03. THE CHEST

CHEST + FEMALE BREAST | ABNORMAL CHEST | BREAST FINDINGS | INTERNAL CHEST | ESOPHAGUS | LUNGS | HEART | CHEST PAINS

The chest is a cage of breastbone, ribs and vertebrae, covered with muscles, ligaments and skin. In its external aspect, the chest includes the breasts, ribs, breastbone and upper spine, while internally it houses and protects the heart, lungs and esophagus.

Examination of the External Chest

Stand unclothed to the waist before a full-length mirror, breathe normally and make the following observations:

1. The breastbone has a bony ridge two inches from its top, called the sternal angle, but is otherwise flat from top to bottom where the ribs join. A small tender bone called the "ziphoid process," can be felt here. Deformities may result in pigeon breast, funnel chest or emphysema.
2. The  rib  cage  is  somewhat  bell-shaped,   and  breathing should produce painless and equal rib motion on both sides. Limited or painful motion on one side may mean lung diseases, such as tuberculosis, lung abscess, bronchiectasis, pneumonia, pleurisy, or disease of the rib joint itself— Tietze's Syndrome.
3. In right-handed people, the right shoulder is lower than the left, but a great difference in shoulder level may mean curvature of the spine.
4. With the fingertips, press tightly against the ribs along the sides of the breastbone; painful spots in this region may indicate Tietze's Syndrome, a form of arthritis.

Fig. 33. The chest is a most vital region. The breast, heart, lungs, giant blood vessels, rib cage and swallow­ing tube may cause difficulties here. Disease in this region is hard to hide because pain and other symptoms are noticeable early.

Examination of the Female Chest

1.Stand before the mirror in the usual erect position, with all clothing removed above the waist. Note any difference of the breast in size, shape or position and closely inspect the nipple for possible inversion.

2. Raise both arms straight overhead and lean slightly for­ward. Note in the mirror any denting or bulging irregularity of the skin surface. Look especially for skin areas of "Peau-D-Orange," a finely dimpled orange-like skin.

In lying-down position, elevate the left shoulder blade on a pillow and rest the left arm under the head. With the right hand, feel along radial (wagonwheel spoke) lines, the inner half and then the outer half of the breast. Note any solitary enlargements, lumps or masses.

4. Now place the left arm at the side and again feel along radial lines, the outer and then the inner half of the breast. The normal, rubbery soft breast tissue may have an all-over granular feeling, but nodules, lumps or soreness are defi­nitely abnormal findings.

Abnormal findings of the chest wall and breast

Pigeon Breast. This deformity is a sharply projecting breast­bone resembling the protruding breast of a chicken. It is usually present since childhood, because of rickets or malnutrition, and is of little importance in adult years.

Funnel Chest. A common deformity which is the opposite of pigeon breast. The chest wall has a pushed-in appearance due to the breast bone being pulled back against the spine by muscles and ligaments. Funnel chest may interfere with proper heart and lung action in childhood, but in later years seems to cause very little difficulty.

Fig. 38. Emphysema may produce barrel chest deformity. The chest must be constantly overexpanded to compensate for a thinned out and less effective lung.

Emphysema (Barrel Chest). This enlarged chest is actually a constantly over-expanded chest. The disease consists of thinned out lung tissue, with the chest over expanding in an attempt to better use the remaining lung. This is a debilitating disease con­fined to later age groups. (See Lung Disease).

Lateral Curvature of the Spine (Scoliosis). Curvature of the spine is very common in later years and is possibly the result of childhood rickets, mild poliomyelitis, or foot and leg difficulties.

Work habits also can produce a mild degree of curvature of the spine, but usually lateral curvatures are not even suspected until the deformity is accidentally found in an examination. Sel­dom do they cause any difficulty. (See Deformities of the Spine.)

Breast findings

Breast findings in the over fifty age group revolve about the one consuming thought—cancer. Breast cancer accounts for 15,000 deaths yearly in the United States alone, but it is well worth knowing that most breast difficulties are not cancers.

Absent Breast. This is a very unusual inherited condition. It is not considered a disease and has no significance regarding can­cer of any source.

Extra Breast (Polymastia). This is not a disease, and more of a curiosity than anything else. Usually, only the nipple is present and found below the normal breast in line with the umbilicus. Extra breasts are not indicative of cancer or of other disease, but are usually removed for cosmetic reasons.

Enlargement (hypertrophy). The greatly enlarged breast may present considerable inconvenience, but has no great significance in disease for the present or future.

Nipple Retraction. A retracted nipple existent since breast development has little significance. However, if the nipple re-

Fig. 39. Nipple retraction of many years usually has no signifi­cance, but a recently retracted nip­ple may mean serious disease.

traction has developed recently, especially at fifty years or more, it may have great significance for malignant disease of the breast. It is the first sign of trouble in about 3 percent of the breast cancers, and demands a physician's examination immediately.

Skin Disease of the Nipple. A reddened or itching irritation of the skin immediately about the nipple, may have real disease significance. Such an irritation without apparent cause, lasting longer than two weeks, is possibly the "Paget's Disease," present in one percent of all breast cancers. It should be examined by the physician immediately.

Discharge from the Nipple. A nipple discharge has definite significance, especially in the post-menopausal years. If the dis­charge is not blood stained, it is associated with cancer in ap­proximately three percent of the cases but if the discharge is blood-stained, cancer possibilities rise to nearly fifty percent. The physician's examination is imperative here.

Dimpled Skin. Skin of the breast, with a dimpled orange peel appearance, has great significance in breast disease. If such dim­pling follows trauma, such as an automobile accident, it has little meaning, but dimpling of unexplained origin in the over-fifty age group assumes great importance. It is the first sign of trouble in about one percent of breast cancer. This makes neces­sary the physician's examination.

Lump in the Breast. A lump, mass or nodule is very important in breast disease and is most often discovered accidentally during

Fig. 40. A breast lump is always significant. While only one out of ten lumps is actually serious, only a physician can advise a proper course of action.

routine bathing and dressing. Though ninety percent of all breast lumps are non-cancerous, the remaining ten percent will be found to be of cancerous nature. Breast lumps should be examined by a physician without delay.

