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 assure the patient that the condition can be improved, which in most instances is the truth. There can be no question of such urgent assurance, 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 assurance that he requires.
Careful questioning, and if necessary scientific examination of the stomach, may show that the patient has hyperchlorhydria, ulcer of the stomach or duodenum, dilatation of the stomach, or some growth in the stomach as a cause for the pain referred to the region of the heart. Gallstones in the gallbladder may also give such referred pains. Other lesions in the abdomen may cause pain referred to the cardiac region. Not only will the demonstration of these causes and their treatment assure the patient that he has not neuralgia of his heart, but also, if curable, the cause of the pain may be removed.
Dry pleurisy of the left chest is not an infrequent cause of these pains, and of course serious disease of the lungs, as tuberculosis, unresolved pneumonia, pleuritic adhesions, ennphysema and tumor growths, may all be the cause of a referred cardiac pain, the heart being disturbed secondarily.
A stomach cramp is a not infrequent cause of serious pain referred to the heart, and the rare condition of cardiospasm must also be remembered as a cause of pseudo-angina. In other words, the interpretation of these pseudo-anginas means a careful diagnosis of the condition, and, as previously stated, not only must the above- named causes be excluded, but also the reverse must be remembered: that many disturbances treated as other conditions really are due to cardiac weakness. The diagnosis of a real angina pectoris from a false angina may not be difficult. A real angina generally occurs after exertion of some kind, be that exertion ever so slight. False angina may occur at any minute with or without exertion. Pain referred to the heart which awakens a patient at night is not likely to be a true angina; nervous patients are prone to have such night attacks of cardiac disturbance of various kinds. A true angina causes the patient's face to look anxious and pale, with the breathing repressed. A false angina shows no such paleness, allows deep breathing, crying and lamenting, and allows the patient to move about in bed, or about the room. The true angina makes the patient absolutely still and quiet: he hardly dares to speak or tell what he is feeling and fearing. True angina is of course much more frequent in older persons, while false anginas occur in the young, and especially in the neurotic. With all the other manifestations of hysteria, palpitation and cardiac pain are often symptoms.
It should not be decided, however apparently self-evident that a referred pain is not due to cardiac lesion until a careful examination of the patient has been made. Real cardiac disturbance can of course occur at any time in a neurotic or hysterical patient, and there should be no mistakes of omission from carelessness or neglect on the part of the physician.
Other frequent causes of more or less disturbance of the heart's action, often accompanied by pain, are overexertion, worry and mental anxiety, and intestinal toxemias due to too much protein or disturbed protein digestion. Frequent causes are tobacco, and the overuse of tea and coffee. Many a patient's pseudo-anginas are corrected by stopping tea and coffee. The effects of caffein and tobacco on the heart will be considered later when toxic disturbances are under discussion.
The above-mentioned causes of pseudo-anginas have only to be named to indicate the treatment which will prevent the pain attacks. At times, the cause being intangible, it may be necessary to change the whole life and metabolism of the patient, as so often necessary in hysteria, neurasthenia, gout, intestinal fermentation and kidney inefficiency. Besides a rearrangement of the diet and measures for causing proper activity of the bowels, massage, exercise and hydrotherapy should lie utilized toward the end of improving the nutrition of every part.