On Irritable Heart; a Clinical Study of a Form of Functional Cardiac Disorder and its Consequences. By J. M. DaCosta

Carte De Visite, Jacob Da Coasta, MD, c. 1870

THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES

JANUARY 1871.

On Irritable Heart; a Clinical Study of a Form of Func¬ tional Cardiac Disorder and its Consequences. By J. M. Da Costa, M. D., one of the Physicians to the Pennsylvania Hospital, etc.

In this paper I propose to consider a form of cardiac malady common among soldiers, but the study of which is equally interesting to the civil practitioner, on account of its intimate bearing on some obscure or doubtful points of pathology. Much of what I am about to say I could duplicate from the experience of private practice; yet I prefer to let this inquiry remain as it was originally conducted on soldiers during our late war. The observations here collected were made on a series of upwards of three hundred cases. That so large a number were examined is thus explained. Shortly after the establishment of military hospitals in our large cities, I was appointed visiting physician to one in Philadelphia, and there I noticed cases of a peculiar form of functional disorder of the heart, to which I gave the name of irritable heart—a name by which the disorder soon became known both within and without the walls of the hospital. In a communication addressed to the Department in December, 1862, I further called attention to this form of cardiac malady, more particularly as it was observed subsequent to the Peninsular campaign. Afterwards, through the fostering care of the Medical Directors and Inspectors of this Military District, and the liberality and kindly interest of the Department at Washington, most of the cases of the kind were sent to my wards, thus enabling me to study the affection on a large scale. Some of the general facts recognized by this investigation I published in April, 1864, in the first edition of my Medical Diagnosis; but it was a mere outline, and the inquiry being pursued further, I intend here to give the complete results. The publication of the paper so long after the observations were made has been delayed by several causes; partly by want of leisure to analyze critically so large a number of cases; partly because it was my original intention to have offered this contribution as a report to the official history of the war; but chiefly because I found that, as I still from time to time encountered my former patients, I should by waiting have the opportunity of ascertaining the sequel to many of the eases recorded. And this—for reasons which will soon become evident— struck me in the examination of the subject as of particular value...

...Let us now look at the medical aspects of the question.

Symptoms: Having indicated the general history of the malady, let us look in detail at the symptoms, taking for analysis merely the cases which were really of functional kind, or at least did not present decided organic change. And in the whole examination to follow, the remarks apply to this class of cases, unless the contrary is distinctly stated. To investigate the palpitations first.

Palpitation: Both the severity and frequency of the palpitations differed considerably in individual cases. In some (as in Case 208), the attacks lasted several hours and were attended with increased pain in the cardiac region, and under the left shoulder. They were often accompanied by a great deal of distress and were really painful. They occurred at all times of the day and night, varying in frequency from one to five or six attacks, or more, in the twenty-four hours. Yet there were cases that did not have them for days at a time. The seizures were, of course, most readily excited by exertion, and might be then so violent, that the patient would fall to the ground insensible (Case 119). This happened to some on the march (Cases 8 and 45), or field of battle; or they fell in the ranks, and were taken prisoner (Book V., p. .45, and ib. p. 56). But attacks also occurred when the patient was quietly in bed, disturbing his rest, or waking him up (Case 116); and some reported that they were worse at night (Cases 64 and 65), and early morning (Cases 111 and 230). They were very variously, sometimes whimsically, described. The rapid action was often commented on; but a “slow, hard” beat of the heart was also spoken of (Case 202); and one soldier (Book Y., p. 45) likened the cardiac derangement to the “fluttering of a chicken, when taken by the legs.” The fits of palpitation were not only associated with cardiac uneasiness and pain, but in some with headache, dimness of vision, and giddiness. As a rule, the patient could not lie on his left side, for fear of exciting them; but there were those who could lie as well (Case 263), or better on the left side than on the right (Case 253), or who could not lie on either the right side or back (Case 118).

Cardiac Pain: Pain was an almost constant symptom. I cannot recall a single well-marked instance of the complaint in which it was wholly absent; and often it was the first sign of disorder noticed by the patient. It was generally described as occurring in paroxysms, and as sharp and lancinating; a few likened it to a burning sensation (Case 111) or spoke of it as tearing (Case 122), or as burning at times, and at others cutting; or as a “dull sullen” pain, becoming at times acute (Case 69). In some cases, no other pain happened than what occurred in these sharp attacks (as in Case 91), or a mere feeling of uneasiness in the region of the heart existed; but in the large majority there was a substratum, as it were, of discomfort, or of dull heavy pain. In exceptional cases the pain was altogether of this character. Unwonted exercise or exertion would generally produce an attack of sharp pain, and a fit of palpitation was very apt to do the same; but the acute pain also happened without any unusual disturbance of cardiac action, and was, in truth, in rare instances, noticed to be decreased by exercise, or (Cases 92 and 257) to be most severe when the patient was free from palpitation. Deep breathing was stated to make the pain severe, when it was otherwise but slight (Case 15); cough produced (Case 86) a kindred result.