Pain in the Breast. Pain is not importantly related to cancerous disease of the breast. Breast difficulties resulting from men­struation, nursing or menopausal changes are likely to cause breast pain, but cancer is notoriously silent and painless until far advanced, and only 2 percent of all cancers are accompanied by pain. However, in the post-menopausal group, pain com­bined with breast lump, nipple discharge or skin changes, de­mands the physician's examination for correct diagnosis.

Examination of the Internal Chest

The internal chest must be examined without the aid of sight or touch. Therefore, the heart, lungs and esophagus are exam­ined by determining how well they are functioning. From their working, we know their condition.

Fig. 41. The open chest reveals the close heart and lung relationship. With no waste space the chest holds and protects the vital organs neces­sary for life. Many chest diseases are now accessible to surgery and other therapy.

Examination of the Esophagus

The function of the esophagus (swallowing tube) is to carry swallowed nourishment from the throat into the stomach, and nearly all esophagus difficulties interfere with the swallowing act.

1. Swallow an ordinary glass of water. Normally done easily, pain or vomiting may be due to a far-advanced obstruction. It is possibly a stricture, diverticulum or cancer.
2. Swallow some soft food, as cereal or mashed potato. These are normally carried down  the esophagus without sensation. The appearance of pain may also indicate an obstruction which is not complete.
3. Swallow a piece of solid food, such as meat or soft rolled bread. Normally, solid food can be felt passing down the esophagus painlessly. Pain with this act may indicate cancer or esophagitis (heartburn).

Diseases of the Esophagus

Cancer of the Esophagus, occurs mostly in men, beyond the fifty-year age level. It grows slowly here to gradually obstruct the esophagus and make swallowing progressively more painful and difficult.

At first, difficulty is slight, but as the growth enlarges, it be­comes more painful to swallow solid foods. To avoid pain, the diet is often changed to soft or liquid items, but with further obstruction of the swallowing tube by the tumor growth, even liquids eventually produce pain in swallowing. Finally, when nothing can be swallowed, and food intake is diminished, weight loss begins, and anemia, fever and extreme weakness soon follow.

Treatment of cancer in the esophagus demands relief from the swallowing obstruction. This can be achieved by surgical means or certain forms of x-ray therapy. Such treatment requires excep­tional skill and should always be placed in the hands of a physi­cian experienced in this field.

Fig. 42. Stricture blocking the esophagus or swallowing tube is usu­ally due to cancer when it begins after the age of 50 but accidental swallowing of lime or other corrosive liquids also may cause stricture. Surgical correction of the stricture is necessary to allow food to pass.

Heartburn (Esophagitis). Heartburn is a sharp, burning chest pain beginning slowly an hour or so after eating and growing to feel eventually like a knot inside of the chest. It is caused by stomach acids backing up into the esophagus, to create a painful irritation and possibly scar formation which may eventually cause stricture destruction of the swallowing tube. The painful irritation is frequently thought to be a heart attack and causes real alarm, but its name "heartburn" is used only because of its chest position, and drinking milk, soda or even plain water pro­duces almost miraculously quick relief. This relief is obtained because the swallowed foods wash down the stomach acids from the esophagus and relieve the irritation.

Heartburn is very simple, both in cause and in temporary treatment, but some of its complications, such as stricture forma­tion, may create complex medical problems requiring skilled medical or surgical treatment.

Fig. 43. Heartburn is caused by stomach acids backing up into the esophagus. The resulting pain is felt in the chest and may become severe. It is often thought to be a heart attack.

Diverticulum of the Esophagus. A diverticulum is a ballooned-out weak spot on the esophagus, usually in the neck level, and may cause swallowing difficulty when food lodges in it. This difficulty does not completely obstruct the swallowing tube, but often goes on giving difficulty for a long time. An x-ray examina­tion is usually required to identify it, and treatment is often un­necessary.

Stricture of the Esophagus. Stricture of the esophagus is simply a narrowing of the swallowing tube, partly obstructing its channel. Strictures in the over fifty group are usually the result of a scar which contracts, as all scars do. The scars are the result of an ulceration type disease of the swallowing tube, possibly from many years of heartburn (esophagitis). Experienced medi­cal attention is necessary for adequate care.

Fig. 45. Esophageal stricture is usually a result of scar contracture, possibly caused in early years by swallowing corrosive liquid. It also may result in later years from long-standing irritation, such as heartburn, and of course, also accompanies cancer and other growths within its lumen.

Examination of the Lungs

1. Inhale and exhale normally while at rest. Normal painless breathing varies between sixteen to twenty breaths per minute. Excessively rapid breathing may be due to a body fever or lung disease, while painful breathing is usually the pain of pleurisy.

Fig. 46. Like tree roots the air way from the throat branches into the spongy lung tissue. Millions of tiny air balloons on its branches are thus connected to the outside; lung expansion sucks in fresh air and contrac­tion forces out exhaust air. The cycle is completed about 20 times per minute for effective respiration. An adult's deepest breath generally has a volume exceeding one gallon of air.

2. Place a palm on each side of the chest, breathe deeply several times. No vibrating or rasping sensation should be felt, no wheezing or gurgling sound should be heard. Detection of such abnormalities may indicate asthma or bronchitis.

3. After breathing deeply several times, exhale completely and then cough until some sputum is obtained. Normal sputum contains no blood flecks under any circumstances. It may mean tuberculosis, lung abscess, or bronchiectasis. 4. Measure the breath volume by exhaling a deep breath com­pletely into a toy balloon. Clamp and push the balloon down into an over-flowing water filled pail. Withdraw the balloon and measure the water necessary to fill up the pail. It should equal at least one gallon—the same as the least normal breathing capacity of the lungs. A total breath volume, markedly under one gallon in volume, may indi­cate heart disease, emphysema or other lung destroying diseases.

