Disturbances of the Heart / Discussion of the Treatment of the Heart in Its Various Disorders, With a Chapter on Blood Pressure

by Oliver T. Osborne

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 pass 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 glass 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 analysis 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.