressure. They soon lose their elasticity, and if this occurs in parts which are soft and flexible, the arteries become more or less tortuous by the force of the blood current twisting and bending them, owing to the irregularity of their hardening. The extremities readily become numb, or the part "goes to sleep," as it is termed. This occurs frequently at night. Sooner or later some edema of the feet and legs occurs in the latter part of the day.
Sometimes abdominal colic attacks occur, caused by disturbed circulation. Various disturbances of metabolism may occur, depending on the circulation in the different organs or on coincident disease, and the liver, pancreas and kidneys may be affected.
The blood pressure, if taken in the arms especially, may appear excessively high, but really the actual pressure in the blood vessels may be low. This is on account of the inability to compress the hardened arteries. A heart may be weak and actually need strengthening even while the blood pressure reading is high.
The treatment of this disease is successful only in its prevention, and consists in treatment of hypertension before arteriosclerosis is present. When the disease is actually present, there is nothing to do except for the patient to stop active labor, never to overeat or overdrink, to prevent, if possible, toxemias from the bowels, to keep the colon as clean as possible, and for the physician to give the heart such medicinal aids as seem needed, vasodilators if the heart is acting too strongly, possibly small doses of cardiac tonics if the heart is acting weakly; always with the knowledge that a degenerative myocarditis may be present in considerable amount, or that coronary sclerosis may be present.
As stated above, coronary sclerosis probably seldom occurs without more general arteriosclerosis. Obstruction of the coronary arteries, however, not infrequently occurs at their orifices in conjunction with sclerosis of that region of the aorta and of the aortic valve.
The more these arteries are diseased and the more they are obstructed, the more the myocardium of the heart becomes degenerated, softened and weakened, when dilatation of the ventricles, especially the left, is liable to occur. Sooner or later such a condition will cause attacks of angina pectoris and more or less p.r.o.nounced symptoms of chronic myocarditis and fatty degeneration, as previously described.
TREATMENT
The treatment of a suspected coronary sclerosis is the same as that of general arteriosclerosis--primarily the elimination of anything which tends to cause high tension or to produce chronic endarteritis. When either general or local arteriosclerosis is present, the treatment which should be inaugurated comprises anything which would tend to inhibit the endarteritis and the cla.s.sification--necessary periods of rest, the interdiction of all physical effort or physical strain, and the regulation of the diet, digestion and elimination. Perhaps there is no greater preventive of the advance of this disease than a diet considerably less than would be suitable for the same person when in perfect health and at his regular work. The amount of protein especially should be reduced, and the meal hours should be regular. Ordinarily all tea, coffee and tobacco should be forbidden, and alcohol should be allowed only to the aged, if allowed at all.
It has long been considered that iodin would inhibit abnormal connective tissue growth. Iodin most readily reaches the blood as sodium or pota.s.sium iodid. Large amounts of iodin are not needed to saturate the requirements of the system for iodin, from 0.1 to 0.2 gm. (1 1/2 to 3 grains) preferably of sodium iodid, twice a day, after meals given with plenty of water, being sufficient; but it should be continued in one or two doses a day not only for weeks, but for months. Whether this iodid or iodin acts per se, or acts by stimulating the thyroid gland to increased activity and therefore to more normal activity, so that it is the thyroid secretion which is of benefit, it is difficult to decide. In view of the fact that in advanced years the thyroid is always subsecreting, and after the very diseases which cause arteriosclerosis or during the diseases which cause arterinsclernsis the thyroid is generally subsecreting, it would appear that the value of iodin is in its effect in stimulating the thyroid gland.
If a small amount of thyroid secretion is evidenced by other symptoms, thyroid extract should be given. The dose need not be large, and should be small, but should be given for a considerable length of time. If the patient seems to be improving on small doses of iodid, however, and the thyroid is supposed not to be very deficient, it is better not to administer thyroid extract, unless the patient is obese.
A serum treatment given intravenously, hypodermically, by the mouth, and by the r.e.c.t.u.m was inaugurated some years ago (1901 and 1902).
and is known as the "Trunecek serum." This first consisted of sodium sulphate, sodium chlorid, sodium phosphate, sodium bicarbonate and pota.s.sium sulphate in water in such amounts as to stimulate the blood plasma. Later small amounts of calcium and magnesium phosphate were added to the solution to be injected. These injections seemed to lower the blood pressure, but it is doubtful whether they have any greater ability than a proper regulation of the diet to inhibit arteriosclerosis. At any rate, these injections are but seldom used.