Diseases of the lungs

Bronchitis is an inflammation of the bronchial tubes. It fre­quently follows a cold, produces a cough, a sensation of tight­ness in the chest and a mild fever. Bronchitis may occur by it­self, or with other difficulties, such as influenza, a common cold, grippe or allergy.

Bronchiectasis, a chronic lung disease in nearly three percent of all adults, is a stretching, ballooning enlargement of the

Fig. 47. Bronchiectasis, discovered usually in adult years, most often begins in childhood. Definitely present in over 3 per cent of all adults, it is often the cause of many stubborn and longstanding coughs.

bronchial tube with the lungs. It is most often caused by measles and whooping cough infection of early childhood, which weak-

Fig. 48. Pain of pleurisy is caused by the lung "rubbing" against the outer chest wall. In normal breathing, the lung glides in the chest, like a swimmer in water. Brushing against a rough surface (broken ribs) pro­duces knife-like pain.

To and fro motion of the lung is produced by the bellows-like motion of the outer chest wall. Holding the breath, stops the pain, shallow breathing produces only slight pain; deep breathing causes terrific pain. But breathing in any way would not effect pain from the heart.

ens the bronchial tubes and invites troubles which increase with age. Most people with bronchiectasis have very little trouble, but some will cough up daily a cup or more of thick, yellow sputum, which at times is blood-streaked.

This disease is occasionally confused with lung cancer and other diseases. Its successful treatment requires careful guidance by a physician skilled in lung disease.

Pleurisy is not a disease, but rather a chest pain caused by the lung and chest wall rubbing against each other. In ordinary breathing, the smooth glistening lung surface glides painlessly

Fig. 49. Emphysema is a thinned out lung substance in an enlarged chest, found most frequently in senior years. A cause of difficult breath­ing, it can be relieved greatly but not cured.

over the smooth inner chest wall, as the eyelid glides over the eye. However, if either the lung or chest wall become irritated, the gliding action becomes a painful rubbing action, much worse with deep breathing and usually relieved by very shallow breathing. It can be caused by colds of the lungs, bronchitis, or more serious disease, such as cancer, tuberculosis or lung ab­scess. Therefore, severe frequent pleurisy calls for the physi­cian's investigation and diagnosis.

Many pains are called pleurisy but, unless they are definitely related to breathing, they are probably not true pleurisy pains.

Emphysema is a thinning out of the lung tissue itself and is seen only rarely below the age of fifty. When not enough lung tissue remains to carry on easy, effective breathing, more rapid breathing is required for complete full respiration. It is simi­lar to breathing on mountain tops where breathing is difficult because the air is rarified. The accompanying chronic cough in emphysema is a dry hack, usually not productive of any sputum.

Cure of emphysema is not possible, but the physician usually can treat this disease with measures which make breathing much easier.

Lung Abscess is a boil-like pocket of pus in the lungs. It is nearly always accompanied by pleurisy pain, fever and chills,

Fig. 50. Lung abscess is very serious. It can follow lung disease as pneumonia or tuberculosis or may result from inhaled objects like pea­nuts or other small objects.

heavy night sweats, loss of weight and the general appearance of very severe disease. A productive cough usually brings up great quantities of pus and often bloody sputum. Any of these symp­toms should be enough to send a person running to his physician. Lung abscess is a serious infectious disease, possibly following pneumonia or other lung infections, and it requires exceptional medical care for effective treatment.

Tuberculosis is amazingly widespread, but most people who have had this disease are not aware of it. In larger cities where tubercular infections are more common, about 40 percent of the twenty-one year old population has had tuberculosis, whereas, 95 percent of those over fifty years of age have been infected. Happily, very few develop this disease to a noticeable state, and for most of us, only a few scars seen by x-ray remain as evidence of a by-gone, unnoticed disease.

Fig. 51. Lung tuberculosis formerly regarded with horror now seems to be slowly disappearing. Evidence of tuberculosis in the lungs sur­prisingly is found present in over 90 per cent of adults.

The occasional severe case may begin with a cough, possibly productive of sputum, containing flecks of blood. There is char­acteristically mild fever and continuous fatigue along with weight loss. These symptoms are very common and easily dis­regarded, and as a result tuberculosis is not often suspected. It is discovered most often in routine examinations—another reason for thorough and regular examination—especially if we have been in contact with anyone found to have tuberculosis.

Asthma, the devil's disease, is due to temporary closure of the small air passages, in the deep lung tissues where effective breathing takes place.

The difficulties in asthma are:

1. Labored, wheezing breathing.
2. Spasms of coughing, between gasps of air.
3. Choking, caused by the wheezing and coughing, often caus­ing bluish coloration in the skin—a sign of lack of air.

Asthmatics, over fifty years of age, usually have had attacks through the years since childhood and are aware that their asthma is worse during colds, emotional excitement, periods of great effort and occasionally seasons of allergy. Many people learn to live with their disease and usually find relief in inhalers and certain drugs. The individual asthmatic can help himself considerably, but the greatest relief from unnecessary suffering is found under the guidance of a physician well schooled in this problem.

Cancer of the Lung is a most important disease after the age of fifty. Much more common in men than in women, its occur­rence rate is increasing faster than any other kind of cancer. The cause remains unknown but tremendous evidence points to tobacco's guilt, although automobile exhaust fumes and other gases are also strongly suspected.

Cancer in the lung often begins with an innocent cough which may be dry or productive of blood streaked sputum. The pos­sible, noticeable difficulties are wheezing, pain in the chest, hoarseness and weight loss, all indicating the possible presence of a serious disease.

The diagnosis of lung cancer is made with an x-ray of the chest, and often aided by other kinds of examination to more accurately pinpoint this disease. Effective treatment of any lung cancer demands early detection, best done by the routine physi­cal examination, including a chest x-ray each year by a compe­tent physician.

Pneumonia. This is an infection and inflammation of the lung itself. The two types are the commonly seen virus pneumonia and the more serious bacterial pneumonia.

