L E C T UR E S ON
A N G N A PEC T
R 8
A N D A LL IE D S T A T E S
BY
WI L LIA M O S L E R M D
FE LLO W O F T E ROYA L C O LLE G O F PH YS ICIANS L ON D ON
P R O FE S S OR O F M E D ICINE JO HNS H OPKINS UNIVE RS IT Y BALTIM O RE
A UT H OR O F A PRA C TIC E O F M E DICINE
LE CT URE S ON T H E DIA GN O SIS O F A BD O MINAL T UMO RS E T C
,
H
.
E
.
,
,
,
,
N E
D
.
A
W
P P L E T ON
YO R K
AN D
1 90 1
COMPAN Y
.
TO
RE GI US
W T
P R OFE SS OR OF
.
M D
I
.
O
N
M E D CI E IN
TH E
O
,
F R S
.
.
.
’
S
S
U N IVE R IT Y OF G L A G OW
D e a r D r G airdn er
.
P le as e
o
in t ken
br e thren
our
ac c
ep t
th e
f
feel of
o
profession
.
dedica tion of
t he
e
o
app r c ia t i n
t he
va lu
t h is litt le
whic h y ou r
e of yo ur
life
v
o lum e
c is- a t la n tic
a nd
w
ork
in
S i n cerely y ou rs,
WIL L IA M OS L E R
.
.
N O TE
T H E S E lect ures
m e d i c ine
were
.
delivere d t o
the graduate class in
at the J ohns H op k ins H ospital
York M e d ica l Jou r na l, 1 8 9 6 ,
here republished
with
,
vo l
appeare d in
an d
.
1 xiv
.
They are
sli gh t additions and corrections
.
CONT E NT S
.
LEC T U RE I
PA
H isto ry of t h e re c ogn iti o n O f angi na — H eb e rde n R o ugn on M o rgagni
—L iterature —D e fi nit ion —F o rm s O f h eart pain —Classific at ion
of t h e form s of angin a —P h ysiology an d path ology Of th e c oro
nary art e ri e s
GE
.
,
.
,
.
.
.
.
LEC T URE II
A NG I NA P E C T O R I S VE R A ZE TI O L OG Y G E N E R A L
.
.
TH E
I
.
D SE
AS E
DE S
C R I PTI O N
OF
.
—
S e x —A ge —Epi de m ic in
flu e n c e s
H e red it y
G o ut
D iab ete s Syph ilis Spe c ific fe
v e rs —H e art d ise ase —
L o c o m ot o r atax ia —G en e ral pic ture of t h e
d isease
Inc i denc e O f t h e
dise ase — Station
.
.
.
in life
.
.
.
.
.
.
.
.
20
LEC T URE III
ANG I NA PE C T O RI S VE RA P HE N O ME N A OF T H E ATTA C K
E xc iting c au ses —Sym ptom s —State Of h e art and pulse —P eric ard itis
—R e spiratory features —C astro intestinal sym pto m s —Nervous
an d psyc h ic al sym pto m s
45
LEC T U R E IV
A LL I E D A N D A S S O C I AT E D C O N D ITI O N S
I S ync ope angin o sa —II T h c A d am s Stok es synd ro m e —III
S i n e d ol o r e
IV Card i ac asth m a
67
.
.
.
.
.
.
.
-
.
.
.
.
-
.
.
.
i na
A ng
-
.
.
LEC T U RE V
P S E UD O A N G I N A P E C T O R I S
I Neurotic grou p : (a) H ysteric al and n e urasth en ic c ases ; (b ) A ngina
—
m
s
n
a
a
i
n
:
x
c
T
e
c
r
i
o
o
t
o
R
e
e
i
II
o
i
fo
t
a
as
m
r
i
a
fl
n
n
a
c
x
a
; ( )
g
p
g
of h e art pain f om tob ac c o
.
-
.
.
o
v
-
.
r
r
86
C O N T EN T S
vi
.
LEC T URE VI
T HE ORI E S OF ANGI NA
—
r
r
r
r
n
m
nt c lau d ic ati o n
r
n
a
a
s
as
i
o
t
e
of
o
o
t
e
d
i
e
e
I
t
e
i
tt
e
m
r
n
c
a
c
T he
y
y
p
—State O f t h e h e rt m usc le in an attac k —S eat and c ause Of t he
—
—
l
h
n g e s in an g in
ati o n s O f spuri o us an d
i
n
V
o
m
o
t
o
r
a
R
e
a
s
c
p
true angina
.
.
.
.
a
.
a
a.
-
LEC T U RE
IAGNO I
VII
P R O GNOS I S A N D T RE AT ME N T OF A NG INA
Anom alous c ases of h e art pain —E le m ents in t h e d iagnosis of tru e
an gi n a —D ifi e re nt iat io n of tru e an d pse u d o an gi n a —P rogn o sis
—T re at m ent of angin a pec toris Ve ra —T re atm ent Of false angina
Conc lusio n
D
S S,
111
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,
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.
NOT E
1 31
APP E NDIX
.
A —B ougn ou s c laim
B —T h e c ase of Mr M atth e w A rn ol d
C —R et e nti on O f c o nsc iou sn ess after
h eart s action
’
1 57
.
.
1 58
.
.
’
r
appa e nt
e
tion O f
c ssa
1 60
B u t we t I woo t th o u d oost m y h ert e to
Th a t I
o
a lm st
h ave
Th e w o rd
a nd
c a ugh t a
es o f t h e
H
ost
t h e P a rd o ne r
.
t o t h e P h isic ie n
—CH A UC E R
.
L E CTUR E S ON
P E CTOR IS
A N G IN A
A N D A L L IE D S TA TE S
L E C T UR E
I
.
.
tory of t h e re c ogniti on of an gina —H eb erden R o ugnon M orgagni —L it
—
—
—
m
h
n
l
ss
ifi
i
ar
r
D
fi
n
i
n
F
o
s
of
e
t
i
C
a
c
a
t
o
n
of
t
h
fo
e at u re
e
it o
e
ms
p
of angina —P h ysiology an d path ology of t h e c o ona y arte ri e s
H is
,
.
r
.
a
,
.
r
.
r
.
~
.
r
TH E
.
h istory of t h e reco gn ition of t h e disorder know n as an
gina pectoris is c onnected w it h th e names of three celebrated
—
men H eberden Jenner, an d John Hunter
O n July 2 1 , 1 7 68 H eberden read at the R oyal C olle g e of
f a D isorder of the
P hysicians a paper enti t led S ome A ccount O
Breast, w h ic h w as publish ed in V o l ii o f th e M e d ica l Tr an s
a c tion s Of the C olle g e o f Ph ysicians 1 772
A n extract from
t h e original description must be quoted :
T here is a dis
order o f th e breast marked w ith stron g and peculiar sym p
tom s considerable for th e kind o f danger belon g in g to
it
T h e seat o f it and sense o f stran g lin g and anxiety
w ith w h ich it is attended may make it not impr operly be
called an gina pectoris
Th ose w h o are afflicted w it h it are seized w hile the y are
w alkin g and more p articularly w h en th ey w alk soon a fter eat
in g w ith a painful an d most disag reea b le sensation in the
breast w h ic h seems as if it w ould take their li f e aw a y if it w ere
to increase or to continue ; th e moment they stand still all this
uneasiness vanish es I n all oth er respe c t s th e patients are at
t h e be ginnin g o f th is disorder perfectly w ell, and , in part ic u
.
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1
.
AN GI NA PEC T ORIS AND ALLI ED S T A T E S
2
lar h ave no sh ortness
,
fe re n t
of
breath, from
w h ic h
it
is
.
totally dif
”
.
S ubse quently , in th e celebrated Com/me n ta/rie s upon
w h ic h
g randfathers in t h e profession w ere ed u c ated, H ebe rden
g ave a fuller account o f h is experience w it h t h e disease T h e
n ame w h ic h h e adopted c an not be re g arded as alto g ether sat
tin g a ffections
isfac t o ry since it w as already in use in desi gn a
—
of the throat w it h w h ic h its literal meanin g a stran g lin g
is muc h more in h armony I n one sense how ever, th e term is
fa irly appropriate since as noted by G airdn e r, th e w ords an x
ie t y and an guish , expressive o f t w o o f t h e most prominent fea
tures of the disease , h ave a derivation from th e sam e Greek
w ord as an g ina
I n 1 7 7 3 Joh n H unter h ad h is fir st attack , w hic h w as
graph ically described by his neph ew E verard H ome : While
h e w as w alkin g about th e room h e cast h is eyes on th e lookin g
gl ass an d observed h is countenance t o be pale h is lips w h ite
givin g th e appearance o f a dead man Th is alarmed h im an d
led h im to feel for h is pulse but h e found none in eit h er ar m ;
th e pain continued and h e found h imself at times not breat h
in g Bein g afraid o f death soon takin g place if h e did not
breath e h e produced th e voluntary act o f breath in g by w ork
”
I n 1 7 7 6 h e h ad a
ing h is lun g s by th e pow er o f th e w ill
second attack and w h en convalescent h e visited Bath H ere
h e w as seen by h is friend and pupil E dwa rd Jenner o f Berke
ley ; and o n e of the most interestin g and sa gacious letters
o f that distin guished man w as w ritten to H eberden
gi vi n g
h is dia gnosis o f Joh n Hunter s case and su gg estin g fo r the
first time th e probable association Of disease o f th e coronary
arteries w ith an gina pectoris T he letter is w orth quotin g
in full :
Wh en you are ac quainted w ith my motives I
our
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Baro n
’
s
Life of Jenner
,
L o nd o n, 1 8 2 7
.
H IS T ORY O F T H E RE C O G N I T I O N O F ANGINA
3
.
presume you will pardon th e liberty I take in addressin g you
I am prompted to it from a kno w led g e o f the mutual re g ard
t h at subsists betw een you and my w orthy friend Mr H unter
Wh en I had th e pleasure of seein g h im at Bath last autumn
I th ou gh t he w as affected w ith man y symptoms o f th e an gina
pectoris T he dissections ( as far as I h ave seen ) of th ose
w h o h ave died of it th ro w but little li g h t upon the subj ect
Th ou gh in the course o f my practice I h ave seen many fall
victims to this drea df u l disease yet I h ave only h ad t w o op
I
n
t
h
e
first
of
n it ie s of an examination after deat h
o
r
t
u
p
th ese I found no material disease O f th e h eart except th at th e
coronary artery appeared thickened
A S no notice h ad been taken of suc h a circumstance by
anybody w h o ha d w ritten o n th e subject I concluded that w e
must still seek fo r other causes as productive o f th e disease ;
but about t h ree w eeks a g o M r P ayt h e ru s a surg eon at R oss
in Herefor dsh ire desired me to exam ine w ith h im the h eart
f
e
w days
a
f
a
person
h
ad
O
the
an
g
in
pectoris
a
i
e
d
d
h
o
w
of
before Here w e found the same app e arance o f th e coronary
arteries as in th e former case But w h at I h ad taken t o be
an ossificat ion o f th e vessel itself M r P discovered to be a
kind o f fir m fl esh y tube formed w ith in th e vessel w ith a
c onsiderable quantity of ossific matter dispersed irre gularly
th rough it Th is tube did not appe ar t o h ave any vascular
connection w ith th e coats o f th e artery, but seemed to lie
merely in simple contact w it h it
of
a
the
h
eart
I
believe
in
every
subject
t
h
t
h
as
died
AS
th e an gina pectoris h as been found extremely loaded w ith
fat and as th ese vessels lie quite concealed in th at substance
"
it
possible
t
h
is
appear
nce
may
have
been
overlooked
T he
a
is
import ance o f the coronaries and h ow much the h eart must
suffer from t h eir not bein g able duly t o perform their func
tions (w e c an not be surprised at the painful spasms) is a
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ANGI NA P E C T ORIS AND AL L IE D S T AT E S
4
.
subject I need not enlarg e upon therefore shall just remark
th at it is possible that all the symptoms may arise from t his
,
C irc umstance
on e
.
