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Home , Referred pain, Shock (circulatory), The Bill (series 24)

Postgrad Med J: first published as 10.1136/pgmj.24.277.601 on 1 November 1948. Downloaded from 6oi

PRECORDIAL By BRUCE MACLEAN, M.D., F.R.C.P. Physician and Cardiologist, North Staffordshire Royal lnfirmary

During the 1939-4S war, the incidence of pre- left-sided infra-mammary pain. The statement cordial pain increased, organic disease accounting, that pain in this area is never due to disease is in my experience, for rather less than half the incorrect. Though it is usually a symptom of cases. Often the diagnosis is difficult because of neurosis, when it accompanies mitral disease pain misleading symptoms and a paucity of clinical is probably the result of both mental and physical signs. Sometimes the symptoms alone make the fatigue. diagnosis easy; and in between these extremes Apart from invasion of the spine, pleura and are cases of such a curious mixture that it is fair to adnexa by neoplasm, other causes of pectoral pain conclude that in the past the combination of both are not common. A causing pain functional and organic factors has not been and dyspnoea, especially on exertion, is easily sufficiently emphasized. confused with true particularly when there is a partially collapsed left difficult to diagnose Common Causes of Pain on clinical examination. A sudden onset in par-

The commonest cause of pain in the chest is ticular simulates a thrombotic attack. Protected by copyright. the functional disorder usually termed benign cardiac pain or angina innocens, but better Left-sided Infra-Mammary Pain described as left-sided infra-mammary pain. It is Nomenclature. This syndrome was first due to an anxiety state and is discussed below. described by Da Costa (I87I) during the American Pectoral fibrositis is very common and is Civil War and was often associated with . diagnosed not only by the presence of tender areas During the I914-I8 war, it came into prominence elicited by deep palpation but also by the patient's once more under the heading of D.A.H. (dis- statement that the pain arises on movement of the orderly action of the heart), irritable heart, effort and on muscular contraction in the affected syndrome, soldier's heart, and neuro-circulatory area. When the upper part of the chest is in- asthenia; but these descriptions do not always volved, it is possible to produce in fit . There may be no disorderly action, the by pressing on the painful site. In many such as or irregularity of the heart- instances there has been strain of the pectoral beat, and occasionally no complaint of dyspnoea. The syndrome occurred in civilians in the I939-45 tissues and a toxic state provokes persistence of http://pmj.bmj.com/ the symptoms and signs. Introspection following war more than in soldiers,2 for the obvious reasons strain of the pectoral muscles and-giving rise to that past experience had taught us to weed out chronic tenderness and aching of the left breast is recruits undergoing medical examinations who regarded by Mendlowitz' as the second most showed any likelihood of this disorder, and be- common cause of pectoral pain in American cause the civilian population were subjected not soldiers and recruits to military service. only to real warfare but also to general anxiety. Arthritis of the -joint is not infrequently Aetiology. Left-sided infra-mammary pain is associated with fibrositis and should always be commonly encountered in overworked and highly on September 23, 2021 by guest. sought in suspicious cases with in the upper strung people. In peace-time, females with hyper- part of the chest. tension form the majority of such patients, but True angina and pain from coronary during I939-45 a large proportion has consisted of are dealt with below. males aged seventeen or more. Cardiologists con- Paroxysmal tachycardia (with its coronary in- sider that the condition is due to mental fatigue sufficiency), pericarditis, and pleurisy are not and not to coronary insufficiency. A strained difficult to exclude by their special characteristics. pectoral muscle can initiate fear, with psycho- Here one may refer to those cases of coronary somatic disturbance, and infection lowers the infarction where deep also causes pain resistance and morale. Certain it is that re- in the precordial area as the result of pericardial assurance can effect a cure, provided the mental involvement. at the same time is removed. Mitral stenosis is sometimes accompanied by Infection (focal ) appears to play a part. 602 POST GRADUATE MEDICAL JOURNAL November I1948 Postgrad Med J: first published as 10.1136/pgmj.24.277.601 on 1 November 1948. Downloaded from In contradistinction to the association with Treatment dysentery noted by Da Costa, I have found It is a pity that the word ' angina' is used so pharyngeal infection to be the most constant toxic often in connection with what is described as factor. benign cardiac pain; it is better to discard a name Experiments point to the hypothalamus, with which to the layman is associated with