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ANGINA PECTORIS is not a disease of the heart or great vessels, but rather an assemblage of symptoms which occur in many forms of cardiac disorder. In themselves, however, they are so striking and important, and they have been so often described as constituting a special form of disease, that it will be desirable not only to point out their character, but to investigate their pathological history, and trace them to the lesion in which they originate.

The symptoms of angina pectoris in its simplest and most fully developed forms are at once striking and characteristic. The patient is suddenly seized with acute, agonising pain in the præcordial region, shooting through to the back, and extending sometimes up the neck, but more commonly along the left arm to the elbow, or even as far as the fingers. The pain, which is always sudden in its accession, is generally of a stabbing or lancinating character, but oftentimes it is said to be quite indescribable, and to produce a sense of intense oppression, or of impending suffocation—a feeling as if death were about to occur. As soon as it commences, the patient becomes deadly pale; his countenance is expressive of extreme anxiety and suffering, the skin is bedewed with drops of cold perspiration, and the pulse falters, and may be almost imperceptible. Fearful of augmenting the agonising “ breast pang,” which threatens to put an end to his existence, he ordinarily avoids breathing deeply, so that the respiration is at once shallow and hurried, and in some instances, after a time, there may be not only hurried breathing, but lividity of the face and total inability to lie down. The least motion aggravates his sufferings, so that, whatever he may be doing at the time of his seizure, he is unable to stir or otherwise assist himself. Yet, with all this evidence of intense suffering and nervous derangement, his consciousness is usually undisturbed, and the spinal as well as the cerebral functions remain unaffected. There is no spasm, no convulsion, no delirium, no paralysis. Not unfrequently the rhythm of the heart remains undisturbed, and the patient does not experience palpitation, but sometimes the action of the heart is so much deranged that syncope, or even sudden death, occurs.

The original pain may last a few minutes only, or may recur at intervals, for some hours, or it may persist uninterruptedly, though with variable severity, for the space of half an hour or an hour. It usually subsides as suddenly as it came, and if it does not occasion death by syncope, it leaves the patient pale and exhausted.

Until the first accession of the disease, and during the intervals between the attacks, the patient may be apparently in good health ; there is rarely much palpitation or dyspnea-in the best marked cases absolutely none-and there is no pain or uneasiness in the region of the heart until the sudden occurrence of a breast pang announces the existence of fearful cardiac derangement, and threatens the immediate extinction of life.

The first attack is generally induced by violent bodily or mental excitement. Thus the effort of walking briskly up hill, a sudden fright, and a paroxysm of rage, have often proved the harbingers of anginal mischief, and when an attack has once occurred, there is too much reason for anxiety as to the future. For as the disease progresses, the paroxysms usually recur at shorter and shorter intervals, and not only become more severe in their character, but are excited by the slightest exercise or mental emotion, so that the least attempt to walk up an incline, the least straining on going to stool, the acts of stooping and coughing, and even a sudden movement of the arms, are all liable to induce an attack, as are also severe mental exercise or emotional excitement.

The pathological history of the disease may be briefly told. There is no form of cardiac or aortic disease with which angina pectoris has not been found associated; neither is there any form of structural mischief with which it is invariably or even generally present. The older writers, who did not employ the microscope, affirm that it is sometimes observed in cases in which the heart and arteries are healthy, as proved by dissection after death; but knowing, as we now do, how impossible it is, without the aid of the microscope, to determine whether the structure of the heart is healthy, it is obvious that no reliance can be placed on those statements, the more so as I believe no case is on record in which a genuine attack of angina has been traced to a heart which the microscope has proved to be structurally sound.

But, though angina may occur in connection with many forms of cardiac and arterial disease, there are two forms, which are closely allied pathologically, with which it is specially prone to arise. I refer to calcification or obstruction of the coronary arteries, and to fatty degeneration of the muscular tissue of the heart. Its connection with the former has long been recognised, and the microscope has revealed its connection with the latter. And, inasmuch as obstruction of the coronary arteries always results in malnutrition of the muscular tissue of the heart, and is generally followed by fatty degeneration, there are good grounds for believing that in malnutrition, if not in fatty degeneration of the texture of the heart, we have discovered one of the pathological elements of the disorder.

It is obvious, however, that something more is needed than malnutrition or fatty degeneration of the heart to induce an attack of angina ; for innumerable instances of ill-nourished and damaged hearts are met with in which symptoms of angina do not make their appearance. That this additional element is a nervous element, and that the par vagum and the filaments of the sympathetic nerve distributed to the heart play an important part in the production of the attack, must, I think, be conceded. The suddenness of the seizure, the intensity and peculiar character of the pain which accompanies it, the rapidity with which it subsides, the treatment by which it is relieved, and the patient's perfect freedom from uneasiness when the paroxysm has passed off, are all symptoms which point to its nervous origin. The only question which can arise is as to the precise nature of the affection.