I fre q uently w rite to M r H I h ave been some time
in h esitation respectin g the propriety o f communicatin g the
matter t o h im and should be exceedin gly th ankful t o you
S hould it be admitted
sir for your advice upon t h e subj ect
th at th is is t h e cause o f t h e disease I fear t h e medical w orld
may see k in vain for a remedy , and I am fearful ( if Mr
Hunter Should admit this to be t h e cause o f th e disease) th at
”
it may deprive h im of th e h opes Of a recovery
I n another letter Jenner gives as h is reasons fo r not pub
lish in g his view s earlier an anxiety lest they should be a source
S oon after M r P aythe
o f annoyance to hi s friend H unter
rus met w ith a case P revious to our examination o f the body
I offered h im a w a g er th at w e Should find the coronar y art eries
This h ow ever proved not t o be exactly true ; but
o ssifie d
A t this time my
the coats o f the arteries w ere h ard
valued friend M r John Hunter be gan t o h ave th e sym ptoms
and th is
o f an g ina pectoris too stron g ly marked upon h im ;
circumstance prevented any publication o f my ideas o n th e
subject as it must h ave brou gh t o n an unpleasant conference
”
betw een M r Hunter and me
H e says t h at M r C line and
Wh en h ow
M r H ome did n ot th ink much o f h is Vie w s
ever M r Hunter died Mr H ome ver y candidly w rote to me
”
immediately after th e dissection to tell me I w as ri gh t
T he f urther details of H unter s remarkable case are al w ays
referr ed to From 1 7 8 5 w hen he h ad a severe illness th e at
tacks became increasin g l y fre quent and w ere brou gh t o n par
t ic u larly b y exercise an d by w orry and an g er ; and indeed h e
w as accustomed to say
th at h is life w as in th e h ands of any
AS
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P arry
A nginosa ,
A n In qu iry in to th e S y mpt om s a n d Ca uses
c o m m o n ly c a lled A ngin a P ec to r is, 1 79 9
.
.
f
o
,
o
th e S y n c p e
H IS T ORY O F T H E R EC O GN I T I O N O F ANGI NA
5
.
”
rascal w h o c h ose to annoy and tease him
D urin g the last
fe w years O f h is life th ou g h he did a lar g e amou n t o f w ork
the atta cks seem to have b een very fre que n t and w ould come
o n after very sli gh t exertion and w h ile h e w as operatin g
As
h e h ad himself predicted death came suddenl y in c o n se
n
f
n g o f t h e g overnors o f S t
u
e
c
e
o
a
fi
t
of
temper
at
a
meeti
q
G eorg e s H ospital O ctober 1 6 1 7 9 3
W hen contradicted
fl atly h e left the board room in S ilent ra g e and in the next
room g ave a deep groan and fell dow n dead T h e coronar y
arteries w ere found to be converted into open bony tubes an d
th e aorta w as dilated
A ttempts h ave been made by Frenc h w riters to claim the
priority in the description of the disease for R ou gnon pro
fe sso r of medicine in t h e U niversit y of Besan con
In a letter
addressed to M L orry dated February 2 3 1 7
h e describes
the case an d circumsta nces o f t h e de at h of a C aptain C harles
Th e patient h ad become asth matic and on w alkin g fast h ad a
sort of suffocation S ix w eeks be fore h is death h e h ad c o m
plained to M R ougnon o f u n e gen e sin gulié re su r t ou te le
”
T
he
ar tie a n t e r ie u r e d e la p oit r in e e n for m e d e p la str on
p
and disap
a ttacks evidently occurred w it h g reat suddenness
it
h
e
q
ual
abruptness
T
he
c
h
ief
stress
is
laid
upon
re d w
e
a
p
the feelin g o f su ffocation but it is evident that associated w ith
it there w as pain o f g reat intensit y ; se u le m e n t u n e d ou le u r
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’
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f
”
a fter
C
aptain
C
harles
died
very
suddenly
shortly
a tion s
oc
f
dinin g w ith h is friends The pericardium w as fatty ; the
heart w as larg e ; there w ere no valvular de f ects ; the coronary
veins w ere enlar g ed prodi giousl y
no mention w as m ade
R ou g non la y s stress
o f t h e condition o f t h e coronar y arteries
upon th e O
bstruction in th e lun g s an d excessive ossification of
a tive
r
a
/v
g
d a n s la
r é gio n
da
c aeu r ,
lor squ il ep r ou uoit
’
’
se s su
,
.
.
.
L e ttr e
d M
.
L orry
sur u n e
m a la d ie
o e l le
n uv
.
on
B e sanc
,
1 768
.
.
AN
6
GI NA PEC T ORIS AND ALLIED S TA T E S
.
t h e cartilag es H e confesses h ow ever t h at th e condition w as
very puzzlin g an d th e autopsy not at all satisfac to ry t o h is
f riends : M Char le s e st m or t disoie n t ils p a/rc e gu il e st
.
,
,
,
-
,
m or t
’
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”
.
I c an not ag ree w it h P rofessor Grairdn e r, w h o says th at
there w as no trace of anythin g like a clinic al description o f
”
an g ina pectoris in M R ou gn o n s letter
Th e suddenness
of the attacks, the pain in th e re gion o f th e h eart th e abrupt
—
termination and th e mode of deat h durin g exertion after a
—
full meal favor th e View that th e case w as o n e of tru e an
gina ( N ote A )
T o Morg a g ni not R ou gnon , is due th e credit o f th e first
description of a sin gle case I n th e splendid section on aneu
r sm o f the aorta h e describes an g ina pectoris accurate ly in
y
C ase V , refer rin g to th e paroxysms, t h e pain t h e diffi culty of
breath in g th e numbness of th e left arm , and th e e ffe ct o f e x e r
tion I read y o u h ere extracts from the case
’
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A lady f ort y t w o years of ag e wh o fo r a long time had
b een a valetudi narian and with i n the same period o n usi n g
pretty qu i ck exerci se Of b ody She was sub j ect t o attac k s o f Vio
lent angui sh in the upper part Of the chest on the le ft side ac
comp anied wi th a diffi culty of b reath i n g and numb ness o f the
lef t arm ; b ut these p aroxysms soon sub si ded when sh e ce as e d
from exerti on In these c ircumst ances b ut w i th cheerfulness
She undertoo k a j ourney f rom V enice purpo sin g t o
o f mi n d
travel alon g the cont i n ent when She was sei z ed wi th a paro x
n
n
m
and
died
o
the
spot
I
exam
i
ned
the
b
od
y
o
the
f
ollo
w
s
y
i n g day
The aort a was c on si derab l y d i lated at its curva
ture ; and in place s throu gh it s whol e tract t h e inner surface
The se appearances w er e propagate d
w as un e qual and o ssifie d
”
into the arteri a innomi nata The aortic valves w ere i ndurated
H e re mark s : The delay of b lood in t h e aort a in t h e heart
in the pulmonary vessels and in the vena cava would occasion
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L a nce t
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1 89 1 ,
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p 604
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H IS T ORY O F
TH E
REC O GNI T I O N O F ANGINA
7
.
the symptoms o f which the woman complained durin g l i fe ;
namel y the Vi olent un e asi ne ss the diflic ult y o f b re athin g and
”—
r agn i
M
o
C
oo
k
e
s
t h e numb ness o f the arm
(
g
)
‘
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’
.
.
Th ere ar e th ose , indeed , w h o re g ard S enec a as th e first to
describe t h e affec t ion , in th e rem ar kable account w hich he
g ives o f h is ow n disorder With this View Forbes and C aird
ner a gree, but P arry and S tokes do n o t I quote from P arry
th e follow in g translation o f part Of S eneca 8 g rap hic ac c ount :
Th e attack is very sh ort an d like a storm I t usually ends
I h ave underg on e al l bodily in fir m it ie s and
w ith in an h our
dan g ers ; but none appear s t o me more g rievous Wh y n o t "
Because t o h ave any other mal ady is only to be Sick ; to h ave
”
th is is to be dyin g
S eneca states t o o , th at h is p hysici ans
called the disease a m e d ita ti o m or tis
Th e li t erature of an gin a pectoris h as become very volumi
nous E n glish w riters h ave contributed most larg el y to the
clinica l description of th e disease P erh aps the t w o most
valuable articles are lectures xxxvii an d xxxviii in L ath am s
Clin ic a l M e dic in e w h ich you w ill find in v o l i of th e N e w
S ydenh am S ociety edition o f h is w orks ; and P rofessor C aird
’
ner S essa y in R e yn olds S yste m of M e dic in e Th e best recent
expositions in Frenc h an d G erm an ar e to be found in H u
c h ard s Tr a ité c lin iqu e de s m a la die s da caeu r second edition
1 8 9 3 w hich g ives a most e x h austive accou n t o f the various
forms o f an gina , and O R osenbac h s D ie Ifr axnkhe ite n d e s
E crze n s 1 8 9 6 I p ass about for y our inspection a number of
t h e mono graphs an d j ourn al articles w hic h I h ave collected
o n t h e subject
P arry s essay h as become very scarce but it
is in all th e l ar ger medi c al libraries B oug no u s L e ttre pub
lish e d at Besan con 1 7 6 8 is still more rare
T h e copy in the
S urg eon G eneral s L ibrary is the only one I h ave ever seen
I w ould ask y ou to look at t h e first part at least o f th ese fly
l eaves w h ic h I picked up in an Old book sh op a fe w years a g o
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AN GINA PEC T ORIS AN D AL LIED S T A T ES
8
I t is a letter to D r H eberden from a
.
m an w h o
signs h imself
”
U nknow n descriptive of his o w n case H e had seen in
th e Cr itica l R e v ie w an extract from H eberden s ori ginal
paper and recognizing his malady h e w rote in this letter o n e
of th e very best accounts w hich exists in the literature I t is
particularly noticeable for t w o th in g s : H e clearly dissociated
the pain Of th e attack from the a n gor o r mental feature and
h e first made use Of the n ow hackneyed phrase describin g th e
latter aspect as an universal pause w ithin me of the opera
tion s of N ature
E xpectin g a sudden deat h h e left orders
that H eberden should examine h is body With in three w eek s
from the w ritin g of the letter th e dissection w as made by Joh n
H unter
—
D E F I N ITI ON
In the consideration o f a dise ase it is w ell
if possible to s t art w ith a clear understandin g or at least some
c oncise statement
of its nature an d o f th e c h aracters o f the
manifestation s by w hich it is reco gn ized W ith some disorders
this is a very easy matt er For ex ample insuffic iency o f th e
aortic valves is a clear l y defined afle c t io n w ith it is true a
diverse ae tiolo gy a varied anatomical pictur e ( from a tri flin g
cu rl o f th e ed g es o f a val ve to a clean shavin g of a se gment
from th e aortic rin g ) ; but w ith all it s va riations there are asso
c iat e d definite se q uences an d w ell characterized si gns
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A n g ina pectoris is not a disease but a syndrome o r sym p
t o m g roup ( w ithout co n stant aetiolo gical o r anatomical fo u n da
tions) associat ed w ith complex conditions org anic o r func
t io n al of t h e h eart and aorta
P ain about the h eart o f an
a g oni z in g character occurri n g in paroxysms is th e dominant
feature o f all varieties o f the syndrome
U sed to defin e
—
—
parox y smal attacks of pain in the chest breast pan g— w e em
plo y th e term g enericall y q ualify in g t h e varieties by suc h
n ames as true false h ysterical and v oso motor
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ANGINA PEC T OR IS
10
AND
ALLIED S T AT ES
w hic h
.
is acknow ledg ed to be only a symptom or as it h as been
expressed a neurosal inciden t of cardio vascular disease ; but
there ar e practical advan t a g e s w hich far outw ei gh any theo
—
r e t ic al O bj ectio n s
advanta g es o f the very greatest moment in
prog nosis and in treatment
Follow in g the w ork o f H eberde n P arry and others there
w ere cases reported as an g i n a w hich did n o t belo n g properly
to th at cate g ory an d the disorder w as con f oun ded w ith cardiac
asth ma w hich w e n o w term car diac d y sp n oe a A s earl y as
1 8 1 2 J L atham read a paper o n ce rt ain s y mptoms usually but
n o t al w ays denotin g an g i n a pectoris (M e d ic a l T r a n sa c t ion s
H e remark s th at w hen the ex
R o y al C olle g e o f P hysicians)
tremit ies are cold t h e cou n tenance is bluish o r purplish t h e
pulse is rapid and respiration is performed w ith difficulty and
in an upri gh t position of the body the prac t itioner has usually
concluded that the disease is a n gin a pe c toris The class of
c ases w h ich he described w ere evidently orthopn oe a and c ar
diac d y spn oea associate d chie fly w ith affections of the abdo
men H e calls the state a n g in a n o th a spurious an g ina th e
first time so far as I am aw are that t h e te rm w as used in
literature
L aennec reco gni z ed di ffere n t de g rees of intensity in an
gina statin g th at it w as far from possessin g the de g ree of
”
severit y attributed to it by man y authors and w as evide n tly
a w are th at it occurr ed commonly enou gh w ithout indicatin g
any serious disease o f the h eart o r lar g e vessels
A n g in a
pectoris in a sli gh t o r middlin g de g ree is extremel y common
and exists very fre q ue n tly in persons w h o h ave no organic
”
affec t ion o f th e h eart or larg e vessels
B y far th e most important contribution to th e reco gnition
o f varieties o f an g i n a pectoris w as made b y W alshe w h o in
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F o rb e s s
’
editio n of L a e nnec fo urth edition
,
,
p 650
.
