severity or mildness, of the diversity of symptoms referable to the
different {757} forms of disease of the heart with which the affection
may be associated, and of the varied disorders which may be
accidentally connected, the clinical picture of angina is by no means
uniform. There is, however, no practical advantage in making formal
varieties of the affection. Eulenberg makes four different types, their
differential characters being based on the different nerves supposed to
be especially affected, as follows: 1st, excito-motor cardiac angina;
2d, regulator angina; 3d, excito-motor sympathetic angina; and 4th,
vasomotor angina. Assuming that there is ground for these pathological
distinctions (which, to say the least, admits of doubt), in a practical
point of view they involve difficulties not compensated for by
important bearings on diagnosis and treatment. One point of
distinction, however, has important bearings--namely, the existence of
angina with or without organic disease of the heart. It cannot be
doubted that in the vast majority of cases angina is incident to some
form of cardiac lesion. That it may exist without any appreciable
lesion is admitted. The propriety of recognizing it as a functional
disorder rests on the latter fact.[5] Practically, the coexistence of
organic disease of the heart or otherwise, and, if organic disease
exist, its nature and extent, are points which it is important to take
into account in the diagnosis with reference to prognosis and
treatment.
[Footnote 5: Of 71 cases analyzed by Gauthier, in 3 only was the
affection to be regarded as purely functional. Vide Eichhorst.]
DIAGNOSIS.--The diagnostic points in cases of angina are the præcordial
seat of the pain, its radiations thence into the shoulder and upper
extremity, generally of the left side, the character of the pain, the
accompanying anguish and sense of impending death, the coexisting
disorder of the heart (which occurs as the rule), and the voluntary
immobility of the body. These are positive criteria which, if marked,
render the diagnosis easy and certain. The diagnosis is further
substantiated by finding the signs of organic disease of the heart,
especially if there be lesions at the aortic orifice or within the
aorta. Well-marked angina is in itself strong presumptive evidence of
organic disease of the heart. Not infrequently the existence of the
latter is for the first time discovered by an examination suggested by
the occurrence of an attack of angina. The cases in which the diagnosis
involves difficulty are those in which certain of the above-mentioned
diagnostic points are either wanting or not well marked.
The affections which may be mistaken for angina are gastralgia and
intercostal neuralgia. In gastralgia the pain is seated below the
præcordia. It may radiate in different directions, but does not extend
to the upper extremities, and is not accompanied by irregularity of the
heart's action. The patient writhes and changes the position of the
body in the effort to obtain relief. There is not a sense of impending
death. The paroxysms are of much longer duration than those of angina.
These differential points should suffice for the discrimination.
An acute attack of intercostal neuralgia does not differ so widely from
angina, but the differential points are generally distinctive enough
for a positive diagnosis. The pain in intercostal neuralgia is not
seated in the præcordia. It does not shoot into the upper extremities;
it is increased by the act of inspiration; the peculiar anguish of
angina is wanting; the action of the heart is likely to be regular; and
the diagnosis is confirmed by finding tenderness over circumscribed
areas in the intercostal spaces anteriorly, laterally, and posteriorly.
Cardiac lesions in cases of angina are to be excluded by finding no
physical signs of their existence. But it is to be remembered that
angina is not infrequently associated with lesions not readily
recognized by signs--to wit, obstruction of the coronary arteries and
fatty degeneration of the heart. Persistent feebleness of the heart's
action and symptoms other than angina {758} incidental thereto render
it probable that one or the other or both of these lesions exist. It is
probable that these lesions have been overlooked in examinations after
death in some of the cases in which angina has been reported as not
connected with any organic affection of the heart.
PATHOLOGY AND ETIOLOGY.--The paroxysms of angina have the distinctive
traits of neuralgic affections as regards the character of the pain,
its extension in the course of sensory nerves, the occurrence of
intermissions, the absence of fever, the functions of digestion and
assimilation remaining often unaffected, and the attacks not always
being referable to any exciting cause. The association of the
affection, as a rule, with organic disease of the heart is evidence of
course of some pathological connection. What is this connection? A
difficulty in answering this question arises from the fact that the
affection is associated not with any one lesion, but with different
lesions. It may be associated with obstruction (usually from
calcification) of the coronary arteries, with insufficiency of the
aortic valves, with rigidity from calcareous degeneration of the aorta,
with aortic aneurism, and with fatty degeneration of the heart, these
different morbid changes existing either singly or more or less of them
in combination. The question then resolves itself into another--namely,
What is the pathological condition common to these different lesions
which stands in a special etiological relation to angina? It is a
logical conclusion that the affection must depend upon some condition
which is common to these lesions. The association with the lesions is
too frequent to be explained by mere coincidence. The etiological
relation involves evidently a condition which exists only in a small
proportion of the cases of these lesions. This statement is a logical
deduction from the great infrequency of angina and the frequency of
these varieties of organic disease of the heart. I submit, as the most
rational theory, that the pathological condition on which the angina
depends is ischæmia of the heart. This theory is supported by the
frequency of the instances in which in cases of angina the coronary
arteries are obstructed; by the fact that not very infrequently this is
the only lesion found after death (two instances having fallen under my
own observation within the past year); by the association with aortic
insufficiency and rigidity of the aorta, lesions which interfere
materially with the supply of blood to the heart if it be admitted that
the blood is driven into the coronary arteries, not during the
ventricular systole, but by the recoil of the arterial coats in the
ventricular diastole; and by the association with fatty degeneration of
the heart when, owing to the weakness of the heart's action, the supply
of blood to the muscular structure of the heart must be diminished.