the dread its sympathetic centres, as the probable site of of sudden death. In fact the terms ' angina,' disorder. The auriculo-ventricular conduction ' tired heart,' and ' flabby heart-muscle ' should time can be lengthened by stimulation of the hypo- never be mentioned to the patient, for they may thalamus in dogs; and sweating and even ulcera- haunt him for the rest of his life. Herein lies the tion of the duodenum can be produced by trau- first principle in the treatment-reassurance. To matic lesions of the hypothalamus in man. the intelligent inquiring patient it must be ex- plained that there is no organic disease, and that Symptoms the symptoms, though real to him, are the result The patient usually complains that pain arises of fatigue and anxiety. This is often a difficult pill in or under the left breast, coming on at any time, for the patient to swallow. Likening him to a day or night, and sometimes waking him in the sensitive wireless set, tuned in to distant stations night, though he is more likely to wake first. The and reacting accordingly, compared with the in- pain is described as stabbing, throbbing, burning, ferior models, does much to satisfy his doubts. It and lasting hours, sometimes all day. It may is explained that if the mind is tuned in to dis- arise with, but usually after, effort; but in so comforts they become so much more apparent and doing it tenos to persist and is not relieved by must be faded out and in this way eventually cessation of activity. It often spreads to the left obliterated. I have known an understanding talk arm, usually the inner border, and this limb may with a patient abolish the precordial pain at one consultation. once feel numb and useless ; sometimes the pain ex- Moreover, the diagnosis has Protected by copyright. tends to the left side of the . I have only been established, further cardiac examinations are twice known the pain to spread to the right arm; redundant and harmful, provoking introspection it has been stated that such a spread excludes the by raising doubts as to the state ofthe myocardium. psychosomatic illness and indicates true coronary Some patients need physical rest, but rest in bed occlusion, but this is incorrect. is bad for those with nothing but an anxiety state. Occasionally the symptoms overlie true angina, It is a different story where the neurosis is super- and then the patient's story is of real service; imposed on organic pathological conditions such as his attitude and reaction will probably give the hypertension, valvulitis, and coronary dysfunction. clue to the assessment. It is in such cases that In any case sedation is necessary. Bromides are we tend to make a wrong diagnosis of pure a good standby though used far too in- neurosis, the symptoms of true angina being discriminately; if they are given for too long they overshadowed. may cause depression, lack of concentration, and even incoordination with nystagmus. Restlessness Signs and insomnia may require barbiturates, par- ticularly in a hypertensive patient. It is wise to http://pmj.bmj.com/ There is not infrequently tenderness to pressure substitute a non-barbiturate from time to time, over the area of pain. Thomas Lewis3 pointed out such as carbromal, or bromo-iso-valeryl urea during the I914-I8 war that pinching the sterno- (B.V.U.); isobrom is a happy combination of mastoids, trapezii, and pectorals provoked more these latter with enhanced action, and can discomfort on the left side: be used during the day with little narcotic effect. Hyperaesthesia has often been described. I have For those who cannot sleep on retiring a quick- found the left mammnary , in both male and acting is best, such as Seconal or Car- female, tender to the grasp, and believe that the brital. Hexobarbitone is rapid in action but doses on September 23, 2021 by guest. hyperaesthesia of the left chest described by larger than 4 gr. may upset the digestion and cause various authorities probably refers to tenderness . Evidorm, a combination of quick and on deeper palpation. True hypersensitiveness of slow acting barbiturates, has a rapid and more the skin is rare. lasting effect. Digitalis is often useless in cardiac and radioscopy reveal no neurosis except for its vagotonic effect in damping signs of disease. The exercise-tolerance test may be down the pacemaker at the sino-auricular node in faulty, the systolic -pressure infrequently patients with tachycardia and overaction of the raised, tachycardia present, and a soft systolic sympathetic supply. Small doses of belladonna murmur detected at the apex of the heart, none of also stimulate the vagal endings and slow these features being contingent upon organic the heart-rate; large doses paralyse and provoke defect. tachycardia. Postgrad Med J: first published as 10.1136/pgmj.24.277.601 on 1 November 1948. Downloaded from Nrovembe 1 948 MACLEAN: Precordial Pain 603 True Angina gall-bladder disease, which then excites the angina Aetiology. True angina, coronary pain, effort and can be likened to the trigger of a loaded gun. angina, or angina pectoris occurs