.
,
F ORM S O F ANGI NA
P E CT OR
IS
11
.
h is text book o n D ise a se s of the Ife ar t descri b ed a pseudo
angina pecto ris occurri n g particularl y in w ome n an d in the
subjects of h y steria spin al irritatio n , an d various forms of
neuralgi a
The reco gnition by Beau , Graves S tokes and others o f the
relation betw een the abuse of tobacco and attacks o f a n g i n a led
to t h e sep aration O f the impor t a n t g roup of toxic c ases O ther
forms of p seudo an g ina w hich are describ ed are those depend
ent upon re fl ex ca uses and the vaso motor t y pe of No t h n age l
In an y lon g series the cases of an g ina f all i n to t w o g roups :
those in w hich there are S i g ns of lesion of the heart or ar t eries
or o f both and those in w hic h all sympto ms o f org anic diseas e
ar e abse n t
This w as th e importa n t division reco g n i z ed b y
—
n
n
n
n
Forbes i to or g a ic and functio al a gin a the an g in a pec
—
toris vera and the an gina pectoris notha the true and the
pseudo a n gin a
In loo k i n g over t h e cases w hich form th e basis of these lec
tures I fin d that they fall in to the follo w i n g groups : ( 1 ) A n
g in a pectoris vera an d ( 2 ) an g in a pectoris notha under w hich
are grouped h y sterical vasomotor an d toxic form s
—
T H E C O R ON ARY A R T E R I E S
A fe w esse n tial poi n ts in the
anatomy and ph y siolo g y of the hear t ma y here en g a g e o u r at
tention for a fe w minutes The coron ar y arteries are the
”
A bana an d Pharpar o f the vascular rivers
lucid stream s
w hic h w ater th e very C it adel o f life
B y me an s of these in
n s w hi c h I p ass arou n d
spe
ime
may
refresh
y
our
d
c
o
u
e
c
t
e
j
y
memories o n th eir distributio n The arteries are as y ou see
lar g e in proportion to the size o f t h e org an to be n ourish ed
From the po sition o f th eir ori g in it is eviden t that the y must
be subje c t to blood pressure duri n g b oth s y stole an d di astole
Th e left coron ary is usuall y the lar g er and di v ides i n to t w o
main branch es : th e circum fl ex or posterior w hi c h run s in the
groove bet w een the left ventricle and auricle and the anterior
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ANGINA PEC T OR IS
12
AND
ALLIED S T AT ES
.
descendin g ramus N ote part i c ularl y the branches of th e
latter vessel w hich runs in the anterior interventricular
g roove Y o u w ill se e a very larg e branch w hic h is given off
to the ante rior w all of the left ve n tricle an d several bran ches
w hi c h pass deeply i n to the septum
This anterior bran c h is
the impor tan t one in the mor b id an atom y of t h e coronary
arteries sin ce it is by far the most fre q ue n tly found th e seat
o f exte n sive sclerosis o r of embolism o r t h rombosis
I t may
be called the a r te ry of s udd e n d e a th
From the date of S ir Joh n E ric E richsen s observations o n
the subj ect ( 1 8 4 2 ) to the prese n t the e ffects o f closure of the
coro n ar y arteries have been much discussed A very good his
t o ric al summar y is g iven b y TV T P orter in the Jo u r n a l of
P hysiology vol XV 1 8 9 3 I t is remarkable h o w discord an t are
the state m ents of different observers A s this author remarks
seldom have the results of ph y siolo g ical studies been more at
variance ; there is no state m e n t w hich is not denied no fact
w hic h is n o t disputed
More rece n tly P orter has a g ain g one
over the w h ole q uestion w it h a g reat deal of Skill an d I w ill
*
give y ou here some of his conclusions
T he fre quenc y o f the stoppa g e of the h eart s action is in
proportion to the si z e of the arter y tied L i g ation of the small
est ar ter y t h e arteria septi does not cause arrest ; of the next
in si z e the coronaria dextra fourteen per ce n t of the li g ations
w ere follo w ed by arrest ; t h en comes the larg er descendens
w ith t w enty ei g ht per cent ; an d finally the circum fl ex the
lar g est arte r y o f all w ith Sixt y four per cent
T he effect o f closure o f th e coronary a rteries on the blood
pressure w ithi n the heart is of g reat importance A fter the
t y i n g of a sin g le vessel there is a diastolic rise o f pressure
w hic h is not compe n sated for b y any i n crease of pressure in
or
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Journa l of E xperim en ta l M ed ic ine
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v o l.
i,
No
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1 , 1 89 6
.
TH E
C ORO NARY A R T E RIES
13
.
t h e coronary ar teries ; on the contrary in them the pressure
is fallin g w hile that in the auricles is risin g I t is k no w n that
the normal mean pressure in the auri c les and conse que n tl y
in the coronary veins near their mouths is ver y lo w A rise
o f a fe w millimetres of auricular pressure m i g ht i n terrupt the
entire coro n ary C irculation This is o n e o f the most impor
tant poin ts brou g ht o u t by P orter s researches an d I q uote
h ere a paragrap h on this point :
I t must be ackn ow led g ed
t h en that a ri sin g auricul ar pressure after lig ation m ay at
len g th put a stop to the w h ole blood suppl y o f the cardiac mus
c le
and as this rise is often occasioned by the closure of a
sin gle vessel it is plain that the e n tire coronary circ ulation
in fact be interrupted by the li g ation of one coron ary
c an
”
artery
I t h as been much debated w heth er t h e coronary arteries
are really te rmin al o r e n d arteries A natomicall y it ma y be
show n that th ey are not sin ce an injection li q uid can be m ade
to pass from o n e artery throu gh commun i catin g b ra n ches i n to
t h e ot h er A ll are a g reed h ow ever that the an astomosis is
not sufficient to permit collateral circulation to keep a vascular
area alive after the distributin g arter y is bloc k ed The effect
o f plu gg in g of the arter y is the production o f w h at is k n o w n as
an an ae mic i n farct a w ell reco g n i z ed pathological con ditio n
the consideration of w hich need not detain us A ver y i m por
tant matter relates t o the e ffect of plu g gin g of the coron ar y
arteries upon the heart b eat ; the con tractions become of the
type kn ow n as fib r illar y and it is difficult or impossible to g et
—
the org an to resume the ordi n ar y c o ordinated beats thou g h
experime n tall y this has been don e even a f ter fibrill ary con
traction has been established
The relation of coronary art ery disease to an g i n a pectoris
w h ic h w as su gg ested by Jenner h as directed the very p arti e n
l ar attention of w riters to t h e C han g es in these vessels I t does
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ANGINA PEC T ORIS AND AL LIED S T A T ES
14
.
good to look over th e older literature and to n ote th e ac
curacy w ith w hich some of the cases h ave b ee n recorded par
P arry too g ives an i n terestin g se ries
t ic u lar ly b y Mor g ag n i
from t h e O lder w riters The su b j ect is S O exte n sive that I c an
but I may perhaps
n o t e n ter upon it here in g reat detail
brin g it before you w ith suffi c ient emph asis if I speak o f the
common se quences in con n ection w ith illustrative c ases
T he coronar y arteries are ver y subj e c t to deg enerative
C han g es particularl y in pe rsons w h o have passed the middle
period of life The y m ay b e a ffected alone o r as part o f a w ide
spread disease Of the vessels For practical purposes w e need
n o t consider an y ot h er C ha n g e than arterio s clerosis in its var i
o u s g rades from a tri fl i n g thickeni n g to atheroma and ri gi d
calcification W e must h ow ever reco g nize an a ffection of the
orifices o f th e arteries apart from the common de g eneration
A gradual n arro w in g o f the orifice of a vessel
o f t h e trunks
may be quite as se rious as extensive disease of t h e bran c h es
Th ere is a form o f aortitis met w it h n o t infre quently in men
betw een the a g es o f thirty and forty w h o h ave h ad syp h ilis
and w h o h ave w orked h ar d and drank deep (de v o te e s o f
V e n us Bacc h us and V ulcan ) in w hich the intima is sw ollen
almost corru g ated w ith fresh t ranslucent areas of endar teritis
I skip all considerations o f it s an atomy T hree se rious se
a
u
e
n
c
e
w
:
R
f
ma
y
follo
upture
t
h
e
orta
sometimes
o
s
a
q
( )
o n ly o f the intima as clean cut as w ith a r azor in h alf o r a
third of th e c ircumference sometimes w ith th e formation of
a dissectin g a n eury sm ; ( b) the slow development of the ordi
nar y form o f aneur y sm o f the arch ; and ( 6 ) narrow in g o f the
orifices o f the coron ar y arteries
A n gi n a attac k s sudden
death and slo w ly developi n g m y ocarditis and its se q uences are
the possibilities in th is th ird cate g ory I pass around thi s fine
plate o f C orri g a n s ta k e n from th e D u blin Jou r n a l in w h ich
w
g
re
t
s
ellin
g
of
t
h
e
intima
above
t
h
e
v
ves
due
as
o
u
se
e
a
a
l
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C ORO NARY AR T E RIES
TH E
15
.
C orri g an expressed it to an effusion o f organized lymp h b e
”
t w een the li n in g membrane an d the fi b rous coat
Th e pa
tient in this case a man o n l y thirty ni n e years o f a g e suffered
w ith severe attacks o f an g i n a
L e t me illustrate by these Specimens some of the more com
mon patholo g ical conditions associated w ith disease o f the
branc h es o f the ar tery H ere is an extraordinary heart w h ic h
illustrates h ow mu c h o f the coronary circulation can be cut o ff
if t h e Obstruction t akes place g radually T h e org an w as tak en
from a man a g ed about thirty six o r thirt y —
seven w h o h ad
been an Inmate fo r ei ghteen years o f the In stitution for
Feeble minded C hildren at E lw yn P a
He w as a large
pow erful imbecile dum b but n o t deaf H e w as very g ood
tempered did a great deal o f w ork a b out th e farm and fre
quently did very h eavy liftin g H e never h ad epilep sy ; h e
w as n o t kno w n to be Short o f breath nor h ad h e complained
One
o r indica ted in an y w ay that he w as o u t o f healt h
afternoon h e h ad a sort o f fit the face became very mu c h c o n
gested and h e died in about h alf an hour T here w as nothin g
special found in t h e brain The heart as you see is large an d
There w as g eneral hypertroph y w ith
w ei gh ed t w enty ounces
dilatation T here w as q uite extensive fi b roid m y o c arditis
part icularl y in th e anterior w all o f the left ventricle at the
apex and in the low er portion o f t h e septum ventriculorum ;
t h e valves w ere norm al But w h at I w ish you to examin e
most p ar ticularly is the state o f the coronary arteries w hich
are freely dissected o u t The le ft vessel is almost o b literated
only a pin point ch an n el remainin g w hile o f t h e rig ht arter y
t h e main division pa ssin g betw een th e auricle and ventricle is
converted into a fibroid cord "
I t is muc h more common t o find one art ery extensively dis
eased o r even completel y o b literated T ake for exam ple this
specimen w hic h w as removed from a colored man , ag ed about
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AN GINA PEC T OR IS
16
ALLIED S T A T E S
AND
.
