Alfred Martinet.

Clinical diagnosis, case examination and the analysis of symptoms online

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turn, upon the heart either in a direct mechanical manner or
indirectly and reflexly.

The medullary centers, on the one hand, and the myelogang-
lionic nerve paths, on the other, are manifestly influenced alike
by stimuli of psychic and special sensory origin (special sen-
sory stimuli and concepts, images, recollections, emotions, etc.)



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1258



SYMPTOMS.



and by cenesthesic stimuli arising through visceral sensation,
which may be pleasant or unpleasant, or even painful.

The result of all this is an exceedingly close interdependence
of the nervous and circulatory systems, which leads the circu-
lation to react with extreme sensitiveness to any nervous stimu-
lus, whether latent or manifest, conscious or unconscious.
Clearly, the circulation reacts, perhaps more than any other
system, to such incessant nervous traumatism as characterized
the late war. How does it react under such conditions? Actual-
ly, in very diverse fashion, according to the individual.







Heart



Fig. 853. — The nervous system as related
to the circulation. Connections of the vag^us
nerve and the sympathetic system.



In most ostensibly normal persons the neurocardiac, or bet-
ter, neurocirculatory reaction does not extend beyond a condi-
tion of temporary insomnia with accelerated pulse rate, nervous
overexcitability with exaggerated reflexes, transient subjective
alarm and tremor, and a few evanescent vasomotor and secre-
tory manifestations, such as pallor or hot flushes, "goose flesh,"
sweats, temporary diarrhea, etc. Within a few days a more or
less complete tolerance becomes established, the vegetative nerv-
ous system adapts itself to the new conditions, and the cardiac
and vasomotor reactions are reduced to a physiologic minimum.

In others the emotional shock persists, leading to a pro-
tracted or permanent loss of neurocirculatory balance charac-
terized by appearance of the symptoms already mentioned as
constituting the cardiac neurosis.



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PRECORDIAL PAIN. 1259

As in the case of the reserve power of the heart-muscle itself,
so the reserve power of the nervous system in these cases, in-
cluding the capacity of resisting without collapse or even adapt-
ing itself to certain psychophysiologic stresses, varies exceedingly
in different individuals. Some nervous systems resist and adapt
themselves even to the most severe trials, as in the case of the
peasant who was buried for twenty-five days among the debris
in a landslide and whose first words when finally set free were :
"Have the animals been saved?" In other instances the mere
fact of entering the barracks is enough to upset the nervous
system completely.

As a matter of fact, the author saw just as many, if not more
cases of cardiac neurosis among subjects on duty far from the
scenes of military action than among those who had actually
been subjected to the gruelling life at the front.

Huchard used to remark that "the physical heart is lined with
a mental heart." The author some years ago read in an Italian
periodical^ the following naive yet truthful statement concerning
subjects suffering from organic heart disorders and fully conscious
of their infirmity: "Sustained by small doses of digitalis and more
particularly by their valorous spirits, they were able to perform long
and fatiguing missions, even as aviators."

This statement serves as a good paraphrase of Turenne's
sublime remark to his own "beast" or body. "You are trembling,
carcass ; 5'ou would be trembling much more if you knew where
I am going to take you." A penetrating statement this was
from the standpoint of body physiology : We are powerless to
restrain the reflexes of our medullary and spinal vegetative
system, but an "energetic, valorous spirit" can always make its
"beast" of a body advance, even if it is "shivering" and "palpita-
ting" at the time.

Cases even occur in which the stimulus afforded by constant
danger exerts a favorable effect on a preexisting cardiac neurosis.
Such is the personal case of Longhi, the Italian translator of
Stokes's^ classic work, which he describes as follows in his trans-
lation :

1 Mendes : Manuale di medicina chirurgia di guerra, Rome, 1915.

2 Stokes : Malattie del cuore c delV aorta. Prima traduzione italiana del
dott. A. Longhi, Turin, 1858, p. 223.



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1260 SYMPTOMS,

**In the course of the winter of 1848, I was constantly troubled
with palpitations and with the dejection of spirits which neariy
always occurs in heart disorders. Tired of suflFering, I went to
see a distinguished colleague, a specialist in chest disorders,
who told me that I had a hypertrophied heart — not a very serious
condition in itself, but one which is incurable like any other
dependent upon an organic lesion. He prescribed for me a line
of treatment calculated to moderate the heart action and advised
me not to give way to melancholia, as the disorder was not
serious and would allow me to continue living a long time, even
though I might experience slight discomforts from it.