Virus pneumonia, not necessarily associated with any bacteria, is a mild lung infection and just about everyone contracting it eventually recovers. The disease is often considered a deep seated cold, accompanied by dry, hacking cough, a moderate temperature and great fatigue. Many physicians treat virus pneumonia with rest, diet, aspirin compounds and occasionally antibiotics. Without a chest x-ray, this diagnosis is difficult to make, and is sometimes entirely overlooked. Happily however, nearly all patients eventually recover from virus pneumonia anyway.

In the more serious bacterial pneumonia infection, the lung tissue becomes solid with bacteria, pus, blood and swollen lung tissue. The symptoms produced are high fever, severe pleurisy pains in the chest and considerable coughing, productive eventu­ally of a bloody or rust-colored sputum. Treatment of bacterial pneumonia requires x-ray diagnosis, considerable supportive treatment, such as adequate fluids, rest, and usually powerful antibiotics.

Pneumonia was once a deadly disease but now it succumbs readily to effective antibiotics in the hands of the physician. Though treatment is now effective, this disease should never be taken lightly, as it still brings about many deaths each year and readily causes significant and permanent body damage.

Examination of the Heart

1.Sit motionless and determine if the heart action is noticeable. Normally, it cannot be felt and sensations within the chest usually described as flip flopping are regarded as palpitations. They are often caused by extrasystole or heart block irregularity.

2.Press the right palm just below the left breast and lean forward against a solid wall, and the normal heart beat can be felt. Heart beat sensations of a sawing nature (thrill) are definitely abnormal and may represent mechanical difficulties which produce murmurs.

3.Count the pulse rate (same as heart rate) at the wrist, normally, sixty to eighty beats per minute. A resting pulse rate above 100 may represent tachycardia. An irregular beat, unlike the steady beat of marching feet, is a heart beat irregularity.

4.Press one finger firmly against the leg just above the ankle.Quickly withdraw the finger and a deep dent left in the leg which lasts for a minute, may indicate the inadequate cir­culation of partial heart failure.

Fig. 52. The blood pump of the body is nearly in the center of the chest and is larger than imagined. Weighing less than a pound it lies on its side looking little like the typical "valentine" heart. It pumps 10 tons of blood daily and beats over a million times every 10 days. The heart works hard enough each day to lift you 1000 feet straight up in the air; it is expected nowadays to keep working for 70 years "plus." The heart must receive enough of the blood it pumps or it "cries out" with pain. The heart or coronary arteries return to the heart from the aorta the main blood vessel from the heart. Chest pain shortness of breath and palpitation (feeling the heart bounce) are signals of heart trouble. Diseases of the heart annually account for half the deaths in the U.S.

5. Inhale and exhale rapidly several times and finally hold a deep breath. If the breath can easily be held for a full minute, serious heart disease is improbable.

Diseases of the heart

Heart difficulties are not all serious and are often interpreted in terms of noticeable heart action, breathing difficulty, chest pain or swelling of the ankles.

Heart Murmurs. Heart valves which open and close imper­fectly may give rise to a sound similar to the whistling of wind

Fig. 53. The heart valve normally closes perfectly but a diseased valve cannot close correctly. An imperfectly closing valve is the cause of heart murmur heard during heart beat. The tricuspid valve has three lips the bicuspid two lips.

rushing through a partially closed doorway. When valves open widely and blood flows freely, there is no sound, but when heart valves are deformed or do not close completely, onrushing blood creates a "murmur."

There are different types of murmurs in the heart, some have serious significance, while others are of little importance. If a heart murmur is known to exist, explanation and expert guid­ance from an experienced physician in this field becomes ad­visable.

Heartbeat Irregularity. The regular heartbeat is similar to the

SINUS ARRYTHMIA

(BREATHING   IRREGULARITY)
BREATHING IN      BREATHING OUT

Fig. 54. Sinus arrythmia is a slowing of the heart rate when breathing out and a quickening of the rate when breathing in. It is caused by the rate of blood return to the heart as it is influenced by expansion and con­traction of the heart.

steady rhythm of marching feet and anything disturbing this steady beat is called an irregularity. Irregularities are very com­mon, some are important and some are not.

Sinus Arrhythmia (Breathing Irregularity). This is the most common heartbeat irregularity. It means a heart rate increase as we breathe in, and a decrease as we breathe out. It is found to some degree in everybody, and is not thought of as a disease.

Extrasystole (Extra Fast Heartbeat). This is a single heartbeat out of step, and often feels like a flip-flopping within the chest. In this irregularity, one heartbeat arrives ahead of step and is followed by a slight pause, awaiting the next beat back in reg­ular step. The heart then goes on beating regularly until an­other extrasystole appears in the heartbeat order.

EXTRASYSTOLI

(OCCASIONAL FAST BEAT)

Fig. 55. Extrasystoli is irregularity of the heart beat. It is due to an occasional beat stepping in ahead of schedule, creating an apparent pause before the next regular beat. A common irregularity, it is not necessarily serious.

They frequently follow heavy eating, smoking, exercise or other excitement, and often are noticed when lying down in bed. Heavy tension and over-indulgence in tobacco are suspected as the chief causes of this irregularity.

While an occasional extrasystole is usually not serious, the ex­perienced physician's opinion on this matter will help to dis­cover any possibly serious underlying difficulties.

Tachycardia (Fast Heart). In this condition, the heartbeat rate speeds up two or three times the normal rate. It is often found in young people with no serious heart disease, but who are frequently bothered with these uncomfortable and terrifying attacks. Relief is often obtained by taking and holding a deep breath or firmly massaging the side of the neck and still another

TACHYCARDIA (FAST HEART)

Fig. 56. Tachycardia is temporary rapid speed up of the heart beat. It may be twice the normal rate, start up at any time and last minutes or hours, stopping as suddenly as it started.

way is drinking something cold. While tachycardia is usually not serious, there may be some important underlying factors in­volved and if the attacks are frequent, the physician should be consulted to follow any necessary precautions.