thirty fiv e w h o h ad aortic insufficien cy w ith dyspn oea and
H e died suddenl y thou g h he had for
oedema of the le g s
some w eeks great dilatation of the h e ar t and g eneral anasarca
Th e aortic se g ments are curled an d thickened ; the ascendin g
arc h is greatly deformed w it h a recent g eneral endarteritis
Th ere are a fe w calcar eous plates The ri ght coronary artery
is completely obliterated There is no Openin g w hatever o n
the aorta Th e left vessel is dilated and presents atheroma
tous patch es Th ere are ar eas o f fi b rous m y oc ar ditis in the left
ventricle but in o t h e r respe c ts the muscular substance o f the
h eart does not look abnormal and it is not fatty
H ere is a muc h more common condition I n th is anterior
coron ary artery you se e a firmly adherent t h rombus w hic h
completely occludes the desce n din g bran ch to the lumen of
I t w as taken from a man about
w h ic h it is firmly attached
—
fifty years of a g e w h o had mitral valve disease and had a g ood
deal of c ar diac dyspn oe a E arl y one mo rnin g h e w as seized
w it h severe pain about the heart an d s h o rtness o f breat h and
died in a very fe w moments Both coronary a r teries w ere
thickened and calcified an d presente d atherom atous plates
but no doubt t h e sudden death w as due to th e blo c kin g o f t h e
anteri or branc h of t h e left coronary artery by the t h rombus
When th e occlusion has persisted for any le n g th o f time
before deat h t h e condition o f an aemic necrosis may be found
I am sorry not to h ave a fresh specimen to Show y o u but most
o f you h ave no doubt seen microscopic
if not macroscopic
examples It is important in t h e dissection o f the h eart to
slice c arefully t h e septum and the w all as th ese infarcts of t h e
h eart muscle are found in numbers directl y proportion ate to
the care with w h ich the y are sou g ht W e h ave not ha d any
very lar g e number of cases Th ey are muc h more common I
t h ink in h ospitals w ith Old c h ronic cases or w it h w h ic h th ere
are in connection larg e almsh ouses as at t h e Blockle y Hospi
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ANGINA PEC T ORIS AND ALLIED S TA T E S
18
t ri n sic
.
nerves of th e org an D oubtless some of you h ave seen
in t h e patholo gical laboratory D r Berkele y s w onderful speci
mens illustratin g the ultimate terminations of the filaments
*
betw een and o n t h e fib re s
I n lookin g at them one realizes
t h e trut h of th e remark o f a recent author that it is difficult
to say in w hich t h e myocardium is ri cher nerve elements or
—
muscle fibres E very w here throughout the org an in the t is
sues beneath the e n docardium and pericardium through out
—
the muscle substance and about t h e blood vessels th e nerves
are in extraordinary profusion T he double nerve supply y o u
know from va gus and sympath etic and the double function
the former controllin g C heckin g and in h ibiti n g th e latter
au gmentin g the force and h astenin g th e fre q ue n cy o f the
h eart beats Th e resear ches o f H is junior and R omberg h ave
sh ow n th at the g an glion cells o f t h e h eart even th ose lyin g in
t h e vagus branch es h ave t h e same o ri gin as al l other sympa
t h etic cells Th ey differ in protoplasmic appearances and in
oth er w ays from th e cells o f the spinal g an g lia T h e rh yth mic
action Of th e h eart is probably automatic due to a pow er in
h erent in t h e muscular fibres thou g h this point is still in dis
pute O f th e functions of t h e nerves w e know a g ood deal o f
th e functions o f t h e g an glia nothin g His and R omberg sug
g est that from th em are transmitted to the central nervous sys
tem infinitely delicately graded unconscious impulses w h ic h
re gulate t h e circulation re fle x ly throu gh t h e va g us and acc el
O f K ronecker s c o ordination centre o u r know led g e
c rator
—
indeed its existence h as been called in
is still very in de fin it e
question I h ave seen Kronecker pe rform the experiment
—
and certainly w h en th e point in th e do g s heart is p ricked it
is situated about t h e low er limit o f th e upper th ird o f the v e n
—
septum
th e or g an becomes paral y zed in a state o f
t ri c u lar
This point
fib rillary tremor from w h ic h it does not recover
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D esc rib ed in Johns H opkins H osp ita l R eports
,
v o l.
iv ,
T H E C ORO NARY A RT E RIES
19
.
is with in th e area o f distribution of th e anterior coronary
artery the vessel Oftenest found plugg ed by thrombus or em
bolus in cases O f sudden death
D O these cardiac nerves possess other properties " H ave
t h ey also w ith the special function the endow ment o f re c e iv
in g tactile and painful impressions " C ertainly t h e heart is not
an org an of very acute sensibility Th e most extensive lesions
in fl ammatory de g enerative and neoplastic may not excite a
S in gle painful sensation
P ericarditis o f the most intense
grade w it h deep involvement of t h e myocardium may g ive
not t h e sli ghtest indication of its existence
I n experi mental w ork pinc h in g O f the h eart muscle may
excite re flex movements o f the muscles o f the bod y There are
a fe w interestin g cases in the human subject in w h ich t h e hea rt
h as been exposed by accident sufficiently t o en able it t o be
g rasped or touched I n the w ell known case w h ic h Harvey
gives o f t h e you n g V is c ount de M ont g omery in w h om
Ch arles I w as so much interested in conse quence of a fracture
o f t h e ribs o n t h e left side
w it h excessive suppuration the
h eart w as exposed and from Harve y s account w as quite i n sen
N empe in h omine Vivente e t ve geto citra u llam
sit iv e :
Offe n sam
c o r sese V ib r an s v e n t ric u losqu e e u s pu l san t e s v i
j
deret as m anu t an ge re t Fac t u m qu e e st u t serenissimus R e x
una mecum c o r sensu tactus privatum esse ag n o sc e re t
" uippe ado le sc e n s n o s ipsum tan g ere ( n isi visu aut c utis ex
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t e rio ris
se n sat io n e
,
”
)
Th ere is o n e other point o f g reat importance S ensory
nerve endin g s h ave been demonstrated in the arteries by
T h oma and recently S m irn o w t professes to have demon
st ra t e d similar structures in t h e connective tis sues of the hea r t
—
hi
h e t nks the se nsory nerve be g in nin g s of the depressor nerve
n e u t iqu am
in t e llige b at
.
.
,
,
.
de ge n e r a tion e
i
1
a
t
o
i
e
A
n
e
e
r
895
r
A
n
m
sc
h
z
f
g
E
x e rc ita t io n e s
,
.
a/nim a lium ,
1 65 1 , p 3 1 1
.
.
L E CT U R E
E
TI OL O G
II
.
A N G I N A P E C T O RI S V E R A
GE N E RAL
Y.
DE S
C R I PTI O N
.
OF T H E
I
D SE
AS E
.
I nc ide n c e of t h e disease —Stati on in 1 ife —S e x — A ge —Epide m ic in flu enc es
—H e re d1 t y —G o ut —D i b ete — Syph ilis — S pe c ific f ev ers —H e a t dis
e ase —L o c o m ot o r ata ia —G en e al pi ture of t h e d ise ase
.
.
a
.
s
.
.
r
.
.
x
.
.
r
c
.
— As
noted lon g ago by S ir
G ilbert Blai n e an gina pectoris is a rare affection in h ospital
practice G airdn e r criticises this statement rather sharpl y and
y et I th ink that a maj ority o f h ospital p hysicians w ould be
found to support it D urin g the ten years in w hic h I lived in
M ontreal I did not se e a case of the dise ase eith er in private
practice or at th e M ontreal G eneral H ospital A t Blockley
Ph
iladelphia
H
ospital
too
it
w
an
exceedin
g
l
y
rare
as
f
f
e
c
a
(
)
tion I do not remember to h ave h ad a case under my per
sonal care Th ere w ere t w o cases in my service at the U niver
D urin g the seven y ears in w h ic h th e Joh ns
sit y H ospital
H opkins H ospital h as been ope n ed w ith an u n usually larg e
”
material in diseases of the heart and arteries and w ith
many cases o f heart pain of various sorts there h ave been
only four i n sta n ces o f an gin a pectoris You w ill fin d the
statement in Fagge s P r a c tic e ( third edition vol ii p 2 6)
t h at t h e w riter h as never seen classical an g ina in h ospital
”
practice
O n th e ot h er h a n d an i n dividual consultant may se e w ithin
a year more cases t h an occur in all th e h ospitals of h is tow n
I NC I D E NC E
OF
TH E
D I SEASE
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20
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A NGINA PEC T ORIS
w ith in
V
E RA
21
.
th e same period I n corroboration of t his strikin g c on
trast betw een the i n cidence of an g in a pectoris in h ospital and
consulting w ork I may refer to the statistics Of the E dinbur gh
R oyal In fi rm ary in w hich for the t w o years covere d b y the
H osp ita l R ep or ts 1 8 9 3 an d 1 8 9 4 there w ere five cases am on g
a total of
medical cases C ompare w ith this the personal
experience of t h e distin guished E dinburgh consulta n t D r
Balfour w h o in h is recentl y Issued w ork on The S e n ile H e a r t
g ives an analysis o f ninet y ei ght cases Of a n g ina pectoris seen
w ithin ten y ears
My individual experience embraces a series
o f sixty c ases
forty of w hic h may be re g arded as tr ue an
gi n a
Th e predisposin g causes o f an gina pectoris vera are those of
arterio sclerosis ; that is to say so i n timately associated is the
true paroxysm w it h sclerotic conditions of the coron ary ar
t e rie s that it is extremel y rare apart fro m them
Men of mus
c u lar even athletic build w h o h a ve bee n d e v o te e s of B acchus
and of V enus form perh aps the lar g est contin g ent G out
syp h ilis and hereditar y in flue n ce the causatio n onl y so far as
t h e y tend to cause sclerotic chan g es in the art eries ; but it
w ould be alto g et h er too narro w a vie w to suppose that the
ae tiolo gy o f t h e disease is ide n tical w ith that O f arterio sclero
sis
T he one is so common and the o th er com parativel y rare
even amon g the individuals most prone to sclerosis that there
must be a third element an indefinite someth in g w hich yet
escapes o ur know led g e b ut w hich is t h e essential factor in t h e
production o f this terri b le a ffli c tion
S T A TI ON IN L I F E — A s S ir Joh n Forbes remarks it is an at
tendant rath er Of ease an d luxury than of temperance and
labor ; on w hic h account thou gh occurrin g amon g the poor
it is more fre quentl y met w ith am on g t h e rich or in persons
I t is remark able h o w man y prominent
o f easy circumstances
individuals h ave succumbed to t h e disease W e may say of it
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22
AN GINA PEC T OR IS AN D
as
S yden h am did of t h e g out, th at more
A LL
IE D S T AT E S
w ise
.
men t h an fools
Victims
I do not know that any special occupation o r profession
predisposes to it but th e fre q uency w ith w hich ph y sicians are
attacked h as been commented upon by several w riters I n my
list of sixty cases of all forms there w ere thirteen medical men
eigh t o f w h om h ad true an gina T h is percenta g e is doubtless
exceptional and due in part at least to my nomadic h abits
and w ide ac quaint an ce in the profession
—
From the earliest description o f t h e disease t h e re
SE x
markable preponderance of males w h o are attacked h as been
noted H eberden says :
I h ave seen ne arly o n e h undred
people under this disorder of w h ich number there h ave been
t h ree w omen ( Com m e n tar ie s)
Th e statistics collected by
H uch ard g ive in t w o h undred and thirty seven cases of t rue
an gina only forty t w o in w omen I n my ow n series of forty
cases o f true an gina th ere w as only o n e w oman
—
A GE
T h e a g e at w hich it is most common is t h at of ar
—
t e r ios c l e r o sis
after t h e fiftieth year of life O f th e forty
cases o n my list there w ere only four under the fortieth year
O n e of t h ese a man a g ed t h irt y y ears h ad had syphilis five
years before ; the other case a w oman a g ed t h irty t w o years
had mitral valve disease ; the third case had terrible attacks
O f an gina follow in g chron ic pleurisy I n th e fift h decade
there w ere th irteen ; in the sixth thirteen ; in th e seventh
nine ; and of one c ase I did n o t g et the exact a ge T he aver
a g e o f the t h irty nine cases w as about fift y th ree y ears C ases
are reported in quite youn g individuals even in children but
suc h are almost invariably th e subject o f ch ronic valvular dis
ease o r o f adh erent pericardium
E P I D EM I C
I M IT A TI V E A N D E M O TI ON A L I N FLU E NC E S
L aennec w as o f th e opinion t h at th e prevalent type o f disease
”
in fluences its development and adds, I h ave som e ye ars met
ar e
it s
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‘
AN GINA PEC T OR IS
VE RA
23
.