**On the very next day after my visit the revolution broke out
in Milan, and in it I took a rather active part. At the first
gunshots that I saw and heard, my heart began to beat so
strongly that I almost fell to the ground and feared lest I might
be obliged to retire from the fight, not through cowardice, but
from physical weakness. Shortly after, my heart became more
quiet and I found myself drawn into a skirmish in the course
of which I had no opportunity to think of it. Subsequent to
that day I led a very active life at the camp, at first as a volun-
teer and later as a Piedmontese officer of the bersaglieri, without
ever being conscious of my heart action. During the last nine
years I have been in excellent health and have had no precordial
pain. I am convinced that . in 1848 my discomforts were due
principally to a temporary engorgement of the heart resulting"
from the sedentary life I led at tl\at time, spending eight or ten
hours at my desk each day, whereas in my youth I had been
accustomed to a very active life."

The author knows of many neuro-cardiac subjects who no
longer "felt their hearts" after the mobilization, as exemplified
by an artillery officer aged forty-eight who, afflicted with palpita-
tion, precordial pain, and angor, had been living since 1908
obsessed with the fear of aneurysm or angina pectoris and had,
to the author's own knowledge, consulted about ten physicians
in Paris, none of whom had found anything more than neurocardiac
erethism and a moderate degree of hypertrophy. The author
saw him again after he had been one year at the front, including
three months in the trenches with the infantry, at which time he



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PRECORDIAL PAIN, 1261

had entirely forgotten his cardiac discomforts and experienced
merely slight dyspnea on running.

Such a turn of affairs is not exceptional, although, as a mat-
ter of fact, much less common than the converse sequence of
events.

Considering only the heart S3miptoms, the diagnosis between car-
diac neurosis and organic disease is not always easy. Auscultation
may be puzzling and misleading, and various forms of arhythmia
(extrasystoles, sinus arhythmia, etc.) may be observed in either
instance; the same consideration applies to the customary hyper-
trophy of the left ventricle and even more strikingly to the sub-
jective manifestations, vis,, dyspnea on exertion, sensation of con-
striction or actual angina, palpitation, phrenocardia, etc. Yet there
are a number of differential signs:

(a) The first and most important, perhaps, is the neurotic sub-
strate upon which the cardiac neurosis always develops. The car-
diac symptom-group above referred to merely forms part of an
always more or less pronounced neuropathic clinical picture, which
is confirmed, in turn, by the family history and by extracardiac neur-
opathic manifestations, digestive and mental in particular.

(&) The second is the relative frequency and importance of
nocturnal symptoms, such as insomnia, subjective alarm, dyspnea,
and even anginose discomfort and cardiac pseudoasthma, which are
far more common and striking and generally more dramatic than in
subjects with organic heart disease. These characteristic and inter-
esting nocturnal psychosomatic disturbances among neurocardiacs
are in themselves deserving of a thorough study.

(r) The neurocardiovascular instability and lability constituting
an outward expression of abnormal emotivity. The pulse frequency
and blood-pressure exhibit surprising variations from the slightest
disturbing causes. This is often true likewise even of the ausculta-
tory signs which are far from presenting the relatively high degree
of permanency and constancy of those of organic lesions. The
changeableness as regards arhythmias is perhaps even more char-
acteristic (Fig. 854).

(d) There may frequently be noted an absence of the usual
etiologic factors of organic heart conditions, such as rheumatic.



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1262 SYMPTOMS,

typhoid, syphilitic, diphtheritic, and other infections ; plethora and
autointoxication, gout, uricemia, etc.



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Fig. 854.— Cardiac neurosis. H., 1885; 174 cm.; 73.6 kilogr.;
pulse, %; pressures, *'^91oo; viscosity, 4.

The two above tracings were taken about V/i minutes apart. The
first shows premature contractions imparting to the pulse tracing a bi-
geminal , aspect. In the second, all premature contractions have dis-
appeared.

{e) High blood-pressure, systolic as well as diastolic, is noted in
the great majority of cases, in spite of the widely held view to the



S S SItUng
^^••■M Recumbent
I I I Standing
L L L Dipping exercises
1*2*3'. Time in minutes

Blood-pressures
■>■■■■■» Pulse frequency

Fig. 855.— Normal individual. H., 1893; 173 cm.; 70 kilogr.