Fibrillation of the Heart. This means a loss of all regularity to the heartbeat and the heart rate becomes similar to falling rain drops. If the heartbeat is anything like marching feet, it is not fibrillation.

FIBRILLATION

Fig. 57. Fibrillation is heart beat irregularity with no semblance of "bouncing ball" rhythm. Irregular as rain on the roof, it may go on for years, with questionable significance.

This heartbeat irregularity can be temporary or permanent, and is often related to other disease, possibly within the heart as in rheumatic heart disease, or completely outside of the heart, as in thyroid disease. Sometimes fibrillation can go on for years with no apparent ill effect, but certain dangers are constantly present in these hearts. Regaining a regular heart beat is possible if associated disease is cured, otherwise useful drugs are available which may greatly benefit the heart action in spite of continued fibrillation.

Heart Block. This is easily identified. The heartbeat is reg­ular like marching feet, but one beat is missed out of a regular sequence. The missed beat may be noticed after every twenty-four regular beats, or possibly after every five beats; the more

HEART BLOCK

Fig. 58. Heart block is heart beat irregularity in which a single heart beat is blocked out every fourth beat, third beat or any regular number of beats.

frequent the missed beat, the more serious the heart block. This is a disease of senior years, and the physician's help should be of great value here.

Angina Pectoris. Angina pectoris is a heart pain of a come and go nature, varying from a mild pressure sensation to an agoniz­ing chest pain, and frequently extending into the left arm. It is brought on by conditions forcing the heart to work harder, as effort, excitement, heavy meals, and cold weather. It is relieved by rest.

The exertion that will cause chest pain to appear is usually known to the patient. Thus, he can predict that walking up a two block hill will almost routinely bring about chest pain and require a five minute rest for relief.

Angina pain is a cry from the heart muscle for more blood. The normal heart artery can carry an excess of blood to the hard-working heart muscle, but the arteries in angina are con­siderably closed by spasms or hardening arteriosclerotic disease. Heavy emotion, high tension and aged arteries are all suspected of magnifying pain of angina pectoris, so it is wise to eliminate excitement, and to spare the heart any sudden periods of great work. In angina pectoris, the head must rule the heart.

The physician frequently prescribes certain drugs effective in relief of pain by relieving narrowing spasm in the heart artery.

Heart Failure {Congestive Failure, Dropsy). The normal heart pumps more than enough blood for all body functions, but the diseased heart may not be able to pump the minimum required by the body, and then heart failure is said to be occurring. The heart does not fail all at once but by slow degrees, and is usually

Fig. 59. Heart or anginal pain (in shaded region) is variable, generally left-sided, also in the left arm. Pain distribution is due to nerve arrange­ments to and from the heart region. Pain in the left arm is, therefore, usually more significant than pain in the right arm.

marked by increasing shortness of breath, pressure in the chest and a frequent flip-flopping sensation of the heart. Water logging of the body may be noticeable as heart failure begins and body water begins gravitating down into the lower legs. Normal size legs in the morning then become considerably swollen by evening.

Caused by diseases which greatly weaken the heart muscle, heart failure is often a result of childhood rheumatic fever, or in later years, arteriosclerosis of the heart arteries themselves.

The physician can markedly strengthen the weakened heart with digitalis-like drugs, and other drugs effective in combating the heart failure, to promote a stronger normal heart function.

Heart Attack (Coronary Occlusion, A Coronary). Heart attack means a sudden block of a coronary (heart) artery by a blood clot stopping the blood flow to a quickly damaged portion of the heart muscle. If this damage is slight, it might even go un­noticed, but if damage to the heart is severe, it is likely to stop beating, with death following quickly. It is apparent that there are many degrees of severity in heart attacks.

The pain in the chest can be excruciating, causing nausea, weakness, pallor and perspiration similar to extreme exhaustion, and the patient may collapse. A heart attack is nearly always suspected, but cannot be known with accuracy until an elec­trocardiogram has been taken. Possible candidates for heart attack are the fifty-year-old (and younger) individuals, including those who have never known any discomforts or disease. Most vulnerable of all is the person with already existing heart disease who must take extra precaution to spare his heart, and promote as strong and healthy a heart muscle as possible.

The person who dies a few moments after his heart attack could not benefit from any known treatment, but for those who live through the early attack, the physician, with marvelous drugs, can greatly magnify chances of survival. A yearly check-up of the heart condition in all people of fifty years is necessary for sane regard of good health.

Hypertension (high blood pressure)

This is a disease affecting the heart which becomes most noticeable after the age of fifty. Although it is seen at much younger ages, of our 60,000,000 citizens at this age, more than one in every ten has a blood pressure problem and women out­number the men two to one. It is fact that more people die partly or directly because of high blood pressure than all types of can­cers combined.

Fig. 60. Blood pressure in an artery is similar to water pressure in a hose. It is measured by the amount of weight necessary to stop the flow by squeezing the artery shut—exactly like stepping on a hose to shut off the water.

An understanding of blood pressure is basically simple. It is the pressure from the heart necessary to drive blood through our blood vessels and it varies with conditions such as work or rest. We recognize a high and low pressure of a wave corresponding to each heart beat and we determine what is normal pressure from the average of many thousands of people.

Experience teaches us that blood pressure much higher than normal frequently results in a limitation of body activity through easy fatigue, poor endurance and lack of a healthy re­serve. There are, of course, many other difficulties resulting from high blood pressure, including headache, dizziness, short­ness of breath, palpitation and kidney disease. Also in the back­ground of high blood pressure disease hover the spectres of stroke and heart failure.

Fig. 61. The size of the heart and large arteries may be greatly en­larged with high blood pressure. The normal heart weight of 300 grams can enlarge to 1000 grams. When pressure rises too high some arteries may burst, and in the brain this is called a stroke. Nearly half of all definite stroke victims die within two weeks.

The cause of elevated blood pressure for about one-fifth of all cases is from known disease such as arteriosclerosis, adrenal gland difficulty and thyroid disease. Most high blood pressure however, is called essential hypertension, because the cause is yet to be discovered.