”
it fre quently and h ardly at all in others
You w ill find
reference in the literature to so called outbre aks of a n g i n a
L
and by G e lin e au q I
w hich have been reported by K leefeld
c an not se e that t h e cases recorded by K leefeld h ave an y thin g
to do w ith an gina pectoris H e describes t h e epidemic as a r e
mittent fever w ith g astric complications and muc h pain about
the h eart S ome of the cases w ere fat al but no autopsies w ere
made Youn g persons c h ie fly w omen and c h ildren, w ere
attacked
G elineau sur g eon to t h e French corvette L E m b u sc ade
reports a remarkable outbreak amon g the sailors during a pro
lon g ed c ruise in the P acific S curv y had broken out and the
men w ere muc h debilitated and an ae mic T hey bec ame su b
jc e t also to a severe dry colic Follo w in g this there w ere man y
cases o f an gina Th e fir st case w as that of an Old sailor sc o r
butic and an ae mic wh o w h ile climbin g the mast w as sei z ed
w it h intense pain about t h e heart
Five days after five other
men w ere attacked in the s ame sudden w ay and three da y s
later three more G elineau lays a g ood deal o f stress upon
tobacco as a factor in th e causation o f the pain an d also upon
the de b ility follow in g t h e scurvy dysentery and dry colic
Th e effect of imitation that extraordi n ary occult in fluen ce so
potent in many forms o f h y steria must no doubt be taken
into accoun t P erh aps t h e most notable i n stan ce is g iven b y
*
I
D r T aber Jo h nson in h is report of M r S umner s case
ha ve O bserved a curious fact w hic h it ma y be i n terestin g to
refer to here I mean the unusual number o f patients suffer
in g from th is disease w h o previous to M r S umn er s sev e r e
illness h ad never supposed t h at t h e y had any disease of th e
h eart Th is fact h as been referred to by new spap e r corre
w it h
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Jou rn a l d
.
t
r
a
e
p
.
i
H e ilku n de 1 8 2 3 , l vi
,
.
a ze t te d e s H opita u x 1 8 62 x xx v
G
f
urn a l, 1 874
o
o
B
sto n M ed ica l a n d S u rgic a l
1
‘
.
.
,
J
.
AN GINA PEC T OR IS AND AL LIED S T A T E S
24
—
spo n de n t s
.
th at durin g the illness of M r S umner, and
especially since his death , inst ances of its occurrence h ave
co n siderably incre ased and especially am on g those w h o
stron gly sympathized w ith the late senator T his seem in gly
sympathetic cause of disease h as been noticed in other cases
I have been consulted b y as m any as thirty in dividuals since
M r S umner s death w h o ima g ined they w ere afflicted w ith
h is complain t I n some o f th ese cases t h ere w as org anic dis
ease of t h e heart but in a m aj ority o f t h em there w as n o
cardiac trouble at a ll T w o w eeks after the autopsy in M r
S umner s case o n e of the p h ysicians w h o assisted a devot
n d of the deceased died of an gina pectoris
attached
frie
e dl
y
I am i n formed that D r H itc h cock had but a fe w attacks and
that p ri or to Mr S umn er s death h e had never been a su f
”
ferer from an gina pectoris
D r Johnson sa y s that h e h imself suffered from t w o attacks
very closel y resemblin g if the y w ere not really an gina O n e
o f these occurr ed immediately after M r S umner s deat h and
Brow n S eq uard w h o w as present said th e phenomen a w ere
un doubtedly th ose of a parox y sm of an gina Tw enty t w o
year s h ave passed an d h appil y for h imself as w ell as for o u r
brethren of the D istrict o f C olumbia D r T aber Joh nson h as
n o w less mobile nerves
I n C ase X of my series o f pseudo an gin a th e patient s h us
band died suddenl y in a parox y sm o f true an g ina
Mental w or ry severe gri ef or a sudden shock ma y precede
directly th e onset Of the attacks I n C ase XXX VI t h e paro x
n
o
s
n
came
on
after
t
h
e
shock
of
the
annou
cement
that
a
m
s
s
y
h ad committed suicide
H E RE D IT Y — T ru e an gina pectoris is an art erial incident
an d since th e members o f certain families S h o w a specia l tend
ency to arteri al de g eneration it is not surprisin g to find cases
in fath er and son or in brothe rs o r e v e n in representatives Of
v iz ,
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ANGI NA PEC T OR IS
26
C az an av e
AND
ALLIE D S T A T ES
—
family a
R oc h e
de la
.
records three cases in o n e
sister w h o w as affected at t h e time of t h e report a n d t w o
broth ers w h o h ad died of the disease I n C ase X XIII on my
list t h e patient s father died of an gina pectoris
—
G O UT Th e relation o f certain constitutional disorders t o
an gina pectoris h as b e e n much discussed Th e impor ta nce of
g out as a factor w as e ar ly su gg ested and in this interestin g
—
little monograp h of Butter s w h ich I show you h ere the first
—
separate treatise on the disease th e auth or places t h e seat of
t h e disorder in the diap h ra gm an d calls it diaphra gmatic
g out Th e affection h as also b e e n te rmed ast hma arthriticum
N at h aniel Ch apman advocated strongly t h e art h ritic na
ture of an g ina pectoris and t h ere ca n b e no q uestion I t h ink
t h at in a certain number o f t h e Victims g out plays an impor
tant r i fle in indu c in g t h e arterios clerosis
I h ave b ee n p ar ticularly interested in examinin g into th is
point in t h e cases w h ic h h ave come under my observation
w it h in t h e pas t four o r fiv e years
Th ere are four cases at
least o f my se ri es in w h ic h g out seemed to play a part D r
o f V ir g inia s e e n A pril 3 1 8 9 4 a very robust Vi g orous
m an Of forty ei gh t temperate a h ard w orke r w h o h ad not h ad
sy p h ilis an d in w h om the attacks w ere fairly c h aracteristic
t h inks t h at g out (w h ic h is in h is family) is directly responsible
for t h e attacks C ertainly after usin g w ithout benefit for
many month s t h e iodides and th e nitrites h e obtained t h e
g reatest relief from a prolon g ed course o f colc h icum I t is
and h e remains
n o w more t h an t w o years since I saw h im
I n anoth er ca se a patient w it h attacks o f an gina pectoris
w ell
sin e d olor e t h ere h ad b e e n attacks Of acute articular g out
I n a th ird case a man a g ed sixty four t h e upper h alf
Of t h e pinna o f t h e lobe o f t h e ri gh t ear w as firm an d calcified
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L a Tribun e mé dica le , 1 895 , p 8 32
.
.
AN GINA
PEC T ORIS
VE RA
27
.
and t h e same process w as be gin n in g in the left ear T here
w ere no top h i , but t h e calci fication w as to say th e least su g
i
ve
e
s
t
A
a
fourt
h
case
t
h
at
of
a
p
h
ysician
from
N
ort
w
s
h
g
C aro lina a g ed fort y six w h o h ad for man y years attac k s
of g outy art h ritis c h ie fly in t h e bi g t oe less fre q uentl y in the
T here w as a w ell ma rked tophus in the ri ght ear
ankles
—
T h e associ ation of an g ina pectoris w ith dia
D IAB ETE S
betes has b ee n fre q uently noted
N O instance h as fallen
under my personal O bservation Yo u w ill find the w hole su b
very
tho
ou
g
hly
discussed
by
E
bstein
in
a
recent
paper
e
c
t
j
r
in th e B e r lin e r klin isc he Woche n sc hr ift of last year
S Y P H I LI S is one of the potent factors in i n ducin g a rterio
sclerosis and th us indirectl y plays a r é le in a n g in a pectori s
O f t h e cases in my series onl y four g ave a h istor y o f syphilis
Th e instances o f aortitis to w hic h I have already referred o c
currin g in t h e t h ird and fourth decades in men w h o have had
fli
s h ave w orked h ard and have b ee n heavy drinke rs ar e
t
sometimes associated w ith severe attac k s of an gina I n C ase I
L ieutenant X a g ed thirt y y ears a robust po w erful man had
h ad syp h ilis six years before his visit to me T h e secondary
symptoms w ere sli ght and he h ad not h ad ver y thorough treat
ment A ye ar before I saw him he beg an to have severe pains
in t h e h eart recurri n g in paroxysms an d associated w ith pain
dow n th e left arm and d y spn oe a on exertion There w as no
perceptible enlar g ement o f the h ea rt ; there w as a s y stolic
murmur at the apex and a soft bruit at the aortic area w ith
The at
o u t special accentuation o f the aortic second sound
tacks h ad b e e n o f such severity t h at h e h ad been Off duty for
man y months H e improved very much upon the iodide o f
potassium but still h ad attacks six month s after I saw him
C orri gan s case
s ince w h ich time I h ave not h eard Of h im
w
w
remember
the
illustrative
plate
of
h
ic
h
I
sho
ed
y
ou
u
o
y
at t h e last lecture w as in a youn g man and belon g ed to this
.
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ANGINA PEC T ORIS AND ALLIE D S T A T E S
28
.
group T he frontispiece in Balfour s w ork o n the h eart ( sec
o n d edition illustrates another case o f the s ame kind in a still
)
y ou n g er man a g ed t w enty four years The an g ina attacks
w ere associa ted w ith an aortitis w hich narro w ed g reatly the
ori fices o f t h e corona r y art eries
—
In connection w it h the specific fevers
S PE C I FI C FE V E R s
several w riters h ave described an g ina like attac k s Fr ae n t z e l
in h is Vo rle su n ge n il be r d ie K r a n khe it e n de s H e rz e n s (Berlin
describes attacks o f an g i n a pectoris in the w eakened
particularly ery
an d dilated h eart follo w i n g the i n fections
sipelas t y p h oid fever and p n eumo n ia J W Moore h as re
ported t w o instances o f an g i n a s y mptoms in connection w ith
h eart w eakness du ri n g and after the specific fevers I n th e
epi demic O f a remittent fever reported by K leefeld ( and al
ready referred to) the attacks o f heart pain ma y have b ee n o f
this cha racter I do not remember t o h ave seen a case in
w hic h t h e attack developed duri n g convalescence from o n e
o f t h e ordinar y fevers
A m on g the many nervous se q uel ae Of influ e n z a fe w are
more distressin g th an the attacks o f severe cardiac pain In
some cases indeed the disease seems to h ave b e e n th e startin g
point o f attacks o f true an gin a The fre quency o f t h e compli
cation in the practices of some ph y sicians is remarkable I n
a paper o n T he A ction o f In flue n za P oison on th e Heart C ur
tin an d W atson state that w ith in t w o years they met wit h
full y seventy cases of painful attacks about the h ea rt Th e i1
’
lustrative cases in t h eir paper r show that some of th e attacks
must h ave b e e n o f very great severit y but in most instances
the duration o f th e disease w as sh ort and t h e cases evidently
belon g ed to t h e cate gory o f pseudo an gina I h ave seen but
’
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D u blin M e d ic a l Jo u rn a l 1 89 0
.
.
v ol
f In tern a tion a l M edica l M agazin e
,
.
Ix x
x
ix
.
January, 1 89 3
.
ANGINA P E C T OR IS
V ERA
29
.
instances in w h ic h th e attack seemed to follow directly
upon the in fluen z a O ne is certainly pseudo an g ina ; t h e other
proved t o b e the g enuine disease
t wo
-
.