(Mx = systolic pressure; Mn = diastolic pressure; pressures

given in centimeters of mercury).

contrary. There do occur, however, a few cases of cardiac neurosis
with low blood-pressure; thefee are of two varieties, as the author
proposes to show elsewhere.

(/) Lastly, the functional test of the circulation, which consists
in recording the changes in pulse frequency and systolic and dias-



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PRECORDIAL PAIN. 1263

tolic blood-pressure occurring when the subject rises from recum-
bency to the standing posture as well as after a series of carefully
standardized exercises (20 dips with flexion of the lower extremi-



Fig. 856. — Normal subject as re- Fig. 857. — Heart weakness,

gards the circulation. H., 1893, 165 cm.; 60 kilogr.

H., 1875; 169 cm.; 7:^ kilogr.

ties), demonstrates clearly the exaggerated vasomotor reactions
(reflex overexcitability) in well-marked cases, as well as the con-



Fig. 858. — Cardiac neurosis. Fig. 859. — Cardiac neurosis.

H., 1878, 169 cm.; 67 kilogr. H., 1895, 169 cm.; 64^ kilogr.

siderable margin of reserve myocardial power usually present, as
exemplified in the five annexed illustrations, two of which are from
normal subjects, one from a case of weak heart, and two from car-
diac neurotics (Figs. 855-859).



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1264 SYMPTOMS.

In short, the true, organic heart case, when well compensated,
reacts like a normal individual; when poorly compensated, he
reacts like a case of heart weakness and yields a typical curve de-
noting cardiac insufficiency, vis., a weak blood-pressure reaction, or
even a reversed reaction, with slow return to the original state of
equilibrium.

The cardiac neurotic reacts to an exaggerated extent both as
regards pulse rate and rise of blood-pressure, thereby affording an
outward manifestation of his reflex cardiac and vasomotor over-
excitability; on the other hand, his blood-pressure test shows no
tendency toward myocardial insufficiency.

To be sure, an organic heart ca^e may also be neurotic, and a
true neurotic may be found suffering from cardiac debility, plethora,
or even organic heart disease. In such cases the functional test
alone is frequently sufficient to demonstrate the simultaneous pres-
ence of the two disorders; when used in conjunction with the other
methods of clinical investigation it nearly always enables the ob-
server to distinguish that which attaches to the nervous system from
that which is referable to the circulation, and thus to render a well-
founded prognosis and institute a rational line of treatment based
on a reliable physiopathologic conception of the case.

As far as the patient's availability for military service is con-
cerned, it is not, as will readily be seen, the reserve power of
the heart which is the criterion in the matter, ample reserve
power being, as a rule, available. It is rather the power of
nervous resistance and reaction that should be investigated by
appropriate methods.

The cardiovascular symptom-complex here constitutes but a
single outward manifestation, albeit a highly important one, of
an abnormal psychoneurotic state which dominates and governs
the entire symptomatology as well as the prognosis.



From the foregoing description the reader will, it is hoped,
have been led to realize both the complexity and the relative
simplicity of the diagnostic problem which arises in connection
with the precordial pains. Its solution may, on the whole, be
concretely stated as follows :



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PRECORDIAL PAIN, 1265

1. One should make a careful analysis of the characteristics and
nature of the precordial pain present. This initial procedure will
orient the investigation a priori in some particular direction, but
however searching the analysis may have been, it will never lead to
a sound diagnosis, which can only be established by objective exami-
nation of the patient.

2. Only a complete objective examination (carried out as des-
cribed in the section on Systematized clinical examination) zvill per-
mit of obtaining a more or less prompt solution of the diagnostic
puzzle presented.

In concluding this section it seems advisable to go over the sub-
ject of precordial pain summarily from a different aspect, viz.^ by
starting with the clinical conditions themselves and correlating with
them the various forms of pain.

DISORDERS OF THE HEART AND AORTA.