usually in middle Cases are on record where cholecystectomy has age, mainly in men, but has been observed in the abolished angina for a long time. Similarly, in fourth decade, and I have described it in a child some cases the provoking factors are a distended aged fourteen with progeria (premature senility).4 colon or stomach, the result of overfeeding or of Angina pectoris should be regarded more as a indigestion. ; syndrome than a disease, for it may accompany Anginal pain can be incited by exposure to cold, spasmodic conditions of the further afield, as in coming out of a warm theatre or walking as in intermittent claudication; it may occur in from a warm room to a cold one, and then it is not people without evidence of arterial disease; and the effort but the alteration in temperature which it is a symptom found not only in atheroma of the induces the attack, the result, no doubt, of a rise coronary vessels but also in thrombosis and in- in the which increases the work of farction of those vessels, in syphilitic endarteritis, the heart. Getting into bed with cold sheets has a and in rheumatic aortic lesions. It also occurs in like effect. This pain must be regarded as of advanced anaemia and in untreated myxoedema, spasmodic reflex character and associated with from myocardial anoxaemia, when the pain is coronary spasm. a caused by the toxic effects of accumulating Tobacco is a rare primary cause of angina, yet metabolites. the symptoms at times are relieved by abstention, The precordial discomfort is nearly always especially from cigarette inhaling. It seems feasible caused by effort; but emotion, cold, or dyspepsia that some people may become more sensitive to may also bring it on. The pain is quantitatively tobacco with advancing age. Coronary restriction related to effort and s increased by fatigue or can be produced experimentally in animals with and anxiety lessened by a carefree holiday. A nicotine. Repeated arterial spasm is likely to lead Protected by copyright. cardiovascular lesion is surely not responsible for eventually to arteritis and thrombosis. these changes; it is the overlabile autonomic A special type of angina develops during anaemia system and the exaggerated response to stimuli and is then due to the smaller supply of oxygen to with increased or failure of a the muscle when an extra call is made on the heart. vasodilator response of the coronary arteries which This can be cured by restoration of the haemo- causes the ischaemia. There is therefore an globin level. Any anaemia may cause this additional qualitative factor. This overactive symptom, whether from haemorrhage, pernicious autonomic system explains why the effect of over- or hypochromic anaemia, or leukaemia; but young work and fatigue, with inadequate leisure, invokes people and children with severe anaemia do not angina; and why the business man during the get angina. ,week develops pain on walking to the railway Campbell6 holds the view that people with this 'station, yet can play a game of golf without dis- type of angina will eventually develop true angina comfort and be free from attacks while on holiday. of effort, believing that the anaemia alone cannot Only 15 per cent. of patients with calcification cause the angina unless associated with coronary of the coronary arteries have been known to re- sclerosis. Other cardiologists incline to the belief http://pmj.bmj.com/ port an anginal syndrome. Few persons with this that the lack of oxygen suffices to explain the pain, complaint experience pain on going upstairs or in the absence of coronary disease. walking about their business premises; some can Angina has also been described in association even run upstairs without discomfort, but it is with thyrotoxicosis and with myxoedema; it has the slow incline that catches them out. The fact been alleviated by thyroidectomy in thyrotoxicosis that belching seems to relieve the pain suggests and by thyroid administration in myxoedema. It associated gall-bladder disease, but belching must be remembered that, when thyroid extract is on September 23, 2021 by guest. probably denotes the cessation of the attack. administered in overdosage, a state of overaction of Oesophageal spasm may also be present; it can the sympathetic is induced, with the consequent be regarded as a counterpart of anginal pain, for tendency in some people to coronary spasm. it can be prevented or relieved by nitroglycerine. The statement that this eructation is due in most Symptoms cases to air swallowing is erroneous. Some True angina used to be regarded as a sudden patients, thinking their symptoms are due to severe pain associated with a sensation of im- dyspepsia, swallow air while attempting to dis- pending dissolution. We know now that the pain lodge the wind, but they are in the minority. It is may be mild, even a dull ache, and rarely associated also a fact that many patients with angina of effort with the fear of death. It is in the so-called do not complain of associated flatulence. On the vasovagal syncopal attacks and in sensory epilepsy other hand, true angina