Fig. 62. The evidence points heavily to salt as an important factor in high blood pressure. Although its exact role is unknown, the hypersensitive patient often does much better when salt is cut down in the diet.

The treatment of high blood pressure consists principally in the physician's guidance in diet restriction, weight determina­tion, drug therapy and continual observation. In no other medical disease is the close cooperation between doctor and patient so richly rewarded as in the treatment of high blood pressure. Like the fitting of shoes, the physician must guide the blood pressure patient into a practical, effective and tolerable manner of treatment, which the patient will accept and carry on from day to day for complete control of this most significant disease.

Chest Pains

When pain strikes in the chest, one question leaps to the fore­ground. Is the pain coming from the heart or somewhere else? It is the same for all people including doctors themselves, who

Fig. 63. Chest pain strikes fear of heart trouble and possible sudden death. Most pain in this region is not from the heart, however, but from several other distinct causes. It is important not to disregard this pain which may be a warning of more serious possibilities ahead.

as a group seem particularly singled out for heart difficulties.

There is marked fear of chest pain today because most people have the idea that a heart attack is a painful story. This idea, usually correct, is an impression gleaned from newspapers, neighbors and educational literature. However, most people have only a portion of the true story, and they probably differ quite a bit one from another.

A well-rounded idea of chest pains is as important to us today as the much publicized danger points of cancer, because heart disease is the greatest killer in the United States today. Its chief symptom, chest pain, more than any other symptom, will alert an individual to seek expert medical advice regarding the status of his heart. It should, of course, be obvious that the greatest importance in chest pain is the opinion of a competent physi­cian. He is skilled in interpreting pain and associated findings into an exact diagnosis, and will direct the treatment possibly for a severe heart attack or perhaps dismiss the difficulty as due to some less serious cause, such as heartburn.

In studying chest pain possibilities, we know that a slight pain for one of us might be described as unbearable by someone else. Also, we must realize that the severity of chest pain does not always reflect exactly the seriousness of the underlying dis­ease. Chest pain, however, may never be taken lightly, and all too often, severe chest pain is regarded with a shrug, as caused by indigestion. This tragic error has aided many useful in­telligent people to slip into eternity far before their time. The story is frequently heard after it is too late, "He thought it was only a little indigestion."

What can we know of chest pains for our own benefit? Let us look at chest pain generally to observe a few fundamental facts about it. First of all, most chest pains are not caused by the heart. Most chest pains have their cause in either:

1. The breathing mechanism.
2. The muscle, ligament and bone of the chest.
3. Inflammation or tumor growth.
4. The swallowing tube (esophagus).
5. Pain originating from the abdomen.N
6. erves (often called effort syndrome or neurocirculatory asthenia).

Heart pain can best be appreciated if the other chest pain sources are studied first. So let us first examine pain caused by the breathing mechanism. Pleurisy pain is the most common-type pain felt when the lungs or bronchial tubes are diseased. If pain is definitely related to the movement of breathing in and out, and ceases when breathing is stopped, it is nearly always the pain of pleurisy.

What causes pleurisy pain? Ordinarily, the lungs, covered by a smooth, wet envelope called the pleura, slide over a similar sur­face on the inside of the chest wall with each breath. If either of these smooth surfaces is irritated, inflammed or roughened in any way, the gliding movements of breathing cause enough friction to bring about pain (pleural pain). Pleurisy may be caused by various lung disorders such as pneumonia, tuberculosis, lung abscess, a blood clot in the lungs (infarction), pus in between the lung and chest wall (empyema), fractured ribs, and other difficulties.

Pleurisy pain is thoroughly easy to understand and to identify when it occurs. It is not the kind of pain produced by the heart. It is well to know that heart disease is rarely accompanied by any pleural pain.

Let us study next, pain in the chest originating from bone, muscle and ligament of the chest wall. Pain of this sort is usually regularly produced by certain movements of the body, such as sneezing, bending, coughing or lifting. These pains are likely to be of arthritic origin or pressure on nerve roots from the spine, around the neck and chest, and commonly respond to heat and Aspirin.

Pain and soreness of ligaments is common, especially follow­ing unusual or heavy work. Such work just before aches and pains begin, usually tells the patient what type of difficulty has brought about his pain.

Also, pain and soreness of muscles and ligaments which seems related to damp or cold weather, is referred to frequently as myalgia, neuralgia, fibrositis and other names. Such difficulties

Fig. 64. Muscle Pain. Pains, aches and soreness of muscles are made worse if the sore muscles are worked. Usually a "come and go" story, muscle pain is related to cold, damp weather, and may be relieved by aspirin and heat application. If—as a test—pain is produced when the involved muscle is pressed, it cannot be coming from the heart.

seldom worry a person that the pain may be originating in the heart.

Pain sometimes found in the front of the chest and thought to be heart pain is called Tietze's Syndrome. This is a pain pro­duced from an irritation or soreness of the cartilage joints, join­ing the front of the ribs to the breastbone or sternum. This pain is produced easily by pressing on the ribs in front of the chest.It can never be mistaken for heart pain because we will now know that pain produced by pressing on any part of the chest wall, never originates from the heart.

Chest pain due to breast inflammation, irritation or tumor growth is fairly easy to recognize. Here the breast, as the of­fender, presents painful breast situations which may come and go for all women, and occasionally in men. This pain and sore­ness tends to be steady, with occasional periods of increased trouble. These sensations, though considered chest pain, usually worry people more about cancer than about heart disease. It is

Fig. 65. Chest Wall Pain. Pain of the front chest wall—referred to as Tietze's Syndrome—is fairly common. Like any other joint, the cartilage joining the rib to the breast bone may become very painful; unlike other joints, it cannot be rested unless breathing is stopped. There is a definite sore spot (usually over the heart) and pressing on it causes great pain. This eliminates the possibility of heart pain which cannot be produced by pressing anywhere on the chest wall.

a comforting fact to know that painful breasts are rarely any in­dications of cancer, and even less often caused by heart disease.
Of interest is one particular form of pain in the male breast. It is breast pain caused by administration of hormone, for the treatment of cancer or bone difficulty elsewhere in the body. Knowledge of the foregoing hormonal treatment usually clears up the issue for the patient and the doctor, so that he may know the pain is not originating in the heart.

