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

by Unknown

Recurrences of functional disorders of the heart constitute the rule rather than the exception. Their frequency will depend much on the degree of the predisposition, but of course more or less on the causes therewith associated. The mental anxiety and apprehensions which they at first occasion after a time wear away, and they are at length reckoned as belonging among those annoyances of life to which may be applied the common expression, "What cannot be cured must be endured."

TREATMENT.—Prompt relief or palliation of suffering is often the immediate object of treatment when cases first come under observation. The medicinal remedies for this object are the ethereal or alcoholic stimulants, the different antispasmodics, and opium. Chloric ether and the compound spirit of ether (Hoffman's anodyne) often act efficiently. An eligible prescription is the combination of one of these with an equal part of the compound tincture of lavender, of which a teaspoonful, properly diluted, may be given after short intervals. Brandy, whiskey, or some other form of spirit in many cases will afford prompt relief. It should be given not much diluted. These remedies are especially indicated in paroxysms of irregular or intermittent and enfeebled action of the heart. They are less adapted to cases in which the heart's action is violent. Of antispasmodics, valerian, the valerianate of ammonia, camphor, and asafoetida are appropriate. Some one of the preparations of opium is to be employed if the disorder be not relieved by other remedies. Of the different forms of opiate, codeia is the least objectionable, and perhaps as efficient as any other. With a view to promptness of relief in certain cases of severity, morphia may be administered hypodermically. Other palliative measures are a sinapism to the præcordia, and, if the extremities be cold, a mustard pediluvium. Of the efficacy of the ice-bag applied over the heart, which is recommended by German writers, I cannot speak from personal observation. The testimony in behalf of its usefulness is, to say the least, sufficient for resorting to it without apprehension of doing harm. In some cases of obstinate persistence of disorder the opportunity is afforded for trying in succession the various remedies which have been named. Digitalis is sometimes useful. Concomitant disorders which may have originated or which tend to keep up the disordered action of the heart are to be appropriately treated. Flatulence and other ailments referable to indigestion and constipation not infrequently are in this category. Paroxysms may be sometimes arrested by certain mechanical means, such as pressure upon the abdomen, holding the breath after a deep inspiration, and compression of the vagus and sympathetic nerves in the neck.

In some cases of functional disorder there is a persistent increase of the frequency of the heart's action without irregularity in rhythm. The action of the heart in these cases is the same as in cases of exophthalmic goitre, the enlargement of the thyroid body and the prominence of the eyeballs which characterize the latter affection being wanting. In these cases aconite in small doses is to be recommended. From one minim to three minims of the tincture of the root may be given, repeated after intervals of four or six hours and continued indefinitely. In cases the opposite to the foregoing—namely, those in which the disorder is characterized by infrequency of the heart's action—a rational indication is to give remedies with a view to excite the heart. In the cases which have come under my observation alcoholics have had but little effect upon the heart, although apparently useful as regards the nervous symptoms which are apt to accompany this variety of cardiac disorder. As this disorder does not, as a rule, occasion distress, the patient perhaps not being conscious of any disturbances of the heart's action, and as the infrequency does not appear to involve danger, the treatment may be directed to fulfilling other symptomatic indications.

Positive assurances of the absence of danger have often a potential influence in relieving paroxysms of functional disorder. The disorder is not infrequently increased and kept up by mental apprehension, and these assurances therefore do away with an active causative agency. They are also useful in the way of preventing the recurrence of paroxysms. It is evident that in order to exert this moral influence the physician must be competent to decide that the disorder is purely functional. He can so decide only if he have confidence in his ability to exclude inflammatory and structural affections or to determine that the disorder is not dependent on lesions which may coexist. If he have not sufficient confidence in his opinion, he will naturally and properly not give positive assurances, and a lack of positiveness will be likely to lead the patient to infer that the disorder is not devoid of danger. The good effect of certain measures of treatment is in part attributable to a mental influence. This is legitimately a therapeutic object here as in other affections.

The more important part of the treatment in the majority of the cases of functional disorders of the heart's action is that which relates to prevention. The preventive treatment, in addition to the moral influences already referred to, consists chiefly in removing as far as practicable the causes of the disorder. The predisposition cannot be removed, but the causes which are auxiliary thereto in producing disorder are, to a greater or less extent, controllable.

Prolonged mental anxiety is often inseparable from the events of life. "Therein the patient must minister unto himself" The voluntary exercise of the mental faculties, however, can be restrained within physiological limits. Tobacco can be abstained from, and, as a rule, total abstinence is easier than moderate indulgence. Tea and coffee can be used moderately if at all. Dyspeptic ailments are amenable to appropriate dietetic and medicinal treatment. On no account should the diet be reduced below the requirements for ample nutrition. Anæmia, which exists in a large proportion of cases, especially in women, calls for chalybeate tonics, to be continued persistently as long as the blood remains impoverished. It is needless to add that in these cases the causes of the anæmia are, if possible, to be removed, and that chalybeates are to be supplemented by proper dietetic and regiminal treatment. Sexual excess and abuses are to receive adequate attention. There can be no question as to unnatural sexual excitation. But a question often arises in individual cases concerning the physiological limitations of natural indulgence. These limitations probably differ widely in different persons. They are, however, always exceeded if the indulgence exceed the instinctive demand—that is, if its increase be made an object for voluntary efforts. Long-continued and violent muscular exertions should be interdicted. Uricæmia or the gouty diathesis claims appropriate remedies and hygienic regulations.

Several of the various causes just recapitulated are frequently combined, so that the preventive treatment is by no means always limited to the removal of a single cause. The treatment will prove successful in proportion as the efforts to remove the causes are effectual.

Angina Pectoris.

The name angina pectoris was introduced by Heberden in 1768 to designate a group of symptoms which from that date has been regarded as constituting an individual affection. The word angina, signifying strangulation, has but little pertinency in this application of it, and various other names have been proposed in its stead. For the most part these are based on pathological views which are either erroneous or hypothetical, and at the present time the name angina pectoris is generally adopted in all countries.

The affection may be defined as a paroxysmal neuralgia, the pain of which is seated within or near the præcordia, shooting thence in most cases into the left shoulder, and extending downward to a greater or less extent into the left upper extremity, the right upper extremity being sometimes similarly affected. In some instances the pain extends to the lower limbs; the paroxysms often accompanied by a feeling of anguish and of impending death, the affection in the great majority of cases being incident to organic disease of either the heart or the aorta and involving liability to sudden death.