is often associated with that this dread is more commonly experienced. Postgrad Med J: first published as 10.1136/pgmj.24.277.601 on 1 November 1948. Downloaded from 604 POST GRADUATE MEDICAL JOURNAL November I 948 There is always a positive history of the symp- Diagnosis toms produced by effort and relieved in a short The diagnosis can frequently be made from the space of time by rest or by nitroglycerine; fre- description of the symptoms alone. Clinical quently aggravated by exposure to cold or effort examination may not reveal any significant sign in after a meal. Cold raises the blood pressure and the heart, arteries or blood pressure. There may throws greater strain on the heart; while a full be no evidence of cardiac failure. Radioscopy has stomach with increased blood supply reduces the frequently revealed a normal size and contour of coronary flow. heart, and aorta, in undoubted cases. Electro- Some patients get pain first thing on making an cardiography may not reveal any sign of a patho- effort after breakfast, and then are relieved for the logical kstate of the heart muscle until permanent rest of the day. There is a story of a doctor who occlusive changes arise. In doubtful cases it is preferred to wind up his car and get the trouble advisable to repeat electrocardiography im- over rather than have the symptoms tending to mediately after exercise or after inhalation of IO persist over a longer period. Other patients com- per cent. oxygen, thereby provoking precordial plain mainly at the end of the day when they are pain. By these tests, which should be accom- tired ; in this instance the sympathetic nervous plished within three minutes of the onset of pain; system comes strongly into play. one may observe an alteration of the complexes Some patients lose their angina for a time. This in the electrocardiogram, revealing signs of tem- fact does not indicate an error in diagnosis. The porary muscle defect. Injections of adrenalin will threshold for pain has been lowered by the provoke angina but the concomitant risk of removal of anxiety and consequent overaction forbids its use as a test. of the sympathetic nervous system. On the Confusion sometimes occurs in the interpretation other hand, patients cease to experience effort of an inverted T-wave in lead i in hypertensive angina after sustaining a myocardial infarct, patients. Intravenous injections of Protected by copyright. presumably because the pain-producing area has salts will cause the T-wave to become upright in necrosed. pure hypertension, whereas they will accentuate An objection to the term.' precordial ' is that, the inversion in coronary occlusion. Unfortunately whereas true anginal discomfort is often sternal in this procedure is not without risk, since potassium site, it is usually felt across the upper chest, or salts given intravenously slow the conduction arises in areas to which the pain may spread. I mechanism of the heart. have known anginal pain arise in the left wrist or I would refer briefly to those unfortunate both wrists; in the left arm or both ; in the people with para-oesophageal hernia. This hiatus back or nape of neck; though in alnmost every case hernia provokes three types of symptoms: chiefly it was also experienced across the upper chest. gastric, occasionally respiratory, and not in- The pain may spread to the throat, especially to the frequently precordial pain simulating angina. The left , and even the left side of the face and to common occurrence of pain with flatulence after the left eve and behind the ear. When this pain meals, the persistence of the pain or discomfort at spreads from the upper sternum to the right arm rest, and the daily recurrence over long periods http://pmj.bmj.com/ it is almost proof of coronary occlusion. Very will suggest this abnormality. To add to the rarely is pain felt in the right arm in cardiac confusion I have found that nitroglycerine will give neurosis, but it must be remembered that anginal relief by its antispasmodic effect on oesophageal pain may on rare occasions be described only in tissue, in the same way as inhalation of octyl- the right upper chest and right arm. nitrite. When angina is due to syphilitic occlusion of the mouths of the coronary arteries (in contradistinc- tion to the usual atheroma extending along the I believe that patients without true pain, on September 23, 2021 by guest. coronary vessels), the pain on effort tends to last especially where there is no spread to the neck and longer, is not soon relieved by rest, is often more jaw, or where the discomfort is mainly one-sided, spasmodic, and is associated with nocturnal and particularly those who can walk off their paroxysmal dyspnoea and angina decubitus. symptoms and have no sense of constriction or These nocturnal symptoms are the outcome of the suffocation, have a more favouable prognosis. mechanical effect on the coronary flow, relative to Spasmodic angina, though little understood, pressure from a dilated aorta in recumbency. It sometimes has a favourable prognosis, especially must be remembered, however, that