Shingles (Herpes Zoster) is a burning, aching pain usually on one side of the chest wall. We know where the pain is coming from as soon as we recognize shingles, for a skin eruption usually

Fig. 66. Breast Pain. Caused by several different disease possibilities, pain in the breast probably will afflict almost all women at some time or other. By comparison the undeveloped male breast is only seldom the seat of any trouble. Most people are surprised to learn that breast pain hardly ever means cancer, but that pain usually means a benign (non-malignant) condition, like "cystic disease of the breast." Breast pain never means heart disease.

shows up over the course of the pain in just a few days to a week. Also, in shingles, pain is produced by pressing with the finger along the course of the nerve, between the ribs, and we know now that any kind of pain produced by pressing against the chest wall, in any area, is never recognized as pain originating from the heart.

Chest pain coming from tumor growths of the chest wall itself, is extremely rare. Because of the rarity and difficulty in attempt­ing to describe such tumor growths, we will only say that the enlargement of the tumor will certainly be noticed much before the pain. This alone should bring the patient to his physician.

Chest pain of great importance may originate from the swal­lowing tube (esophagus) running from the throat to the stomach.

Fig. 67. Shingles Pain. Often called Herpes Zoster, the pain of shingles is due to soreness of a nerve itself. The pain typically burns, aches and stabs, and follows the nerve route between the ribs (generally the 4th, 5th and 6th ribs). The usual shingles skin eruption may appear within a few days, itching furiously and inviting constant scratching.

This type of pain is worthy of special study in the age-fifty group, because it is so common and so often severe.

Real pain of the esophagus which might be confused with heart pain, is nearly always that of heartburn (reflux-esophagitis or achalasia). In heartburn, the acids normally in the stomach back up into the esophagus and cause intense burning pain. Being situated deep in the chest, in the heart region, this chest pain is named heartburn, a well-known name among chest pains.

Heartburn may be very severe, but can usually be identified by several characteristics. It often becomes much worse soon after eating; it is sometimes relieved by standing up; it is fre­quently made worse by bending forward or by lying down. Heartburn is suddenly relieved with a drink of soda water, or sometimes even plain water, and this miraculously sudden re­lief is felt because the irritating acid in the esophagus was washed down into the stomach again.

This is a very common chest pain, and is often thought to be

Fig. 68. The name heartburn is misleading. The burning pain has nothing to do with the heart but is felt in the area thought of as the "heart." The source of "heartburn" pain is the swallowing tube (esopha­gus) which is "burned" by stomach acids washing upward toward the mouth. These stomach acids irritate the esophagus causing intense pain. The patient may fear a heart attack but is relieved when the acid is washed down with water soda or milk.

coming from the heart. But when it has been present for a while, a person usually thinks of it as his "indigestion." There is only one real danger here. When a person who has been accustomed to the pain of heartburn, really does have some heart difficulty, he is likely to confuse the two and to regard the real heart pain also as "indigestion."

Pain in the chest may have its cause in the abdomen. These pains are relatively uncommon and are usually identified by the fact that they occur the same time after meals, or after certain types of food. The stomach, gallbladder, pancreas and some dif­ficulties of the colon (discussed in another chapter) occasionally cause chest pain. It may take a careful physical examination on the part of the physician, to reveal the source of the pain, which will eventually be found to be outside of the chest itself.

As in all parts of the body, chest pain may be more imagined than real. This type of pain occurs in a group of people who have hypnotized themselves to think that they have heart trouble. Many explanations for this type of "heart trouble," eventually come to be regarded as a lazy person's excuse for his

Fig. 69. Heart pain varies greatly in intensity and duration. Its loca­tion, however, follows a fairly typical pattern involving the left chest, neck and inner surface of the left arm.

unwillingness to work, or to explain his failure at a certain work. Most of these people with imagined chest pain, who complain of heart disease for years, have had several good doctors tell them, that there is nothing wrong. However, the patient fears losing his good excuse (heart disease), above anything else, and therefore, the complaint goes on and on.

These people rarely die of heart disease, but it may take a physician skilled in psychiatry to uncover this patient's problem.

Heart Pain—The usual cause of heart pain is directly due to a too-small supply of blood to the muscle of the heart itself. This is hard to understand when we know that all of the body blood goes through the heart itself to be circulated. The fact is, however, that the heart muscle actually is receiving an under-supply of this blood for itself. The explanation is as follows: The heart pumps the blood out into the main artery called the aorta, which has small branch arteries directed backward, to pierce and feed the muscular wall of the heart. These heart arteries are the coronary arteries, and if for any reason they cannot carry the supply of blood required by the heart muscle at the moment, the blood hungry heart cries out in the only way it can—with pain. This makes heart pain understandable.

When pain in the chest is caused by the heart, it is nearly always felt just in back of the breastbone, but it may travel down toward the abdomen, up into the neck, or out through either shoulder or arm. The most common path for radiation of pain seems to be into and down the left arm. Heart pain may vary considerably in amount and length of time.

While the production of heart pain is always due to a lack of blood to the heart muscle, the mechanics producing this lowered supply of blood may differ, and therein is created the several different types of heart disease attended by chest pain.

1. Heart Attack—sometimes called: "Coronary Thrombosis," "Myocardial Infarction," or "A Coronary."
2. Arteriosclerosis    sometimes    called:    "Coronary    Insufficiency."
3. Angina Pectoris known as: "Temporary Ischemia."