.
s e veral occ asi ons in Toronto a medical fri end wh o
after a tolerab ly severe atta c k o f i n fl u e n z a ab o u t three years ago
b e gan t o ha v e atta c k s o f agon i z i n g p ai n ab ou t the h e art The y
c ame o n w i thout w arn i n g the p ai n appe ar i n g i n vari o u s p arts
o f the chest commonl y under b oth should e r b l ade s an d e spe
There was at first n o irregu l ari ty
c ially severe i n b oth w ri sts
o f the pul se o r d i ffi cult y in b reath i n g ; b ut i n some attac k s there
A t fi rst th e se att ac k s w ere
w ere pip i n g Tale s d u r i n g exp i rat i o n
almo st ni ghtly ; several t imes they ende d i n vomi t i n g (preceded
b y pro fu se salivat i on ) the p assage o f more o r le ss flat u s an d
cop i ous sw eat i n g There w as n o mental anxiety w hateve r e x
cept as he expressed i t the pa i n was so i n tense tha t I w as
”
T h e p ai n
a frai d I w ould recover i n order t o endure it a g ai n
i n the arms was c h i e fl y i n the front o f the w ri st s The p at i e n t
had n o t had any seri ous i llne ss previ ousl y had never h ad syphi
lis had n o t b ee n a heavy dri n k er b u t had b ee n a prett y h e av y
smo ker The att ack s re c u rred w i th i nten sit y throu ghout the
When I saw h im there w ere n o si gns o f
e arly part o f J an u ary
cardi ac di seas e H e had had a g ood de al o f di gest iv e di st u rb
ance D urin g the f ollo w i n g sum m er and autu m n he progr e s
siv e ly i mproved
an d I he ard f rom h i m re c e n tl y t o the e ffect
that n o w o n l y i n an y extra strai n an in the attendan c e u po n a
di ffic u lt c ase o f lab or does he feel an y p ain H e use d the i odi de
stead i ly fo r som e t i me w i tho u t an y spe c i al be n e fit H e at
tri bute s more b enefit t o lavage o f the stomac h w ith h o t
water n i ght an d morn i n g
H o w far the i n fl u e n z a in th i s c ase
w as re spo n si b le fo r the att ac k is o f co u rse d i ffi c u lt t o say b u t
when I saw h im fi r st he w as very i n si stent th at i t w as the ca u se o f
h i s w hole tro u ble From the rapi d way in w h i c h the att ack s
have amel i orat e d an d h is pr e sent gen e ral c on di ti on th e re is
t o say t h e le ast a stro n g pr o b ab i l i t y th at it is fu n ction al and
n o t assoc i ated w i th or g an i c d i se ase
The other c ase was th at o f the l ate ch i e f j u st i c e o f th i s S tate
wh o had i n the e arl y winter o f 1 8 9 3 a very sev e re attac k o f
I
saw o n
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AN GINA PEC T ORIS
30
ALLIED S T A T ES
AND
in fluenza w ith much f ever and prostration I n the latter p art
o f D ece m b er h e b e g an t o h av e p ai n a b o u t the he art i n w al k i n g
b ri sk l y up a h i ll Then he had more severe atta c k s but in the
su m mer o f 1 8 9 4 he w as b etter an d w as a b le t o t ak e lon g w al k s
The attac k s recurred ab ou t C hri stm as 1 8 9 4 I saw him o n
J an uary 2 0 1 8 9 5 There was n o en larg ement o f the heart
the sounds w ere clear the secon d aort i c a l ittle a c c e n tuated
T h e o n l y stri ki n g a n omal y w as a cond i t i on o f tri ge m i nal heart
b e at s— g rou ps o f three b eats w i th an i nterval f ollo w ed i n regu
lar se quence
H e improved very much through t h e summer
I n O c to b er he h ad a severe shoc k o n he ari n g o f the
of 1 8 9 5
sudd e n death f rom an gina o f h is b rother in la w ( C ase XXXV
H e d i d n o t ho w ever have an y recurrence unt i l
o n m y l i st )
I saw h i m o n J anuary 5 1 8 9 6 The p ar oxy sms
D e c em b er
I n the f ollo w i n g
h ad b eco m e more f re qu e n t and very severe
w eek he di ed i n an u n usually prolon g ed att ac k The o n set o f
the an gi n a co rresponded wi th the peri od o f c onvale sc en ce from
the in fluen z a w h i ch he alway s i n si sted had cau sed the attack s
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—
D IS E A S E
H E ART
P aroxysms o f a g onizin g substernal
pain w it h radiation to the neck and arm are rare in the ordi
nary forms of h eart disease w hich w e meet w ith in h ospital
H eart pain is common enou gh and if w e counted all
w ork
such cases as a n gina w e w ould not have t o lay stress o n t h e in
fre quence of this syndrome in the w ards Y o u remember th e
small b oy in W ard F durin g th e earl y part o f th is session w ith
greatly enlarg ed heart probably from pericardial adhesions
P ain w as the most distressin g symptom o f the ca se but it h ad
neith er t h e intensity the parox y smal Ch aracter nor t h e ac
c o m pan im e n t s w hich w arrant t h e dia g nosis o f true an g ina
S O too in t h e case o f t h e Old colored w oman at pre se nt in
—
W ard O w ith mitral valve disease and extreme arterio sclero
f
o
I
h
ave
poi
ted
out
to
you
that
the
attacks
sudden
n
i
s s
breathlessness and distress w ith transient pain are o f th e na
ture o f cardiac asth ma w ith w hich as I w ill tell you later
an gina pectoris is often confounded T hen a g ain you h ave
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ANGINA PEC T ORIS
VE R A
31
.
bear in mind the common complaint o f pain beneat h the
left breast in patients w ith chlorosis and various forms of
anaemia
O f valvul ar affections aortic insufficiency is th at w it h
O f th e
w h ich an g ina pectoris is most fre quently associated
forty cas es in my list th ree presented si g ns o f this lesion T he
subjects o f th e de g enerative type o f the disease w h ic h de
v e lo ps in men after th e fo rtieth y ear are much more prone to
an gina th an th ose in w h om th e insufficiency h as follow ed e n
Th e youn g er the subj ect the greater th e proba
doc ardit is
b ilit y t h at t he incompetency results from an acute aortitis
as in C orri g an s case to w h ic h I have referred o n several occa
S ions
A n g ina pectoris is excessively rare in mitral valve disease
*
Th is is w ell illustrated by N othnag el s experience O f fifteen
h undred cases o f valvu lar dise as e of t h e heart s e e n in h ospital
an d private practice very many o f w h ich h ad symptoms of an
gina there w as but a Sin gle c ase in w h ic h th e syn drome oc
curred in connection w ith mitral stenosis O nly o n e of my
cases a w oman h ad a mitral lesion By far th e most common
h eart disease w ith w h ich angina is associated is ch ronic m y o
c arditis the si gns of w hic h ar e often dubious
C ases o f adherent pericardium an d o f a neury sm of th e
aortic arc h may present th e features Of typical an g ina more
Often in my expe rience of constant substernal pain o r o f
cervico brachial neural gia
A majority o f the subj e cts o f an gina present the si gns of
arterio sclerosis w ith accentuation of th e aortic second sound
and sli gh t increase in th e area o f transverse h eart dullness
S ome o f th e most rapidl y fatal cases are those in w h ic h the
p hysic al si gns are very sli gh t o r e v e n absent O f th e cases on
to
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Verh a/nd lungen d e s Co ngresses f in nere M e dicin , Bd
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x.
ANGINA PEC T OR IS
32
AND
ALLIED S TA T ES
.
my list in four only w as th e p hysical exam ination ne g ative ;
t h ree presented apical o r basic murmurs ; o f t h e r e m aIn de r
all o f w h om sh ow ed si g ns of sclerosis of the arteries nin e h ad
indications o f myocardi al chan g es
—
L OCO M O T O R A T A x rA
C onsiderin g the close relationsh ip
o f syp h ilis to this dise ase in w h ic h also arterio—
sc le r o sIS Is so
common it is not su rprisin g that attacks of an gina pectoris
sh ould occur N o instance h as fallen under my personal ob
servation Y o u know that aortic insufficiency is not rare in
tabes A t Blockley t h e association w as a matter o f every day
comment and in the p h y sical dia gnosis class w e w ould send to
t h e o u t w ards fo r the Old tabetics to demonstrate th e lesions o f
arterios clerosis and if not of aortic incompetency o f t h e rin g
in g metallic aortic second sound w h ic h so often accompanied
t h e dilated and rigid aortic arch Yo u w ill find th e subj ect
fully discussed by L eyden in the Z e itschr ift klin M e dic in
for 1 8 8 7 and since his paper t h ere h ave b ee n several less im
port ant communications
—
In any lon g series of
G E N E RA L P I C TU R E OF T H E D I S E A S E
cases o f an gina w e c an reco g n ize four groups :
I S udde n D e a th w ithou t o the r M an ife sta tions of A n gin a
—
M uc h more tru e o f an gina pectoris is w h at A ndral
P e c toris
said of th e fulminant form of c h olera : it be gins w h ere other
—
diseases end in death T he a ffection h as indeed b ee n called
by S ir W alter Foster a mode o f death w h ic h reminds o n e o f
t h e expression o f t h e physicians w h o spoke o f S eneca s malady
as a m e dita t io m or tis N o inconsiderable proportion o f sudden
death s in men o f middle a g e and robust h abits result from
coronary artery disease from th e rapid culmin ation so to
speak o f a condition w h ich in an oth er ( o r on previous occa
w ould h ave caused an ordi
sions in the individual h imself)
Before all is over th ere ma y be a mo
n ary attack o f an g ina
mentary conscious ag ony expressed by a cry but in oth er in
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AN GINA PEC T ORIS AND ALLIE D S T A T ES
34
.
in full h ealth in the prime o f life may b e seized w ith a par ox
an
g
ina
The
cases
in
this
f
an d die w ithin a fe w h ours
m
o
s
y
cate g ory ar e not numerous P erh aps t h e most remarkable o n e
o n record w h ich h as become q uite historic is th at o f t h e cele
b rat e d D r A rnold of R u gby w h o in the w ords o f his distin
f
ar ose
i
h
n
also
a
victim
o
the
disease
d
u
e
so
s
)
g
(
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tread
In the summer morn i n g the roa d
O f de ath at a call un f oreseen
”
S udde n
to
,
,
,
.
T he follo w i n g is
T A
L atham
’
s accoun t :
w i th i n a day o f com plet i n g h is f orty sevent h
year Up t o a fe w ho u rs b e fore h is death b oth b ody an d mi n d
H e st i l l
seemed e qu all y t o g i ve proo f an d prom i se o f he alth
too k h is a c cu stomed pleasure an d re freshmen t i n strenuou s
exerci se H is thoughts were st i ll b usi ly em ployed upon the
h i ghe st sub j e c ts con cei vi n g and compo sin g w it h wonderfu l
ease rap i dit y an d po w er H e ret i red t o rest at mi dnight o n the
1 1 t h o f Jun e 1 8 4 2 f eel i n g an d b el i evi n g h i m sel f t o b e in pe r
f ee t health A t a qu arter b e f ore s e ve n the next morn i n g h is
medi cal atten d ant was c alled What had previo u sly occurred
an d w hat f ollo w ed I w i ll give in the w ords o f D r B u c k n ill w h o
w as wi th h i m d u ri n g the short remain i n g peri od o f his exi st
en c e
O n my en teri n g h is room he sai d tha t h e was sorry t o
di sturb me so soon ; an d that he h ad n o t sent for me b e fore
thi nk in g that i t w o u ld go Off H e added
I h ave had very
severe p ain i n the chest si n c e five O clo c k at intervals an d it
”
g et s worse I th i n k
Thi s p ai n was se ated at the u pper part
o f the chest to w ard the le f t S i de an d extended do w n the le f t
arm H e h ad b ee n rather si ck H e then a sk ed m e w h at the
”
pai n was
Wh at is i t "
H e was n o w alm ost free from p ai n
H i s pul se I could scarcel y feel The ton gue was c lean Th e re
was cold perspirat i on over h is f ace
The fe e t and leg s w ere
.
w as
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t
L a h am
’
o Stanl ey s
al s
’
Wor ks v o l i p 45 3 ; N e w
L ife of Th o m as A rn o ld
s
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,
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S yd enh am S oc iety
,
1 8 76
.
S ee
AN GINA PEC T OR IS
35
.