The chief seat of the pain was the lower part of the precordia, particularly near the apex. But it was not always limited to the region of the heart. It was spoken of as shooting to the left axilla, as passing down the left arm (Case 111), which then felt numb; as being present under the left scapula (Case 239); and as radiating from over the heart in all directions (Case 240). The pain was associated with sensitiveness in the cardiac region, and this hyperesthesia was apt to be increased after attacks of palpitation. In cases which ended in recovery, both pain and tenderness gradually left. The pain was not due to intercostal neuralgia. Thus, in Case 92,1 find this description of the pain, “constant heavy feeling over outer and lower part of cardiac region, and slight soreness. Occasionally pain becomes sharp, and when sharp flies to back, and at times to the head. There is also a slight pain, not, however, persistent, an inch or two above inferior angle of scapula. But there are no painful spots over the spine, or in the course of the intercostal nerves, and which might be attributed to intercostal neuralgia.” The latter affection undoubtedly, in some instances, existed, but it was as a complication. Just as pain in the back was occasionally encountered, due to excretion of abnormal ingredients with the urine, to muscular hyperesthesia, to sprains, and to the many causes which give rise to pain in the back in soldiers.

Pulse: The pulse was mostly noted to be very rapid, varying from 100 to 140. In character it was small, and easily compressible; it might or might not exhibit the abrupt or jerking character, which, as we shall presently see, is one of the chief peculiarities of the cardiac impulse, and this might have a certain amount of force which the pulse would lack. In some cases, it was under 90 and was then apt to be fuller; these were, for the most part, the cases passing into cardiac hypertrophy. The pulse exhibits under any circumstances great variations; and especially in a case following an injury to the spine from a falling tree (Case 232) it changed about between 76 to 120, little influenced by any remedy employed. Slight irregularities in the succession of its beats, and, indeed, in the general rhythm, are very common. The pulse is always greatly and rapidly influenced by position. Thus, in one case (Case 12), in which, in the standing posture, it was from 105 to 108, it became shortly after lying down rather less than 80, and fuller, and then gradually rose to 98; in another case (Case 68), it is noted at 124 standing, at 94 lying; in yet another case in which it often reached 140 to 156, but in which, just prior to the observation, it was 128, it was reduced to 82 in the recumbent position j in yet another (Case 193), it was counted as 120 standing, and as 84 when lying down. On the patient remaining for hours in the recumbent position, the pulse would in some eases slowly reach its minimum; in others it rose again by some beats after this posture had been for some time assumed; in all, the immediate effect of the exchange of position was most striking. In the preceding remarks the pulse has been treated of when no palpitations existed at the time. These heightened it. But even when palpitation was not present, the beat at the wrist reached occasionally an extraordinary rapidity. Thus, in one case (Case 303), it was irregular, and seemed like a wave, slightly jerking and with intermissions; counted as accurately as possible, it was not under 192. Gradually, by rest and digitalis, it was reduced to 110...

...In bringing this inquiry to an end, I may be permitted to point out what I believe to be its chief interest and value. To the medical officer it may be of service as investigating a form of cardiac disorder which every severe or protracted campaign is sure to develop. And from a military point of view, further, it enforces the lessons, how important it is not to send back soldiers just convalescent from fevers or other acute maladies, too soon to active work; it suggests that their equipments be such as will not unnecessarily constrict, and thus retard or prevent recovery; that recruits, especially very young ones, be as far as practicable exercised and trained in marches and accustomed to fatigue before they are called upon to undergo the wear and tear of actual warfare; and it exhibits some of the dangers incident to the rapid and incessant manoeuvring of troops. True, on a movement executed on the double-quick may depend the issue of a battle, a forced march may determine the fate of a nation ; and the time can never come when purely physical considerations can forbid, either one or the other, or dictate how often they may be ordered. But every com¬ mander should be made aware that in so using his men he is rendering some unfit for further duty, impairing others, and thus be led to count the cost of the frequent use of such active movements as carefully as he would the holding of a particular part of a line or the assault on another.

But the chief value of this inquiry is after all to the practitioner of medicine. It traces, I venture to hope that I may say establishes, the connection between functional derangement and organic change, and examines the intermediate steps. And it is a contribution, based on trials made on a very extensive scale, towards the accurate knowledge of the action of remedies on the heart; showing, among other points, how a remedy may specially influence one of the elements of disorder without affecting the others.