Heart Attack Pain. What can we say of the pain in the "heart
attack?" We know now that all heart pain is due to a lack of blood supply to the heart muscle. In the heart attack, a blood clot has plugged one of the heart coronary arteries to reduce the blood supply. For this reason the heart attack is sometimes called a "coronary" or "coronary thrombosis." If most of the plugged

Fig. 70. Pain of Heart Attack. Pain is felt in the heart muscle when it is deprived of its blood supply. The supply is reduced or blocked by a clot in the heart (coronary) artery. "Coronary thrombosis"—or "coronary" for short—means a heart artery is blocked by a blood clot. Almost in­variably, pain is felt behind the breast bone. From there it may appear to travel into the arms or neck. Heart attack also has other symptoms, such as difficulty in getting the breath (dyspnea), a feeling of pressure on the chest (orthopnea), and perhaps nausea and vomiting.

heart artery is still functioning well, with the blood clot plug out near its end, then only a small portion of heart muscle will be deprived of its blood supply, and the pain will not be very severe. A new pathway of small arteries called a collateral circu­lation, usually will build up about this area in approximately six weeks to two months. Thus, a mild coronary goes on to re­covery. We may remember national figures or personal friends who have gone through such an experience.

The other side of the picture in heart attack is more forebod­ing. If one of the heart arteries is plugged with a blood clot near its beginning, a large portion of heart muscle will be deprived of blood. In this case a major portion of the heart cannot go on, and the patient will die. In such cases, the frequent story is that "he dropped dead on the spot."

Suppose, however, a heart artery is plugged with a blood clot somewhere between its beginning and end, approximately in its middle. In this case, everything depends upon how much heart muscle is put out of function by lack of blood supply. If the remaining, well-nourished heart can do the whole job, and will also lend some of its blood supply to the deprived heart region, the patient probably will go on to recovery. Otherwise, this patient's outlook is poor.

The pain in a heart attack is obviously present only while the patient is still conscious, but in heart victims who recover, severe pain in the chest may last for a day or more, accompanied by other symptoms as well.

Modern medicine can do much to save the heart attack pa­tient, but obviously, very little when his future is measured in minutes. Probably the best thing the patient with a severe heart attack can have is a clear conscience as he is about to meet the Master Physician very shortly.

Arteriosclerotic Heart Disease Pain. Arteriosclerosis is our second type of heart disease to cause chest pain. In this disease, the heart artery probably along with other arteries of the body, has a much thickened and roughened wall, which may greatly reduce the inside channel of the artery. This narrowed coronary artery channel allows a flow of blood through it which is insuf­ficient to maintain the heart in a satisfactory and well-nourished state. We can now see why the name "coronary insufficiency" is sometimes used instead of arteriosclerotic heart disease.

Arteriosclerosis causes a good deal of narrowing in the heart artery of some people, and very little in others. Since the insuffi­ciency of blood to the heart will therefore vary, the pain pro­duced will also vary. With just a little arteriosclerosis, heart pain

Fig. 71. Pain of Arteriosclerosis. Pain is felt in the heart muscle be­cause the blood supply is greatly reduced by the diseased and narrowed heart artery. The disease is termed arteriosclerosis (artery-sclerosis), which gradually closes and narrows the artery until it can't carry enough blood. The undersupply of blood to the heart (ischemia) results in pain of possibly severe degree.

may not be noticed at all unless great exertion or hard work is undertaken. Then, the hard-working heart may demand two "or three times more blood, but if its narrowed arteries cannot de­liver this great an increase, pain will develop. We are allowed therefore, to work our hearts only in proportion to the size of our "coronaries," and their ability to carry blood, because with further exertion, pain will be definitely felt. A few people have such severe arteriosclerosis, that their narrowed heart arteries cannot deliver sufficient blood to the heart even while they are resting, and when even rest itself is too much effort for the heart "rest pain" in the chest results. Immediate medical care is neces­sary for these hearts or the future is dark indeed.

Angina Pectoris Pain. Angina Pectoris is a well-known heart chest pain. Like all heart pain, it is due to heart arteries that do not bring enough blood to the heart muscle while it is working. The pain is felt when the heart is working hard and demanding more blood, such as walking uphill, walking or running too fast, and during severe emotional upsets.

The heart artery in angina pectoris is narrow because of a

Fig. 72. Pain of Angina Pectoris. Pain is felt in the heart muscle be­cause its blood supply is reduced by a heart artery which is clamped down or in "spasm." "Spasm," which narrows or closes the artery, is related to work (e.g., walking up hill), tobacco and emotional upset. Often a little alcohol helps to relax the condition. Tobacco is restricted in nearly all cases.

temporary spasm of the artery itself and this temporary feature distinguishes angina from the permanently narrowed artery of arteriosclerosis. Relaxing this constricted artery, and allowing it to dilate, allows more blood to be delivered to the heart muscle again and the pain of angina pectoris is relieved.

Ordinarily, patients with angina pectoris have a so-called emo­tional nature, with possibly intensified spasms of the artery. Be­cause of this, they are usually advised against factors such as tobacco, which stimulates the body and blood vessels. Many doctors forbid their patients any tobacco with the first symptoms of angina pectoris, and following this, heart pain may be com­pletely relieved.

Sometimes these patients are advised on the use of alcohol as a medicine. In the form of whiskey, alcohol is noted for its ability to relax the arteries of the heart and help dispel the pain of angina pectoris. Heart pain probably is most often caused not just by one, but rather a combination of diseases. Actually, some authorities believe angina pectoris pain rarely occurs with­out the presence of arteriosclerosis, and others believe that real heart attacks also rarely occur without the presence of some ar­teriosclerosis. Thus, the easy separation of heart diseases on paper is not quite so clearly defined within the chest wall. We may study the types of heart pains and learn to distinguish them from pains which are not coming from within the heart. It is felt moreover, that such a study will prompt the individual to visit his physician regularly even before any heart pain should make itself felt.

Heart diseases are most difficult to deal with. If this were not so, we should not have so great a number of physicians dying of heart diseases each year. It takes the best of medical brains, with the help of laboratory tests, to deal adequately with genuine heart disease. While things to do, and things not to do for the individual, may be very important in his routine way, total evaluation of the heart patient and his activities must finally be dictated by his physician.

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