1. DiBorders of the Cardiac Orifices. Endocarditis.— (a) Dur-
ing the stage of adequate compensation, endocarditis can hardly
be said to cause pain. The frequency with which patients are
unaware of their condition apart from periods of lost compensa-
tion is well known. Yet the possibility must be recognized that
among some nervous and hyperesthetic subjects there may
eventually occur extra-systoles and a sensation as of cardiac
distention, precordial hyperesthesia, or chronic precordialgia.
Mackenzie doubtless had these cases in mind when he wrote:
"Many subjects suffering from an actual heart lesion, such as
may involve the mitral or aortic valve, exhibit evidences of ex-
aggerated precordial sensitiveness. This sort of thing is witnessed

more particularly in women Attacks of very severe

pain in the chest may be experienced. . . . More frequently

there is an unpleasant dull sensation The hyperalgesia

may extend over a very large area and is sometimes very marked.
.... The pain may not be as distressing as in the more severe
instances of angina pectoris, but it persists a longer time.
.... It is often associated with extreme tenderness of the
tissues of the neck or left side of the chest, especially the left
breast. Where the condition of tenderness of the skin and

80



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1266 SYMPTOMS.

muscles has been tested by pinching them ^between the thumb
and forefinger, the part remains sensitive for several hours."

As a niatter of fact, this type of chronic precordialgia has
seemed to the author quite exceptional among well compensated and
non-neurotic cases of endocarditis. It is the rule, on the other hand,
in the cardiac neuroses (see above), hyposphyxia (see Low blood-
pressure), and cardiac insufficiency of whatever cause. In the latter
type of case, the mechanical factor, distention of the heart, seems
to be more particularly concerned in its causation.

(&) During the stage of lost compensation, ranging from a
mere reduction in the reserve power of the heart to actual heart
failure, the picture witnessed is mainly that of the dyspneic
syndrome, from dyspnea on exertion to continuous dyspnea with
more or less pronounced anginoid phenomena and with the usual
signs of impaired heart action, such as orthostatic oliguria,
cyanosis, edema, etc.

2. MyocarditiB. — Here the signs of lost compensation and
cardiac insufficiency already enumerated constitute the main
feature, sometimes with extra-systoles and attaicks of angina.

3. Pericarditis. — Pericarditis may either be completely latent
or be accompanied by pain so slight and evanescent that some pa-
tients pay no attention to it. In the majority of cases pericarditis,
especially when of the "dry*' variety, induces precordial pain which is
localized in the region about the apex or the sternum and is some-
times recurrent with the successive heart-beats. Examination may
demonstrate the presence of tender points the result of radiation
along the phrenic nerve (Gueneau de Musses points), vis., the
lower point, between the ensiform appendix and the border of the
costal cartilages on the left side; the intermediate points, at the
anterointemal portion of the left costal interspaces, along the sternal
border, and the upper point, between the sternal and clavicular heads
of the sternocleidomastoid muscle.

4. Aortitis. — Dilated Aorta. — ^AneiUTsm.— This disorder may
be accompanied by three sorts of pain :

(a) Pain behind the sternum and in the chest, with or with-
out radiation, either, as is most often the case, toward the axilla and



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Precordial pain, 1267

left arm, or toward the right axilla and arm, or toward both arms,
in accordance with the location and size of the aortic deformation.
This pain appears to be mainly of periaortic, neurovascular origin,
being related to an inflammatory condition and distention of the
nerve plexuses around the aorta. ■

(b) Pain as of constriction of the chest, with a squeezing sen-
sation, subjective alarm, a sensation as of impending death, the
whole constituting the essential factor in the syndrome, known as
angina pectoris, while the preceding type, which so often accom-



Fig. 860. — Aortic aneurysm resulting in an elevated pulsating tumor
on the left side.

panics it, is merely an auxiliary factor. This pain seems to be de-
pendent upon deficient functioning of the heart muscle, or more
specifically, an cu:ute insufficiency of the left ventricle, which is
painfully striving to overcome a resistance so marked as to exhaust
its reserve power.

Dyspnea on exertion necessarily accompanies this t^'pe of
pain. The author has noted its absence, however, with the pre-
ceding type, in particular in a case of aneurysm of the ascending
aorta which had eaten away the sternum, formed a pulsating
tumor of the size of a hen's egg, and induced pain on the right
side of the chest radiating to the right axilla and arm.



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1268 SYMPTOMS,

(c) In the stage of lost compensation are added permanent
paroxysmal dyspnea and the usual signs of heart failure.

5. Arteriosclerosis. Disorders Attended with High Blood-
Pressure. — ^The forms of pain experienced in these cases are
very similar "to those referred to in connection with diseases of
the aorta, which, indeed, is itself often involved in the process.
Thus, there occur:



Fig. 861.— Aortic aneurysm with precordial pulsating tumor.

(a) Pain of the type of dyspnea on exertion, which is the
first to appear.