syphilis does in the emotional type where effort does not play not always.cause dilation of the aorta. Incident- so important a part. Vasodilators are not always ally, in syphilitic angina it is much more im- successful in its treatment, and then the symptoms portant to treat the heart before the syphilis, for run their course. syphilitic tissue is better than none. Angina of old age does not appear to alter the Postgrad Med J: first published as 10.1136/pgmj.24.277.601 on 1 November 1948. Downloaded from 'Vo7-em*ber 1948 br I\ACLEAN : Precordial Pain 605 course of the natural span of life, possibly because in this way than when swallowed. For a longer of the development of multiple anastomoses in the action which need not start so quickly it is better circulation of the myocardium. to swallow the nitroglycerine. The tablets should A patient with angina very rarely dies in the first be fresh. Patients are sometimes afraid of taking attack ; he may live, with recurring attacks, for these tablets, either because they produce i S years or more. Death is usually associated with throbbing in the head and slight giddiness or coronary thrombosis, not necessarily occurring at in those with so-callad , or precisely the same time as the vascular clotting, from a fear of taking. As a rule by redutcing for other factors come into play, such as ventricular the dose one can discover the requisite amount to standstill and fibrillations, contingent upon in- relieve the symptoms without causing unpleasant volvement of the conducting mechanism associated effects. It is wise to start with a small dose, es- with coronary spasm. Such spasm no doubt at pecially for patients with the minor manifesta- times may be widespread involving coronary tions; even I/200 gr. may be found efficacious. arteries without marked atheroma. The prognosis Larger doses, say, I/ISo gr. or I/ioo gr., may be is influenced to a large degree by the mental re- necessary later. actions of the patient to his complaint, by the Food must be carefully chewed; the stomach care taken in regard to habits and diet, and by the cannot take over the duty of the teeth. In- history of thrombotic attacks. digestible food must be avoided. By the age a man develops angina he should know what disagrees Treatment with him. Small meals at short intervals should be There are few conditions where advice is so taken rather than larger meals at longer intervals. strongly needed about general hygienic measures Avoidance of gastric and colonic distension is and regulation of the patient's life. For prophy- very important. Much has been written about the

laxis he must take fresh stock of himself and, harmful effects of and tobacco. If alcohol Protected by copyright. according to the severity of his symptoms, limit his suits the patient, a moderate amount of it, par- activities, especially those associated with over- ticularly in the evenings, does no harm. Cassidv6 strain. declares that tobacco has little if any effect on At the outset it is best to explain to the patient coronary disease, but he admits that cigar smoking -that, with age, there is a lessening of cardiac has been known to induce intermittent claudica- reserve, and this takes the form of warnings that tion. It is therefore wisest to prescribe modera- he is overstepping the boundaries of his heart's tion in smoking and avoidance of inhalation. capacity for work ; that if he limits his physical Vasoconstriction can be caused by nicotine, and and mental effort he will be freer from the pain or some anginal subjects do get pain after cigarette discomfort, and he will need to live within the smoking. We cannot altogether exclude the limits of his tolerance. ' Regular habits ' and psychological effect where the patient has been ' going slow' should be his watchwords. He forbidden this luxury and fears the consequence should take longer over his dressing in the of indulging it. not over his it I am not convinced of the efficacy of nicotinic morning, hurry breakfast; may http://pmj.bmj.com/ even be necessary for him to get up half an hour acid. Experimentally, a high dosage is required earlier. Then he should rest before and after to promote of the coronary vessels, meals. We often hear the patient's story of pain and then tingling and pricking sensations become after breakfast when effort is needed to catch the very unpleasant. Nicotinamide produces less -train or bus, and how much more distress there is side-effects but probably also less vasodilation. if he has to walk against a cold wind. He must The same may be said of testosterone therapy; stop when pain arises, and must curtail his future great claims were made in the United States of