That the sudden withdrawal of a supply of blood to a part may occasion
neuralgia is shown by the intense pain in the limb which directly
follows embolism of the femoral artery. Moreover, general anæmia, as is
well known, favors the recurrence of neuralgia in various situations.
The cardiac nerves in which the pain is seated are doubtless sensory
fibres of the pneumogastrics. Their anatomical connections with the
brachial plexus will explain the extension of pain to the left upper
extremities. To account for the pain in parts which have no direct
connection with the cardiac nerves, it may be assumed that in angina,
as in other neuralgic affections, a centripetal influence conveyed to
the nervous centres may occasion pain referable to different
situations. This explains the shifting of pains which is one of the
diagnostic traits of neuralgia. The explanation of the disturbed rhythm
of the heart's action so often coexisting with the neuralgic pain is
not more difficult than in cases of functional disorder disconnected
from angina. For what is to be said of the rationale the reader is
referred to that portion of this article which treats of Functional
Disorders of the Heart.
{759} Angina, as a purely functional affection--that is, not
symptomatic of any organic lesion of the heart, and not due to any
structural change in, nor mechanical pressure upon, nerves--is obscure
as regards its pathology and etiology, but not more so than many other
neuralgic affections. As already stated, cases in which it is thus
purely functional are few in number--fewer even than has been supposed,
because there is reason to believe that lesions have been overlooked.
Moreover, cases which have been reported render it probable that in
some instances in which the heart has been found free from appreciable
lesions nerves entering into the cardiac plexuses may be the seat of
structural changes or may be subject to pressure from a morbid growth.
But there are cases in which no lesions are discernible during life,
and in which the existence of lesions is disproved by complete
recovery. The affection under these circumstances must be regarded as
purely functional. There is no positive knowledge of the etiology in
these cases. The affection has been attributed to gout, to hysteria, to
the action of cold, to the use of tobacco, and to other causes. These
causes may have a certain amount of agency, but there is an unknown
intervening link in their etiological connection concerning which, in
the present state of our knowledge, it is useless to speculate.
Age and sex have an undoubted influence in the etiology. The affection
very rarely occurs under middle life, and it occurs in men much oftener
than in women.
PROGNOSIS.--As a very rare exception to the rule, a single paroxysm
only may occur, the patient living for many years without any
recurrence. Recurring paroxysms sometimes are separated by long
intervals--weeks, months, and years. In the majority of cases, however,
paroxysms recur with more and more frequency and with increasing
severity. Under these circumstances death may take place after a long
period of suffering.
The liability to sudden death is an important point in the prognosis.
This may occur in the first paroxysm. An instance has fallen under my
observation within a few months, there having been no signs previously
indicative of disease of the heart. Calcareous obstruction of the
coronary arteries was the lesion found after death. A person subject to
paroxysms of angina must be considered as in more or less danger of
sudden death with the recurrence of each paroxysm. The physician should
be sufficiently impressed with the importance of this fact. While it is
doubtful whether it be the physician's duty to apprise the patient of
the fact, the danger should always be communicated to some discreet
relative or friend. To do this is a duty which the physician owes to
himself as well as to the patient. If he omit it, he exposes himself to
censure should sudden death unexpectedly take place. The mildness of
the paroxysms which have already occurred does not afford a positive
security against the liability to a severe and fatal paroxysm. But it
is a hopeful consideration that paroxysms may recur more or less
frequently for an indefinite period without proving fatal. At this time
I am cognizant of three cases in which paroxysms have recurred
frequently for several years, the patients, with that exception, having
had fair health. Let not the physician, therefore, predict with
positiveness that a patient with angina will die sooner or later in a
paroxysm. The uncertainty is a ground of encouragement as well as for
apprehension.
The coexistence of organic disease of the heart and the nature of the
cardiac lesions have a very important bearing on the prognosis. The
danger is in proportion to the importance of these. Recovery is never
to be expected when the affection is associated with well-marked
cardiac lesions, and there is always great danger in the recurrence of
paroxysms when the associated lesions are in themselves dangerous.