The b reathin g at th i s t i m e n o t troub l e d I gave h im
i m m edi ately som e h o t stron g b randy an d w ater an d havi n g
ordered a mu st ard plaster fo r h is c he st t i l l th i s was r e ady I
appl i ed h o t flann e ls an d h ad h is l e g s an d a r m s r u bb e d an d t h e
fe e t wrapped u p i n flan n e ls wru ng o u t o f h o t w at e r an d m us
t ard The pu l se b e c am e n atu ral t h e extrem i ti e s mor e w arm
an d he w as f ree f rom p ai n
The m ust ard plast e r w as b rought an d
put o n I t was n o t large eno u gh an d I ordered an oth e r
The
pa in then return i n g I g ave h im m ore b ran dy an d w at e r an d i t
soon left h im A n d n o w he ask e d me agai n w h at the pai n was
I told h im I b el i eved i t w as sp asm o f t h e he art H e e xc l aime d
”
Ah " I a sked h i m w hether he h ad ever f ai nt e d i n h is li f e
”
N 0 never
I f he h ad at an y t i me d i ffi c ulty o f b reath i n g
”
N o never
I f an y p ai n in h is c hest b ef o re
N 0 n e ve r
I then ask ed h i m i f an y o f h is f am i l y h ad eve r h ad an y di se ase
”
o f the c he st
Y e s my f ather h ad ; h e di e d o f i t
H e in
qu i red i f di sease o f the he art w as su dde n ly fat al I an sw e r e d
"
a
w
s
as
a
m
that i t
W i t com o n d i se ase
I sai d n o t ve ry c o m
”
m on
Wher e do yo u fin d i t mo st "
In l ar g e to w n s I
”
”
"
n
thi k
Why
Perh ap s f r o m an xi e ty an d e ag e r c o m
pet i t i on am on g the h i gher an d i n t e m p e ran c e am on g the low e r
”
cl asse s H e was then qu i et an d free fro m p ai n an d I propose d
t o l e ave h i m for a mi n u te o r t w o
H e h ad n o p ai n what e ve r
in my ab sen c e O n my return the p e rsp i rat i on was st i ll i n drop s
upon h is forehead T h e pul se w as again f e eb l e an d I gave
h im more b ran dy an d w ater an d h ad the flan n e ls w ith mu stard
rene wed A n attac k o f p ai n w as c om i n g o n H e sai d I mu st
”
stret c h mysel f
I too k o n e o f h is han d s an d h e l d i t unt i l t h e
pai n w as g on e o ff I t was o f short du rati on I sai d Is i t
”
”
go n e " H e an sw ered Y e s en t i rel y addi n g th at h e c o u ld
”
sc ar c el y b e ar i t i f i t w e re as severe as i t h ad b e e n
H e th e n
”
ask e d me
what w as the g e neral c au se o f thi s k i n d o f di se ase
”
H e then sai d Is th i s l i k el y t o re tu rn "
I an sw e r e d th at I
w as afra i d i t w as b u t th at as the att ac k s h ad b ee n l e ss se v e r e
f
H e n e x t ask e d
an d les s f re qu e n t I hoped the y w o u ld pa ss o f
me i f the di se ase w as gen e rally su dd e n l y fatal I sai d g e n e rally
f
r tho se w h o k n e w h im w ere a w ar e th at i t w as i m po ssi b l e n o t
o
(
I then ask ed h im i f h e h ad an y
t o tell h i m the exact truth )
c
ool
VE R A
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A N GINA P E C T ORIS
36
AND
ALLI E D S T A T ES
.
pain H e sai d N on e b ut from the b lister ; o n e c an b e ar o u t
”
ward pa i n b ut i t is n o t so easy t o b e ar in w ard pa i n
I was
n o w dropp i n g some laudan u m into a win e glgas s w he n he in
qu i red w hat I was goi n g t o give h im I told him l audan um
H o ffman s anodyn e an d camphor ; and whil e I was preparin g
the mi xture an d b e f ore I h ad fin i shed I heard a rattlin g in the
throat and a c onvul sive stru ggle I calle d o u t and on turni n g
t o h i m I su pporte d his he ad w h i ch was thro w n b ac k o n m y
H is ey es w ere fi xed and his teeth se t an d he w as
S houlder
insensi b le H is b reath i n g w as very lab ori ous h is chest heaved
an d there w as a sever e stru ggl e over the upper part o f t h e b od y
H is pulse w as i mpercept i b le and a f t e r deep b reath i n g s at a
fe w prolon g ed i n terval s all was over H e died in little more
t han h al f an hour af ter I fi r st saw h i m
The exami n ati on sho wed a so f t flacc i d heart musc le There
w as b ut o n e c o r o n ar y arter y and th at cons i deri n g the si z e o f
the heart o f small dime n sion s I t pre se nted also a sli ght at h e
r o m at o u s depos i t an i n ch f ro m it s ori fi ce
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I n no case in my series did deat h occur in th e first
ro x
a
p
T he most rapid case w as M r E ( C ase XXXV) w h o
h ad an a g on i z in g parox y sm at
P M
o n O ctober 1 4 t h
and several lesser recurrences th rou ghout the ni ght T here
w as no attack on t h e 1 5 t h an d h e passed a comfortable ni ght
O n the 1 6t h at
A M he sat up o n the ed g e of t h e bed
to b e helped to t h e commode and fell over dead, about forty
t w o h ours from t h e onset of the first attack
III R e cu r r ing A t ta cks e x te n din g ov e r a P er io d of M on ths
—
or Ye a r s
M uc h more common ly a V ictim o f an g ina pectoris
h as man y paroxysms over a period of many mon ths o r from
th ree o r four t o tw enty or even tw enty fiv e years T he r e
’
c u rr e n c e s may b e at lon g intervals as in Joh n H unter s case
o r they ma y render t h e p atie n t s life un bearable since h e feels
that the sli ghtest tran s g ression muscular o r emotio n al may
precipitate a p ar ox y sm M an y a poor sufferer h as felt w h at
S enator S umner expressed :
Th i s treach e rous disease pro
s
m
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ANGINA
P E CT OR
IS
V ERA
37
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duc es in my mind a positive uncertainty w h en I g o out of
my h ouse w h eth er I shall ever enter it a g ain a livi n g man
and w it h th e pain I h ave to suffer makes m y life suc h a bur
den th at t h e sooner it does its w ork t h e better I shal l be
pleased L ife at the p ri ce I have t o pay is n o t w orth the hav
”
in g
L e t me read you t h e h istory o f a typical case of th is
sort :
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—
C A S E XXV I Mr S
an editor b y occupation a ged fift y
fiv e consulted me J anuary 1 6 1 8 9 4 compl ai n i n g o f att ac k s
o f a g on i z i n g pa i n in the re g i o n o f the heart
The p ati e n t was
o f a nervo u s temperament
b u t had b ee n a very healthy m an
H e had never do n e hard phy si cal w ork and had b ee n moderate
i n the u se o f alcohol and tob acco H e d i d n o t thi n k that he
had ever had syph i li s Three y ears ago f ollo w i n g u pon the
S hoc k o f the announcement o f the sui c i de o f a so n he h ad h is
fi rst attac k o f severe p ai n ab out the heart E ver since the at
tack s have re c urred at i rre gul ar i ntervals at first o f a fe w w e e k s
o r a month b u t w ithin the past y ear the y hav e b een v e ry fre
quent S O that he n o w rarely p asses a da y w i thout paroxy sms
They vary a great deal i n intensi ty I f he w alk s fast o r mak e s
an y unusual exert i on he is stopped b y an intens e pa i n i n the
heart and he h as t o pan t fo r b reath A fter la stin g fo r hal f a
mi nute o r so the pa i n p asses o ff and he i s ab le t o re sume h is
A ny unusual emot i on o r excitement wi ll bri n g o n an
wal k
attac k at once H e n o t un c ommonly n o w h as as man y as a
dozen o r more attac k s in the da y I n the severer p aroxy sm s
he feels as i f the throat was greatl y s w ollen an d say s th at b ot h
h i s throat an d h is temples throb an d that he get s very red i n
the face A s the atta c k s p ass o ff he usu all y swe at s qui te pr o
fu se ly F ro m what I can gather he d i d n o t appe ar t o h ave h ad
paroxy sms o f terri b le a g on y in w h i ch the sense o f impen di n g
d e ath was present H e sa y s ho w ever that the f e e l in g is as
t hou gh t h e heart w as g rasped in a Vi ce an d the p ai n s shoot u p
the neck and do w n the lef t arm T wo w eek s ago in P h ilade l
ph i a while w alk in g t o the stat i on he felt an exc e ssive l y s e ve re
pain i n the chest b ecame short o f b reath an d f e ll u ncons c i ous
When he recovered he found h imsel f in a nei ghb orin g chemi st s
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ANGINA PEC T OR IS
33
AN D
ALLIED S T A T ES
.
hop H e was ab le ho w ever t o proceed o n h is j ourney W hile
in my w ait i n g room th i s p at i e n t h ad t w o att ac k s an d wh i le
I was exam i n i n g h i m he h ad a th i rd t h e phe n o m e n a o f w h i ch
I w i ll de sc ri b e t o yo u l ater Thre e day s af t e r h is vi si t t o me
w h i le walk i n g up the steps o f h is ho u se he dropped d e ad
s
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The great maj ority
th is group
of
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all cases of a n gina pectoris come in
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IV
We e ks
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R ap idly R ep e a te d A t t a cks ove r a P e riod of D ays or
w ith t he D e ve lopm e n t of a S ta te o
ar d ia c A s st ole
C
f
y
’
—
m a l an gin e u w
An
individual in apparently g ood
health w h o may not have had any indications of h eart trouble
or w h o may h ave h ad at some previous date an attack o f an
g ina is seized w ith a severe parox y sm T his passes a w a y but
there is shortly a recurrence and for several days in rapid su c
cession there are subintrant attacks w ith increasin g w eakness
Huch ard describes the condition as l é ta t dc
o f t h e h eart
m a l a n gin e u cc
I n a w ay it is a counterpart of the status epi
le pt ic u s
Th e condition is o n e o f terrible distress I h ave
s e e n but t w o cases and as th is feature Of th e disease h as n ot
b ee n speciall y d w elt upon by w riters except Huch ard I w ill
read y o u an account o f t h em bot h
l e ta t de
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— On
XXX II
Jan uary 3 1 8 9 4 I saw with D r P ole
Mr L aged fift y fiv e y ears merchant wh o for a w eek had had
atta c k s o f severe p ain i n the re gion o f the heart
The pat i ent was a stout large framed m an w h o h ad lived
for man y y ears a l i f e Of gr eat activi t y
H e h ad al wa ys en j oyed
very ex c ellent health ; never h ad had rheumat i sm H e h as
sev en h ealth y children H e had b ee n a moderat e smok er an d
moderate dri n k er ch i efly o f b eer H e h ad n ot h ad syph il i s
S e v e n y ears ago a fter a sl i ght exert i on he h ad a very severe
w hi c h lasted how ever onl y a
at tac k o f pain a b out the h e art
day and then passed o ff H e had n o recurrence and h ad b een
very w ell though occasionall y he has b een a little short o f
CA S E
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ANGI NA
P E CT
OR I S
VERA
39
.