(b) Pain of the type of permanent paroxysmal precordialgia
with dyspnea, subjective alarm, etc., of myocardial origin.

(r) Clawing pains behind the sternum, radiating to the
periaortic region.

Interstitial nephritis and uremia are frequently accompanied
by similar manifestations.

6. Vasomotor Angiospastic Attacks. — The attacks of high
blood-pressure from vasoconstriction induced in some subjects
by overwork, emotional impressions^ or abuse of tobacco may
eventually be accompanied by manifestations of precordial pain



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PRECORDIAL PAIN, 1269

and angina in all respects similar to those already described.
Again it should be emphasized that it is only through the
anamnesis and especially by systematic and thorough clinical
examination that these subjective disturbances can be traced to
their actual causes.

7. Cardiac Neuroses. — This subject has already been referred
to at such length that it seems unnecessary to discuss it again
here. Any form of disturbance may be witnessed, from dyspnea
on exertion to the anginal attack and from extra-systoles to
permanent paroxysmal dyspnea.

DISORDERS OF STRUCTURES ADJACENT TO THE HEART.

1. Pleurisy of the Precordial Diverticulum of the Pleura. —

In this condition there is pain localized at the cardiac apex,
recurring with each heart beat and increased by rather deep
breathing.

In nervous subjects it may lead to the production of reflex
extra-systoles.

2. Aerophagia and Dyspepsia with Gastric Distention. — This is
one of the commonest and yet one of the most frequently over-
looked causes of precordial pain, the individuals concerned often
being neurotic.

Dyspnea on exertion, most marked after meals, feelings of
painful distention in the vicinity of the cardiac apex, extra-
systoles, and attacks of pseudo-angina (angina pectoris of
aerophagics), may be observed. The time of occurrence of the
pain (after meals), the tympany and increased size of Traube*s
space, actual observation of the aerophagia, and the absence of
objective heart signs easily lead to the correct diagnosis if they
are merely thought of.

The orthoradioscopic view shown in Fig. 851 gives a good
idea of the extent to which the heart can be pushed aside by the
air content of the stomach.

3. Gaseous Distention of the Colon. — The rather frequently
encountered accumulation of gas in the splenic flexure brings
about the same symptoms as have already been enumerated, and
through the same process of mechanical displacement of the



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1270 SYMPTOMS,

diaphragm. The patients concerned suffer from spastic constipa-
tion; percussion elicits exaggerated resonance over the colon,
and fluoroscopy sometimes yields an actual view of the gaseous
accumulations. Liquid petrolatum and extract of belladonna are,
as a rule, both diagnostically and therapeutically su<:cessful in
these cases.

4. Mastodynia, when localized in the left breast, may suggest,
albeit only approximately, precordial pain. Any possibility of a
mistake is readily obviated by the most superficial examination,
including palpation of the breast and the observation of diffuse
induration or of small scattered nodules, in conjunction with the
absence of all true cardiac manifestations.

5. Intercostal neuralgia is usually distinguished by virtue of
the three characteristic points of Valleix : Anterior, by the side of
the sternum ; lateral, in the axillary line, and posterior or paraverte-
bral. The neuralgia, moreover, would hardly tend to mislead unless
located exactly in the precordial region. It should be borne in mind
that the term intercostal neuralgia, purely an anatomic expression,
implies nothing as to the cause, which should be sought and may
be either toxic, as in lead fK)isoning, gout, etc.; infectious, as in
rheumatism, typhoid fever, etc.; osseous, as in osteoperiostitis,
Pott's disease, etc. ; pleuro pulmonary, as in pleurisy, pneumonia, etc.,
or even cardiomedic^tinal, as in aortic aneurysm, hypertrophy of the
heart, mediastinal tumor, etc. One should never hesitate to resort
to fluoroscopy in obscure cases.

6. As an exceptional cause, mention should be made of
tabetic pains. Tabes dorsalis is frequently associated, as is well
known, with more or less pronounced pathologic changes in the
aorta, and some tabetics, quite naturally, may experience attacks
of angina pectoris definitely of aortic origin. In at least two
tabetic cases, however, the author has observed paroxysmal and
transient attacks of precordial pain which, since they occurred
in alternation with other paroxysmal attacks of pain referred to



Online LibraryAlfred MartinetClinical diagnosis, case examination and the analysis of symptoms → online text (page 41 of 50)