Lesions which give rise to free aortic regurgitation and to fatty
degeneration of the heart involve more or less {760} danger of sudden
death, irrespective of angina. It is evidence of greatly increased
danger if paroxysm of angina be superadded.
During a paroxysm of angina the immediate danger is to be estimated by
the symptoms denoting disturbance of the heart's action. The danger is
great in proportion as the action of the heart is feeble, irregular, or
intermitting. Per contra, the danger is less in proportion as the
deviation from the normal force and rhythm is small. It may be said
that there is no danger so long as the heart's action remains
unaffected, but the disturbance may be slight or wanting at the outset
of a paroxysm and afterward become fatally great.
A favorable prognosis may be entertained when there are no signs of
cardiac lesion, and when there is little or no disturbance of the
heart's action during the paroxysms. Let it be borne in mind that such
cases are exceptional and extremely rare. Let it also be borne in mind
that lesions especially apt to be associated with fatal paroxysms may
be latent--namely, obstruction of the coronary arteries and fatty
degeneration. The latter fact renders it proper that a favorable
prognosis should always be formed with a reservation, while the fact
that recovery takes place in a few well-marked cases of angina renders
it improper to withhold encouragement whenever lesions are not
discoverable and the paroxysms are not accompanied by alarming symptoms
referable to the heart's action. The long tolerance of the affection in
some cases is not to be lost sight of with reference to the
encouragement which may be fairly derived therefrom.
The immediate cause of sudden death in a paroxysm is probably an arrest
of the heart's action in diastole, or such a degree of diminution of
the force of its action that the accumulation of blood within its
cavities induces paralysis from distension.
TREATMENT.--It is important that a paroxysm of angina be treated as
soon as possible, not alone with a view to the relief of pain, but to
remove immediate danger. If the physician be present, an opiate in a
form to act promptly should be given either by the mouth or
hypodermically; the latter mode is to be preferred. Laudanum or a
solution of a salt of morphia is the most eligible form if given by the
mouth. If the heart's action be weak and irregular, a diffusible
stimulant is indicated. If at once available, chloric ether, Hoffman's
anodyne, and the compound tincture of lavender act efficiently. If
these be not at hand, an alcoholic stimulant should be given, diluted
but little, and the doses repeated at short intervals until the
paroxysm ends and the disturbed action of the heart has ceased. The
duration of paroxysms is generally so short that a physician is rarely
present unless they recur after brief intervals. A patient, therefore,
subject to angina should be provided with remedies and instructions as
to their use at the instant a paroxysm occurs. The amyl nitrite, first
recommended in this affection by Brunton, is a remedy of signal benefit
in some cases. From two to five minims may be inhaled at the
commencement of the paroxysm. It is especially indicated when the
characters of the pulse denote arterial tension. Caution is to be
exercised in its use if there be notable weakness of the heart's
action. Sinapisms, stimulating embrocations, and fomentations applied
to the chest have a certain measure of utility, but they should not
take the place nor delay the use of remedies which are more efficient.
A still more important object of treatment than relief in the paroxysms
is their prevention. During the intervals this object claims assiduous
attention. First in importance is the avoidance of all exciting causes.
Bodily exercise is to be kept within the limits required in order to
incur no risk of a paroxysm being produced. The same precaution applies
to mental excitement. Unhappily, this is not as easy as the avoidance
of muscular exertion. John Hunter's saying, that his life was at the
mercy of any scoundrel who chose to {761} insult him, proved a
prediction. He fell dead on receiving an insult from one of his
colleagues at St. George's Hospital. Sexual intercourse I have known to
prove an exciting cause. Excesses in eating and drinking are in this
category. The diet, however, is not to be reduced below the full
requirements for nutrition, and wine or spirits, as conducive to
digestion, are in some cases serviceable. The use of tobacco is to be
interdicted.
Coexisting affections which have no special pathological connection
with the angina may act as auxiliary causes, and therefore claim
attention. Gout is to receive appropriate treatment. Anæmia especially
is to be removed. This condition strongly conduces to the development
and the continuance of neuralgic affections. Chalybeate remedies and
the dietetic treatment are called for if this condition coexist. It is
a rational indication to supply the heart with good blood if it be true
that angina depends on an ischæmic condition of this organ.
Associated cardiac lesions are to be treated according to symptomatic
indications, as in cases in which angina does not occur. Digitalis may
be used under the proper restrictions. I have known this remedy to
prove highly useful in preventing the recurrence of paroxysms. Nux
vomica is sometimes useful as a cardiac tonic.
Various drugs have had repute as empirical remedies. Of these may be
mentioned the preparations of zinc, arsenic, the nitrate of silver,
phosphorus, the bromine salts, the iodide of potassium, and quinine.