efforts to a point short of the production of this America, but they have not been confirmed in on September 23, 2021 by guest. pain. It is wise to try and break the habit of this this country. Vitamin E has also recently been in pain-producing effort, for by walking slowly the vogue but without convincing testimony. patient may be able to live for years without re- We should also resort to psychotherapy, which quiring va'sodilators; and, when he finds freedom can do much for a hypersensitive patient ; he may in this way, there may appear in time less tendency even lose his angina for a time. to pain. Cardio-omentopexy has gone out of favour, If any special effort is required, or if he knows though some good results were recorded, pre- that a certain effort must be made which usually sumably by supplying fresh channels from the brings on his pain, a tablet of nitroglycerine should vascular tissues of the omentum to the surface of be chewed a few times and allowed to be absorbed the heart. from under the tongue just before such an effort. Thyroidectomy is now little heard of in the The nitroglycerine is more rapidly effective taken treatment of angina. A series of cases published Postgrad Med J: first published as 10.1136/pgmj.24.277.601 on 1 November 1948. Downloaded from 606 POST GRADUATE MEDICAL JOURNAL November 1948 some years ago gave promising results, presumably precordial, for it arises not infrequently in the by lowering the basal metabolism. In a propor- epigastrium, suggesting acute dyspepsia, gall- tion of the cases thyroid feeding became necessary bladder trouble, or a perforated peptic ulcer. In owing to the development of myxoedema, which many cases, however, it is definitely felt over the has also been known to provoke angina. heart, in the left mammary area, or in the mid-line, I am investigating the effects of propyl-thiouracil and it tends to spread to the , ,.arms, but have not yet given it an extensive enough trial. back and nape of neck, just as in angina pectoris. Cervical sympathectomy has given good results. and may be the only It was once believed that abolition of the pain in symptoms and signs of infarction, in which case angina might place the patient in a more serious severe pain may come oh at a later stage. state, since he would make an effort, possibly with There are at times prodromal symptoms of a fatal result, if he did not have the warning pain; indefinite pains under the sternum or of aching in this theory is no more accepted. Smithwick's the left arm; these may exist for as long as I4 operation, by which the lumbar and dorsal days before the attack, and are probably due to a sympathectic ganglia are removed, is of chief value small subendothelial haemorrhage in a coronary for the hypertensive patient with vasomotor angina. vessel leading later to thrombosis. Khellin,7 an Egyptian drug produced by ex- Frequently the first attack has been un- traction of the seeds of a plant (ammi visnaga) recognized and called dyspepsia or pleurodynia, which grows on the shores of the Mediterranean, and has been so slight that the patient has not even has been used for centuries as an antispasmodic sought medical advice. Careful questioning may in the treatment of renal and ureteral colic. elicit the previous history of precordial discomfort Chemical analysis has shown it to be a di-methoxy- on effort. methyl-furano-chromone belonging to the same In contradistinction to angina of effort, the group as the coumarines. Khellin causes a pro- patient with thrombosis tends to be restless in an Protected by copyright. longed relaxation of all the visceral smooth attack. He may move about, trying to secure a muscles, especially the , but it was not until comfortable position. I have known a patient to I945 that it was discovered that khellin acts as a get out of bed and, on her knees, bend forward on coronary vasodilator without affecting the blood the floor, in a partially successful attempt to obtain pressure. The drug can be obtained in this some measure of comfort. In the early stages country from British Drug Houses as a tincture, there are commonly nausea and dyspnoea. and i dr. should be given three times a day; up It has been stated that even where there is no to 3 dr. can be given as a single dose. Khellin also pain there is always dyspnoea. This is not quite has a beneficial effect on bronchial asthma by in- true. I have certainly encountered severe pain ducing relaxation of the bronchial muscles. without respiratory distress. Since infection appears to play a part in coronary disease, eradication of a toxic focus, if possible, Signs should always be advised. Gall-bladder lesions There is evidence usually of the various degrees

are commonly associated with angina; both heart of shock, many very severe with , sweating http://pmj.bmj.com/ and gall-bladder are innervated by the vagus; and and vomiting. Rae Gilchrist8 believes that cholecystectomy is The varies according to the pathological justified in many cases with obvious gall-bladder upset in the myocardium and conducting dyspepsia. A patient with angina usually under- mechanism. One expects to find a weak pulse and goes such an operation well if a skilled anaesthetist lowered blood pressure; yet occasionally the is employed. pulse may be normal, and the condition of the patient fairly good. The pulse, which is usually of

