Postgrad Med J: first published as 10.1136/pgmj.24.277.601 on 1 November 1948. Downloaded from 6oi PRECORDIAL PAIN 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 heart 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 pneumothorax causing pain functional and organic factors has not been and dyspnoea, especially on exertion, is easily sufficiently emphasized. confused with true angina particularly when there is a partially collapsed left lung difficult to diagnose Common Causes of Chest 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 dysentery. 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 thorax 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 referred pain in fit the bill. There may be no disorderly action, the arm by pressing on the painful site. In many such as tachycardia 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 shoulder-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 pains 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 thrombosis 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 breathing 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. stress at the same time is removed. Mitral stenosis is sometimes accompanied by Infection (focal sepsis) 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 neck. 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 drugs 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 tissue, in both male and acting sedative 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 vomiting. 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 Electrocardiography 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 blood-pressure infrequently patients with tachycardia and overaction of the raised, tachycardia present, and a soft systolic sympathetic supply.