An important means of inhibiting disturbance from any arteriosclerosis which should be employed when possible is the climate treatment. Warm, equable climates, in which there are no sudden radical changes, are advantageous when coronary sclerosis is suspected, and warm climates are valuable in promoting the peripheral circulation and lowering the blood pressure in arteriosclerosis. These patients always require more heat than normal persons, always feel the cold severely, and their hearts always have much less disturbance, fewer irregularities and fewer attacks of pain during warm weather than during cold weather.
Simple hydrotherapeutic measures are also necessary for these patients, but baths should not be used to the point of causing debility and prostration. Applications of cold water in any form are generally inadvisable. Very hot baths are also inadvisable; but pleasantly warm baths, taken at such frequency as found to be of benefit to the individual, relax the peripheral circulation relieve the tension of the internal vessels, lessen the work of the heart, and promote healthy secretion of the skin, the skin of arteriosclerotic patients often being dry. This dry skin is especially frequent if there is any kidney insufficiency, which so soon and so readily becomes a part of the arteriosclerotic process.
If the patient is old, small doses of alcohol may act physiologically for good. In these arteriosclerotic patients the activities of alcohol should be considered from the drug point of view, not from that of all intoxicating beverage. Other drugs are considered in the discussion of hypertension.
If the heart actually fails, the treatment becomes that of chronic myocarditis and of dilatation.
Not infrequently in sclerosis of the arteries, especially of the coronary arteries, the blood pressure is not high, but low, and the heart is insufficient. In such patients cardiac tonics may be considered, but they must be used with great care. Digitalis may be needed, but it should be tried in small doses. It often makes a heart with arteriosclerosis have severe anginal attacks. On the other hand, if the heart pangs or heart aches and the sluggish circulation are due to myocardial weakness without much actual degeneration, digitalis may be of marked benefit. The value of digitalis in doubtful instances will be evidenced by an improved circulation in the extremities, a feeling of general warmth instead of chilliness and cold, an increased output of urine, and less breathlessness on slight exertion.
ANGINA PECTORIS
This is a name applied to pain in the region of the heart caused by a disturbance in the heart itself. Heart pains and heart aches from various kinds of insufficiency of the heart, or heart weakness, are not exactly what is understood by angina pectoris. It is largely an occurrence in patients beyond the age of 30, and most frequently occurs after 50, although attacks between the ages of 40 and 50 are becoming more frequent. It is a disturbance of the heart which most frequently attacks men, probably more than three fourths of all cases of this disease occurring in men; in a large majority of the cases the coronary arteries are diseased.
Various pains which are not true angina pectoris occur in the left side of the chest; these have been called pseudo-anginas. They will be referred to later. True angina pectoris probably does not occur without some serious organic disease of the heart, mostly coronary sclerosis, fatty degeneration of the heart muscle, adherent pericarditis and perhaps some nerve degenerations. Various explanations of the heart pang have been suggested, such as a spasm or cramp of the heart muscle, sudden interference with the heart"s action, as adherent pericarditis, a sudden dilatation of the heart, an interference with the usual stimuli from auricle to ventricle and therefore a very irregular contraction, a sudden obstruction to the blood flow through a coronary artery, or a sudden spasm from irritation a.s.sociated with some of the intercostal or more external chest muscles causing besides the pang a sense of constriction.
Perhaps any one of these conditions may be a cause of the heart pang, and no one be the only cause.
In a true angina, death is frequently instantaneous. In other instances, death occurs in a few minutes or a few hours; or the patient"s life may be prolonged for days, with more or less constant chest pains and frequent anginal attacks. Here there is a gradual failing of the heart muscle, with circulatory insufficiency, until the final heart pang occurs.
Anginal attacks before the age of 40, presumed, from a possible narrowing of the aortic valve, to be due to coronary sclerosis, are frequently due to a long previous attack of syphilis. In these cases, active treatment of the supposed cause should be inaugurated, including perhaps an injection of the a.r.s.enic specific, and certainly a course of mercury and iodid, with all the general measures for managing and treating general arteriosclerosis, as previously described.
SYMPTOMS
The pain of true angina pectoris generally starts in the region of the heart, radiates up around the left chest, into the shoulders, and often down the left arm. This is typical. It may not follow this course, however, but may be referred to the right chest, up into the neck, down toward the stomach, or toward the liver. The attack may be coincident with acute abdominal pain, almost simulating a gastric crisis of locomotor ataxia. There may also be coincident pains down the legs. It has been shown, as mentioned in another part of this book, that disturbances in different parts of the aorta may cause pain and the pain be referred to different regions, depending on the part affected.
Instances occasionally occur in which a patient had an anginal attack, as denoted by facial anxiety, paleness, holding of the breath, and a slow, weak pulse, without real pain. This has been called angina sine dolore. The patient has an appearanece of anxious expectation, as though he feared something terrible was about to happen.
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 crushing 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.