Heberden* and most of the older authorities have regarded the paroxysm as due to cardiac spasm, and Dr. Latham, adopting this view, has argued it with much ingenuity.† But I entertain considerable doubts as to its soundness. In the few instances in which I have been enabled to examine after death persons in whom true angina has existed during life, the ventricles of the heart have been always found relaxed and distended with blood—a condition the very reverse of that which would have obtained had cardiac spasm been the cause of death. Moreover, whatever the state of the coronary arteries, and whatever the condition of the heart in other respects, its muscular tissue has always been soft and atrophous and usually in a state of fatty degeneration-a condition in which the contractility of the muscular fibre is

* • Medical Trans.,' vol. iii, p. 3.
† Loc. cit., p. 385.

at its minimum, and in which, therefore, it is most improbable that muscular spasm would occur. Nor are the results of my experience inconsistent with that of other observers. Even before the introduction of the microscope, the researches of Dr. Parry, of Bath, had led him to believe that angina is connected with an enfeebled state of the heart;* and as far as I am aware, no case of true angina has been reported in which the microscope has shown the muscular tissue of the heart to be healthy and possessed of its full contractile power.

This being the case, and it being difficult to comprehend how spasm of even a few minutes' duration, could fail to arrest the action of the heart and destroy life, the conclusion seems inevitable, that angina is attributable to some other cause than spasm of the heart. My own experience induces me to agree with Dr. Parry, in regarding the disease as syncopal in its nature, and connected with an enfeebled heart and an undue accumulation of blood in its cavities; and the pain as of a neuralgic character, referable, probably, to cardiac obstruction, and overdistension, consequent on the sudden failure of action in some portion of the heart's tissue, resulting from the organic changes which have taken place. And this view is confirmed by the fact that when, in the later stages of most forms of heart disease, the power of the heart begins to fail, and blood accumulates in its cavities, symptoms resembling angina arise, less acute indeed, and less sudden in their accession, and more protracted in their duration, but still essentially anginal in their.character, and often so spoken of by systematic writers.

The prognosis of angina pectoris is necessarily unfavourable. In some instances the first attack proves fatal ; in many more a second or a third attack ; whilst in others, and perhaps in the majority of instances, the patient experiences a succession of attacks, each paroxysm being more severe than the former one, until, after a period of variable duration, sometimes extending to six or eight years, but more commonly from six to twelve months, an attack occurs in which the heart's action is arrested and life becomes extinct. Experience, however, has led me to believe that, in some instances at least, if the circumstances of the patient admit of his being placed under the requisite régime, and if due care be exercised in the treatment of the case, the condition of the heart may be so far ameliorated, that the severity of the attacks may be mitigated, and the fatal issue of the disease almost indefinitely postponed.

* Dr. Parry's work, “An Inquiry into the Symptoms and Causes of the Syncope Anginosa, commonly called Angina Pectoris,' will well repay perusal, though published as long ago as 1799.

The treatment of angina pectoris is fairly divisible into two parts, viz., that which will assist in mitigating and removing the paroxysms, and that which will obviate their recurrence. Diffusible stimulants and sedatives are the remedies which are especially needed during the attack, and of these, opium, brandy, æther, chloroform, and ammonia, are the most efficient. Forty to sixty drops of laudanum, or of the liquor opii sedativus may be given at the beginning of the attack in conjunction with æther, chloroform, ammonia, and brandy, and the dose may be repeated if the suffering continues. At the same time mustard poultices and hot fomentations should be applied to the præcordial region, and hot bottles or sinapisms to the extremities. If the patient be gouty, or the stomach acid and distended with flatus, a full dose of soda, magnesia, and ammonia, with six or eight drops of oil of peppermint or cajeput oil, will often prove of essential service as a precursor to or an accompaniment of the stimulants; and a brisk purge of colocynth and calomel may be given if the liver is out of order. Digitalis in full doses would probably prove useful, but as yet I have no experience of its action during the paroxysms, though in two instances I have prescribed it in combination with iron during the intervals between the attacks, and the patients have apparently derived much benefit from its employment.*

Medicine, however, can do little more than mitigate the severity of an attack, and thus it is that the prophylactic treatment of angina pectoris becomes of great importance. If we are unable to do as much as could be wished for our patient's relief during the continuance of a paroxysm, we can at least point out how he mayrender himself less obnoxious to attack, even if he does not escape altogether. Tranquillity of mind, bodily repose, a strict regulation of the quantity and quality of the food, a careful management of the secreting organs, especially of the bowels, which ought never to be allowed to be costive, and close attention to the general health, are the points which have to be principally attended to, the injunctions laid down respecting these matters in the section on softening of the heart being applicable to the treatment of angina. Change of scene and gentle travelling often prove of essential service ; but in these cases, even more than in cases of fatty heart, it is necessary

* For details respecting the action of digitalis in cases of feeble heart, see pp. 144-5, of this treatise.

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