A system of practical medicine. By American authors. Vol. 3

by Unknown

The more frequent varieties of disorder of the heart's action occur in most instances in paroxysms. The paroxysms differ widely in duration as well as in their intensity. They may last for an instant only or for many continuous days. Exceptionally the duration is much longer. I have known a persistent and very great increase of frequency of the heart's action with irregularity, and such a degree of weakness that the pulse could with difficulty be counted, to continue for several weeks, leading to oedema of the lower limbs, prostration, and pallor, so that the patient's appearance was that of one moribund. In this case before the attack and after recovery there was no evidence of any other affection than functional disorder of the heart, and to this the patient had long been subject. In another case an extremely irregular action of the heart continued unceasingly for more than two months, there being no signs of either an inflammatory or a structural affection of the organ, and the functional disorder at length ceasing. As a rule, an attack of functional disorder of the heart implies a liability thereto; other attacks occur after variable intervals. This fact involves a peculiar susceptibility, or, in other words, an irritable heart.

The symptoms referable to the heart may be combined with those of coexisting affections. Disturbances of digestion are frequently associated. Paroxysms of disordered action of the heart are often accompanied by gastric flatulence, and gaseous eructations afford relief. Patients are apt to endeavor to eructate by voluntary efforts. Other evidences of indigestion are not infrequent. The mind is much disturbed, especially if previous paroxysms have not occurred. The facial expression shows anxiety. The apprehension is of organic disease of the heart and of sudden death. This apprehension is excited in a marked degree by intermittence of the heart's action. It is often extremely difficult to convince patients of the absence of immediate danger. They require to be assured of this fact over and over again, and whenever a paroxysm occurs. This statement applies even to medical men who suffer from functional disorders of the heart's action. The surface is usually cool or cold. It is sometimes bathed in perspiration—a symptom probably due, in a great measure, to the condition of mind. Exclusive of angina pectoris, paroxysms of functional disorder are not attended by præcordial pain. The paroxysms may cease either suddenly or after a gradual improvement. The cessation is abrupt in the instances in which the paroxysms last but an instant or but a few moments, and not infrequently when the paroxysms are of much longer duration the normal rhythmical action is at once resumed.

The variety of disorder characterized by diminished frequency of the heart's action is often associated with cerebral disturbance. In 2 cases cited in my paper there were severe epileptiform seizures, together with frequent epileptoid attacks; in 2 cases there was mental excitability amounting to delirium; and in 1 case there was great mental and physical prostration with gastric irritability, the latter due apparently to cerebral disturbance. In 1 case only there was no evidence of disorder of the brain. Of 3 cases which have fallen under observation since the publication of my paper, in 1 there was notable mental disturbance, the mind remaining intact in the other 2 cases.

DIAGNOSIS.—Certain facts pertaining to functional disorders of the heart's action in their ordinary paroxysmal forms render the diagnosis probable. One of these is the occurrence in paroxysms, the action of the heart being normal in the intervals. Another fact is the occurrence of the paroxysms at night oftener than in the daytime. The ability of the patient to take active exercise without exciting a paroxysm and without discomfort is evidence that the paroxysmal affection is functional. A diagnostic feature of a purely functional disorder is great apprehension connected with the disordered action of the heart. The patient is apt to feel that there is imminent danger of sudden death. So strong is this apprehension that it is sometimes difficult to overcome it by positive assertions of the absence of danger. On the other hand, disordered action of the heart, when incident to structural affections, occasions comparatively little mental disturbance; the patient suffers chiefly or exclusively from the physical ailments. In a purely functional affection the patient generally is vividly conscious of the disordered action, whereas the action in structural affections may be greatly disordered and the patient take no cognizance of it. The existence of certain causes to be mentioned under the head of the Etiology bears upon the diagnosis. The liability to functional disorders, as evidenced by previous attacks, is also to be taken into account. These facts, however, are not fully adequate for the exclusion of structural affections of the heart. Moreover, the persistence in some cases of notable disorder for days, weeks, or even months, would seem to render highly probable the existence of some structural affection. The basis of a positive diagnosis is the exclusion, by the absence of their physical signs, of inflammatory affections and lesions of structure.

The physician who undertakes to diagnosticate functional disorders of the heart by symptoms alone—that is, without physical exploration—must often be in doubt, and if not prudently distrustful of his ability as a diagnostician, he is liable to commit errors which are sometimes extremely unfortunate. I was requested to see a young woman who was represented as suffering from a disease of the heart from which she might die at any moment. It was stated to me that her situation was perfectly understood by herself and her family, and that the object of my visit was simply to satisfy some of her friends. I found her in a dark room, with every arrangement to prevent the least mental excitement and physical exertion. Fearing that my questions and the examination of the chest might occasion disturbance which would prove fatal, it was proposed that one of her family be made the medium of the former, and that the latter be dispensed with. This was of course objected to on my part. My questions she answered in a feeble whisper. The examination of the chest showed the absence of all physical signs of disease. The affection was purely functional and wholly devoid of danger. I could cite from cases which have come under my observation not a few in which the error of imputing functional disorders to organic lesions has occasioned the loss of years as regards the duties and pleasures of life, together with the unhappiness incident to living in daily expectation of sudden death. With a degree of practical knowledge of auscultation and percussion sufficient to recognize the signs of inflammatory and structural diseases, and self-confidence sufficient to decide upon the absence of these signs, there is but little liability to error in the diagnosis of functional disorders.

If the apex-beat be in its normal situation, and the areas of the superficial and deep cardiac regions be not extended, the heart is not enlarged; and if there be no endocardial murmur it may be inferred that the valves and orifices are normal. The exclusion of structural lesions under these circumstances is almost positive. It is open only to the exception that certain occult lesions may exist, such as fatty degeneration and obstruction of the coronary arteries. Aside from the infrequency of these, the history and symptoms may render their existence extremely improbable. A hæmic murmur at the aortic or the pulmonic orifices or at both orifices is not uncommon. That the murmur is inorganic may generally be determined by other evidences of anæmia, by an arterial murmur in the neck, and by the venous hum. With the results of physical exploration as just stated, whatever may be the form of disorder, whatever may be its intensity, whatever may be its duration, and whatever may be the associated symptoms, it may be declared to be purely functional.

The diagnosis is less simple and easy when functional disorders occur 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 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 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.