Coronary Thrombosis poor volume, may become slow by damage to the on September 23, 2021 by guest. Etiology. Coronary thrombosis develops usually auriculo-ventricular bundle or to the sinus node, after the age of fifty, but i i cases have been re- producing a wandering pace-maker, or it may be corded between the ages of twenty and thirty, ten rapid from auricular or ventricular tachycardia. of which were in males. There was no syphilitic The abnormalities in auricular rhythm arise es- infection in these ;- a raised blood pressure was pecially when the auricular branches of the found only in one, and signs of arterial disease coronary vessels are involved. Premature beats were absent, apart from coronary atheroma. are commonly encountered. Miller and Woods9 reported one additional case It has often been stated that the blood pressure in this country, in a patient aged twenty-two. falls rapidly in coronary thrombosis; this is true in many cases, but sometimes it takes 12-24 hours Symptoms before it drops. I have known a very dyspnoeic The pain of coronary thrombosis is not always sweating patient with have a blood Postgrad Med J: first published as 10.1136/pgmj.24.277.601 on 1 November 1948. Downloaded from November 1948 MACLEAN: Precordial Pain 607 pressure of I70 systolic, and be-in consequence not then codeine phosphate, i or 2 gr., should be tried. recognized as a case of coronary thrombosis. The If 2 gr. does not relieve the pain sufficiently, no blood pressure in this case dropped to 120 and suc.cess will be attained with larger doses. Hyper- I15 mm. Hg. in 24 hours. duric morphine is also useful for prolonged action. Electrocardiography in difficult cases can give Physeptone is under trial. This new drug (dl. the clue to the diagnosis usually in the three 2 di-methyl-amino 4; 4 diphenyl-heptone-5 one common leads, but occasionally only in the fourth hydrochloride) has spasmolytic and lead. The electrocardiogram can be more easily properties, making it particularly suitable for re- interpreted a few days after the initial attack. lief of pain of visceral origin. It may be ad- Pulmonary congestion must be looked for, and ministered by mouth or by subcutaneous, intra- inquiry made about nocturnal wheezing, as this muscular, or intravenous injection. Weight for portends left ventricular failure. Attention should weight it is equal to morphine in its analgesic be paid to the development of an evanescent peri- action; io mg. of physeptone produces an effect carditis and slight pyrexia with leucocytosis, es- about equal to that of - gr. of morphine, with pecially on the third or fourth day, accompanied by relief of pain for three or four hours; 30 mg. of a raised blood sedimentation rate. physeptone may be required for severe pain. Recurrent precordial pains following a coronary The hypnotic effect and side-effects are less than thrombosis suggest weakening of the cardiac those of the opiates. The relief of pain also muscle and the development of an aneurysm. This combats shock. can be seen by radioscopy, sometimes in an oblique Inhalation of oxygen may be necessary. The view, as a prominent immobile area. funnel method is wasteful. The B.L.B. mask is effective but can be trying to a restless dyspnoeic Prognosis patient; in which case the nasal on a

Patients occasionally die suddenly in a first spectacle frame are best. The oxygen tent is Protected by copyright. attack, but usually they either succumb during the somewhat alarming to the patient and presents first few weeks or make a good recovery tor a difficulty in nursing; it takes time to install and while. needs careful maintenance to prevent sudden Untreated cases seem to develop angina of lowering of oxygen concentrations.. effort more readily than those adequately treated. Of the anticoagulants, heparin has the dis- The amount of shock is a guide to prognosis. advantage of having to be given intravenously and Though the pulse may be good and the condition requires laboratory control by the blood coagula- of the patient fairly good, death may ensue in a tion time. Dicoumarol can be administered by short time from further occlusion. mouth, but again needs control by estimation of Clots forming on the over the in- the prothrombin level. It is slower in action than farcted area are responsible for emboli causing heparin and probably safer. Both may, from occlusion both in systemic and pulmonary circuits, overdosage, suddenly cause haemorrhage in for both ventricles can become involved with one various parts of the body as a result of severe infarct. hypoprothrombinaemia. The risk is particularly Fibrillation carries with it a graver prognosis. great with a patient from coronary http://pmj.bmj.com/ degeneration, where there is liability to subintimal Treatment haemorrhages. I consider the use of this drug is The most essential treatment of coronary contraindicated where there is concomitant hyper- thrombosis is rest in bed and alleviation of the pain tension. From experiments carried out by Peters and shock. For rapid relief of pain there is et al. (1946)10 it was estimated that the embolism nothing so good as an intravenous injection of or mortality rates were considerably reduced.