There is no proof that these remedies have any special therapeutical
effect in this affection, but that they are sometimes useful there is
abundant testimony. Trial should be made of them, with proper care in
their administration. Electricity in the form of the induced and of the
constant current has been advocated as not only serviceable, but as
effecting in some instances a permanent cure.[6] Beard and Rockwell
have found general faradization useful in a few cases.[7]
[Footnote 6: Vide Eulenburg in _Ziemssen's Cyclopædia_, vol. xlv. p.
54.]
[Footnote 7: Vide _Medical and Surgical Electricity_.]
Exophthalmic Goitre (Graves' Disease; Basedow's Disease).
This affection is characterized by three striking symptomatic
events--namely, persistent increase of the frequency of the heart's
action, enlargement of the thyroid body, and protuberance of the
eyeballs. The name exophthalmic goitre relates to the last two of these
three events. It is defective, inasmuch as it does not include the
increased frequency of the heart's action, which is the primary one of
the three events, and the only one which is never wanting. As an
individual affection it was first described by Graves in 1835, although
cases in which these events were associated had been previously
reported. Parry collected 7 cases in which the affection of the heart
was associated with thyroid enlargement, and in 1 of these cases
exophthalmia existed. An account of these cases was published in 1825.
The name Graves' disease, proposed by Trousseau, has been adopted by
French, English, and American writers. Basedow's disease is the name
given to the affection by German writers. The affection was described
by Basedow in 1840 under the name Glotz augenkrankheit.
There are cases in which one of the events in this symptomatic triad is
wanting, the cases in other respects corresponding to the affection.
The exophthalmia is the event oftenest wanting, the goitre, the
functional disorder of the heart, and the associated phenomena being
the same as if protuberance of the eyeballs coexisted. In some
instances the goitre alone is wanting. The name exophthalmic goitre is
not strictly applicable to these cases, but that the affection is
essentially the same as when the three events {762} are present cannot
be doubted. It is a chronic affection, being in the great majority of
cases of long duration. Exceptionally, it is developed suddenly and
disappears after a few days. In these cases the affection has been
distinguished as acute, but its claim to be so called rests exclusively
on the shortness of its duration.
SYMPTOMATOLOGY.--Of the three cardinal events, the increased frequency
of the heart's action is the first in the order of time. This precedes
the other events usually for several weeks or even months. The
frequency varies in different cases within wide limits--namely, from 90
or 100 to 150 beats, and even more, per minute. There is notable
variation at different times in the same case. Generally, the frequency
is greatly increased by exercise and mental emotions. In other words,
irritability of the heart is in most cases a marked feature. As a rule,
there are none of the disturbances of action, in other respects than
frequency, which are found in cases of functional disorder not
associated with exophthalmic goitre. The action may be intermittent or
in other respects irregular, but in most cases the rhythm is not
disturbed. The patient is conscious of the heart's action, and is
annoyed by it, especially under any excitement; but there is not that
distressing sense of the disorder which is felt in the paroxysms of
palpitation with irregularity of action considered in the first
division of this article. At the outset and for a considerable period
there are no signs of any organic disease of the heart, or if the
latter be present the association is accidental; the disordered action,
as far as it relates to the affection under consideration, is purely
functional. At a later period there may be enlargement of the heart as
a result of long-continued increased activity of function. From the
first cardiac murmurs are generally present at the base and over the
body of the heart. These are blood-murmurs due to coexisting anæmia.
Following the increased frequency of the heart's action, after a
variable period enlargement of the thyroid body occurs. The enlargement
may be rapid, but in most cases it takes place slowly, and ceases when
it has reached a moderate degree. Cases are exceptional in which the
degree of enlargement is such as to occasion any obstruction to
respiration. Almost invariably both lobes of the thyroid body are
enlarged, but the enlargement is generally not equal on the two sides,
and, as a rule, it is greater on the right side. The enlarged lobes are
soft at first, afterward becoming hard. The subcutaneous veins over
them are often distended. Pulsation of their arteries is apparent to
the hand and to the eye. A systolic arterial blowing murmur and a
continuous hum are heard when the thyroid region is auscultated. In
some instances the murmur is like that of an aneurismal varix. As a
rule, murmurs are heard over the carotid artery and the jugular vein. A
thrill or fremitus is often felt by the hand placed upon the thyroid
body. The thyroid enlargement is due at first chiefly to dilatation of
the arteries and veins. Hyperplasia of the fibroid tissue occurs
afterward, and then the enlarged gland becomes hard to the touch. The
size of the enlarged thyroid body is often found to vary considerably
at different times--a fact attributable to varying degrees of the
dilatation of the vessels and of the consequent hyperæmia.