$ gr. of morphine or omnopon. This is supple- One should aim at giving dicoumarol on al- on September 23, 2021 by guest. mented by hypodermic injections, and as much as ternate weeks, in sufficient doses to lower the ! gr. of morphine may be found necessary, and prothrombin level below 50 per cent. to 6o per morphine may be repeated every few hours in cent. On an average the dosage employed is smaller doses. Omnopon also contains papaverine, approximately ioo mg. a day; patients naturally -which relieves spasm of unstriated muscle, but vary with their reactions and some require as the amount present is too small to be significantly much as I50 mg. a day. I have known the pro- effective; ioo mg. of papaverine is a useful dose. thrombin level to return to normal in seven days Dilaudid has ten times the analgesic action of following the cessation of the administration of the morphine, but the duration of freedom from pain drug. It must be borne in mind that the effects is not so long. This drug should be used where are cumulative with sudden development of there is idiosyncrasy to morphine. Sometimes severe hypoprothrombinaemia; hence the advocacy the dilaudid provokes nausea and vomiting, and of using alternate weeks for the administration Postgrad Med J: first published as 10.1136/pgmj.24.277.601 on 1 November 1948. Downloaded from 6o8 POST GRADUATE MEDICAL JOURNAL Novenibe7 194S of dic zum.arol, as a safeguard in prolonged therapy. slows conduction, and lengthens the refractory Of coronary vasodilators the nitrites lower the period, but it prolongs the prothrombin time. general blood pressure ; this must be avoided Extra-svstoles can usually be abolished by giving when dealing with coronary thrombosis. Papa- quinidine, 3 gr. a day, or papaverine, IOO mg. three verine hydrochloride has little toxic effect and times a day. apparently is not habit-forming. I have used it Mercurial diuretics may be found more bene- with apparent success but have not yet been able ficial than digitalis in congestive failure, provided to obtain the synthetic compound, eupaverine, the kidneys are not diseased. The drug should be which is said to have a greater antispasmodic administered cautiously; because sudden death effect. The dose of papaverine i's usually ioo mg. has taken place after larger doses, especially where two or four times a day. It has practically no the tubules are degenerated. narcotic or depressing effect on the circulation. The patient should be kept. in bed for a month Aminophyllin is one of the xanthine groups; in mild cases, or six weeks in more serious cases. it has popularity as a coronary vasodilator, and Bed-pans are usually essential. Occasionally the McMichael"' has urged its use as an augmentor of patient Qannot manage a bed-pan, and then the in left ventricular failure; he has best procedure is to bring the level of a commode proved this effect by catheterization of the right in line with the bed. The patient slips his legs auricle. This drug is very effective in reducing outside the bed and is easily lifted on to the venous pressure. Certainly patients with left commode. Returning to bed offers no great ventricular failure improve after administration of difficulty. aminophyllin when given either by mouth or After the patient is allowed up, he should stay parenterally, preferably the latter. There is three months away from his usual work. evidence to show, however, that it should not be used in coronary thromBosis during the period of Summary Protected by copyright. shock, since it may produce a fall in blood pressure The common causes of precordial pain are dis- and tachycardia. Intravenous administration cussed with special reference to left-sided infra- should particularly be avoided where a lowering of mammary pain, true angina and coronary blood pressure may produce ill effects. thrombosis. Ventricular tachycardia, strangely enough, ap- The aetiology, diagnosis, prognosis, and treat- pears to be promoted by digitalis therapy. Unless ment are dealt with in of each disease. there are signs sufficiently significant of cardiac failure, digitalis should not be prescribed. Some REFERENCES i. MENDLOWITZ (I945), Amer. Heart Journal. cardiologists say it should always be avoided, es- 2. PARKINSON, J. (I941), 'Effort Syndrome in Soldiers,' pecially since recent investigations have provided British MIedical Journal, April I2, I, p. 54 . 3. LEWIS, T., The Soldiers Heart ' and The Effort Syndrone.' evidence that there is increased coagulability of 4. British Encylopaedia of Medical Practice, 9, 627. 5. Campbell, M., Communications to British Cardiac Society. the blood after digitalis therapy. 6. CASSIDY, M. (I946), ' Harveian Oration on Coronary Disease.> 7. KHELLIN (1946), British Heart Journal, 8, No. 4, 171. Quinidine is the best drug to restore normal Ammi Visnaga in the Treatment of the Anginal Syndrome.' Anrep, Barsoumn, Kenawy and Misrahy. rhythm when auricular fibrillation develops, and it http://pmj.bmj.com/ KHELLIN (I947), Lancet, April 2I, p. 557. 'Therapeutic should be combined with digitalis when accom- Uses of Khellin," by the same authors. 8. GILCHRIST, RAE, Personal communication. panied by congestive failure. It should not be 9. MILLER and WOODS (I943), British Heart Journal, April. used if a conduction defect is present; it retards io. PETERS, et al. (I946), Journal Amer. Medical Association, 130, 398. 'The Action of Theophylline-ethvlene-diamine.' impulse formation at the sino-auricular node, I i. McMICHAEL (I946), British Heart Journal, 8, No. 4, 235. on September 23, 2021 by guest.