b reath o n wal kin g rap i dly A w ee k ago D ecemb er 2 7t h a fi re
occurre d in h is place Of busi ne ss and he was naturally ve ry
much exc i ted an d helped t o save the p ap e rs an d b ook s That
n i ght he had a severe attac k o f an gi n a p e ctori s accompani ed
w i th vomi t i n g an d sw eat i n g H e was b e tter the n e x t day an d
a b le t o go o u t S i n ce th e n he h as h ad three att ac k s all o f th e m
Of a g ood deal o f severi t y
H e feel s very w eak and f e eb le an d
the pa i ns are sever e enou gh t o re qui re morph i n e L ast ni ght
they were very much worse
H e w as a w ell nouri shed health y loo kin g man T h e pulse
was ab out 9 0 an d there w as n o i n c re ase i n ten si on ; the rad i als
w ere n o t sclerot i c and thou g h the temporal s stood o u t pro mi
n e n t ly the y w ere n o t fi rm
D uri n g the exa m i nat i on the pa
tient h ad an attack o f very severe pain an d cl asp in g his h an ds
over the he art rolled ab out upon the b ed H e w as flushed in the
face an d then b rok e o u t i n to a pro fu se p e r sp i rat i on D u ri n g
the att ac k the pulse d i d n o t c h an ge materi ally i n ch arac ter
b ut remai ned re gular The pa i n w as de scri b e d as very i n tense
a f eel in g as i f the heart was grasped in some th i n g I t extende d
also do wn the le f t arm an d in very severe p aroxy sms do wn
the ri ght arm The apex b e at was di ffi c u lt t o feel on acco u nt
T h e c ard i ac d u llness w as n o t i n creased
o f the f at mamma
The sounds w ere clear at apex an d b ase ; the aort i c secon d w as
The l u n g s were clear o n percu ssi on and the
n o t accentuated
b reath sounds w ere normal
The ab domen was di stended and the stomach tympany was
hi gh A s nitro gl ycerin and n i tri te o f amyl had n o i nfluence
whatever o n his attac k s morph i n e w as used
O n the 4 t h he w as b etter O n the 5 t h and 6t h he had very
severe attac k s re quirin g much morphine O n the 7t h an d 8 t h
he was sti ll w orse an d d i spl ayed a remarkab le re si stance t o the
morph i ne Thu s in the ho u rs b et w een t e n o c lock S atu rday
ni ght and 1 P M o n S unda y he had received b y mouth an d b y
h ypodermic in j e c t i on fi ve gra i n s o f morph ine i n spi te o f wh i c h
he scarcel y slept at all and at the t ime o f the vi si t the pup ils
S o r e si st an t
t hou gh sm all were n o t extremel y contracted
had he appeared t o b e t o the morphine that w e di scarded the
tab lets w hich had b ee n employed and O btai ned a fresh solution
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ANGI NA
40
P E CT OR
IS
AL LIED S T A T E S
AND
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attack s o f p ai n w ere o f great inten si t y and recurred fre
quen tl y They w ere o f the sharp ag oniz i n g f orm an d in the
O nl y the f u llest doses
intervals there was a du ll heav y w ei ght
o f morph i ne o n S und ay an d Monda y k ept h i m f re e from pa i n
O n Tuesday he w as some what b etter and o n Wedne sday he was
almost free
D urin g these protracted attack s h e was f re quentl y almost
b eside h imsel f w i th the pai n and sw eated very pro fusel y an d
o n S un day and Monda y and Tuesda y he h ad severe attac k s Of
vomi ti n g There was n o fever O n Wednesday the l 0t h he
I saw h i m earl y o n the morn i n g o f the 1 1 t h
He
w as b etter
had had a b ad n i ght w i th t h e shortness o f b re ath I f ound h i m
w ith a pul se o f 1 1 5 small in volume ; the heart soun d s feeb le
and di stant
The ch an g e so far as his heart was c on
cerned w as very stri kin g as the he art so u nds had previ ousl y
b een qu i te clear
T O day the y w ere extremel y feeb le
and the action somewhat irr egular O v er the left lun g there
were numerous b ronch i al r ales part i c u larl y i n the axi llary
re gion I n the eveni n g h is condi tion seemed really cri t i cal
The resp irat ions were 4 0 lab ored ; expirat i on prolon ged and
t here were m edium sized ra les heard over the whole chest
He
w as given w hisky f reel y H o ffman s anodyne and ammonia
and i n sp i te o f the thre ateni n g condit i on in his lun g s he was
given durin g the ni ght t wo o r three h ypodermic in j ections Of
morph i ne
O n t h e 1 2 th and 1 3 th the cardiac condition was b etter H e
had had n o attack s o f pain since Wednesda y The b ronchial
symptoms and cough cont i nued
O n t h e 1 4 th he w as n ot nearl y so well The respirat i on s
w ere hurr i ed the cou g h troub lesome an d over the w hole chest
pip in g rhonchi were heard The pulse was at ab out 1 2 0 and
f eeb le H e too k h is nourishmen t b etter and the feel i n g Of
w ei ght ab out the heart had graduall y dimi n i shed A ll alon g
the color Of h is face had k ept prett y g ood thou gh t hat of the
fin ger tips w as someti mes a l i ttle cyanotic
O n the 1 5 t h an d l 6t h he w as dec i dedl y b etter though the
His expectora
wheezin g rhonchi w ere st i ll present everywhere
tion throughout thes e attack s h ad b een muco purulent and
The
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ANGI NA PEC T ORIS
42
ALLIED S TAT ES
AND
.
si n gular character ab ou t the w ri sts ch i e fly the le ft w hich he
sai d felt as i f e n ci rcled b y a b and H e has occa si onally f elt
p ai n ab out the el b o w an d the le ft shoulder T h ey did n o t seem
t o b e rheumatic
Y esterday he had a very co m f ort ab le day
too k a l i ght even in g me al and w en t t o b ed f eel i n g i n h is usual
health H e was aro u sed th i s morni n g at se v e n O clo c k wi th a
very sev ere pa i n b eneath the b reast b one I t extende d t o the
reg i on o f the apex and w as felt very severel y do w n the le ft
arm an d ab out b oth w ri st s H e b ecame p ale b ut D r S her
w ood wh o saw h i m a b o u t hal f p ast seven s ai d th at the pulse
H e O b t ai ned temporary reli e f b y in
was n o t mu c h a ffected
h alati on s o f the n itri te o f amyl b u t b et w een ei ght and ni n e it
b ecame so se v ere that he had t o b e g iven w h i ffs o f chloro form
I saw h i m at
H e w as a healthy look in g m an w it h
gray i sh hai r and mustaches ; t here was n o arcus sen i l i s H e
w as n o t s w e at i n g an d he d i d n o t loo k very g reatl y d i stressed
The pul se was 9 0 o f fa i r volume w ithout i ncrea se o f tensi on
and the co ats o f the vessel were n ot specially th i c k ened T h e
apex b eat w as n o t easi ly t o b e felt The heart so u nds w ere dull
and muffl ed at apex ; there was n o murmur at the b ase T h e
aortic second sound w as n ot accentuated There was n o dull
H e had n o resp i ratory di stres s an d
n ess ov er the manub rium
there were n o p ip i n g Tale s The ab domen was n ot distended
The i ntensi t y o f the p ai n had pa ssed but he was st i ll suffer
in g a great deal from a very severe constant pa i n beneath t h e
b reast b one H e had n o t had an y sweatin g o r spec i al coldnes s
H e was ordered a quarter o f a gra i n o f m or
o f the hand s or feet
phine and t o have it repeated at intervals i f necessary H e
improved somew hat throu gh the day though the pain did n ot
ent irely d i sappear H e had a pretty comf ortab le n i ght
O n Tue sday the 2 5 t h he see m ed b etter H e had five or six
free movements from the b o w els and as he in si sted upon wal k
in g t o the w ater closet they exhau sted him a g ood deal
O n Wedne sday the 2 6t h w i thout an y act ive paroxy sm he
had a great de al o f su b stern al pai n and h is p u lse b ecame feeb ler
H e dreaded very mu ch a ret u rn o f the se v ere pai n an d had
small doses o f morph i ne at intervals I di d n ot se e him a g ain
H e had n ot had a good ni ght and
until Thursday at 2 P M
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ANGINA
P E CT OR
IS
VERA
43
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had b ecome much w orse through the mornin g signs o f great
cardiac w eak n e ss h avin g app e are d H e had had n o s w e at ing
When I saw h im he was greatly ch an ged
The p allor w as
marked and the ge n e ral depre ssi on extre me Th e re was n o
s weat i n g ; the face was pale rather than ash y gray The to n gu e
H is m i n d was qu i te c l e ar an d he c o m
was th i c k l y furred
plai ned only o f feel i n g s o f great exh au st i on an d an unea sy p ai n
b eneath the stern u m The head w as lo w ; the re sp irat i on s w ere
n o t hurri ed
The p u lse w as s c ar c el y t o b e count e d only a fe w
feeb le b eats reach i n g the w ri st There was n o heavi n g over
the prae cordi a ; the soun d s at the apex w ere only j u st audib le
i n gallop rhy thm A t t h e b ase the gallop rhy thm co u ld j u st
b e percei ved There seemed t o b e a sl i ght i n c re ase i n the are a
H e h ad b ee n h avi n g hypod e rmi cs o f stry ch
o f card i ac dullness
n i n e o n e sixt i eth b ut o n e th irt i eth was ordered every t wo
hou rs an d a hun dredth o f a grai n o f d i gi tal i n H e h ad pa ss e d
very sm al l qu ant i t i es o f u ri ne A t ten o clo c k th at eve n in g he
w as de c i d e dl y b etter ; the pulse was stro n g er an d the b e ats w e re
regular There w as st i ll sli ght gallop rhythm at the apex The
soun ds w ere very mu ch more di st i n ct H e compla i ned a g ood
deal o f an un pl e a san t ga sp i n g i n his b reathin g at intervals
wh i c h d i stressed h i m very mu c h
F eb ru ary 2 8 t h
P at i ent h ad had a rather re stles s ni ght
sleep i n g only at i nterval s an d b e in g muc h di stress e d b y gasp
in gs for b reath H e had tak e n small qu a n t it i es o f n ouri shm ent
and had h ad n o vomi ti n g T h e p u lse w as regu l ar sm all an d
a b out the same as l ast eve n i n g
H e h ad h ad di git al i n an d
strychn i n e regularl y through the n i ght H e h ad a v ery c o m
fo rt ab l e day an d seemed alto gether b etter tho u gh he h ad had
some sli ght d e l i ri um an d w an deri n g part i c u l arly after wakin g
H e had sl e pt w i th h is h e ad h i gh an d h ad n o t b ee n qu ite so
much trou b led w i th the card iac asthma H e h ad h ad n o attack s
o f p ai n
Th i s morn i n g he was n ot so w ell H e h ad h ad a
2 9 th
quart er o f a grai n o f morph i n e at ten l ast n i ght w hi c h qu i e t e d
h im b u t he w as arou se d at i n tervals w i th a di str e ssi n g se n se
The d e l i rium was m ark e d an d he look e d
o f the n ee d o f air
d i stressed ; there was n o coldness o f the hands and fe e t an d
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AN GI NA PEC T OR IS
44
ALLI E D S T AT ES
AN D
.
sw eat i n g The pulse was f eeb le i rregular an d intermittent ;
somet i mes three an d f our b eats w ere droppe d in succes si on
The apex b eat w as n o t palpab le The heart sounds w ere o n l y
j u st audib le at the apex There was a g allop rhythm A t the
b ase the second soun d could on l y j u st b e heard There was n o
murmur Throughout the day he w as qui et exc ept for at
tack s Of gasp i n g fo r b reath w h i c h w ere v ery di stressi n g A t
the pulse could n ot b e f elt at the w ri st H e w as c on
sc i ous ; the resp i rat i ons w ere n o t hurri ed though every five or
ten minutes he w ould b ecome a l i ttle restless an d gasp T h e
heart sou n ds coul d b e he ard b oth at apex an d b ase ; a very di s
t i n c t em b ryo c ard i a b ut n o mu rmur The f eet and hands were
co ld b ut he had had n o s w eat i n g I t was rather rem ark ab le
t o se e a m an i n such a desperate co n dit i on ent i rel y consc i o u s
and perfectly alive t o h is surroundin g s H e was at t imes very
nervo u s and re stle ss Throughout the even i n g he gre w w orse ;
the heart sounds b ecame feeb ler and a fter a peri od o f terr i b le
di stress fo r an hour o r more death occurred ab out s1 x days
a fter the onset o f the fi rst paroxysm
no
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L E CT UR E
A N G I NA
P
E C T O R IS
P HE N OME NA
E
xc
III
OF T H E
.
VER A
A
TTAC
K
.
.
—
iti
e Sym pto m s —Stat e of h e art and pulse —P eri c a ditis
—
s
a
u
a
r
s
R e pi to y fe t e Gastro i ntesti n al sym pto m s —Nervous an d psy
c h ic al sy m pto m s
c aus s
ng
.
r
r
.
r
.
-
.
E X C ITI N G C A U S E S
— T h er e
are th ree important elements
muscular exertion mental emotio n and di g estive disturban ces
A ny muscul ar effort w h ic h calls fo r increased action o f the
h eart is liable t o brin g on a parox y sm H e b er d e n refers par
t ic u larly to t h is :
They w h o are a fflicted w ith it are seized
”
w h ile t h ey are w alkin g more especially if it b e up hill
S ome pa tients w h o can not w alk except o n the level w ithout
brin gin g o n a paroxysm c an ho w ever ta k e active horsebac k
exercise In extreme cases e v e n an attempt to move in bed
o r assumin g t h e sitti n g posture w ill cause an attack or such
sli ght exe rtion as stoopin g to lace the sh oes H urr y in g to
catc h a train h as b ee n often th e excitin g cause o f a fatal attack
in the subj ects of an gina T h e muscular and me n tal excite
ment o f coitus is particularl y dan g erous and h as in many in
stances caused deat h T w o o f my patients laid great stress
o n the terrible c h aracter of the attacks w h ich had follo w ed
t h e act
Th e w ell kno w n e ffect of mental emotion h as n eve r b ee n
better expressed th an by Joh n Hunter w h o used to say th a t
h is life w as i n th e h ands of any rascal wh o chose to annoy
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45
ANGI NA P E C T OR IS
46
AL LIE D S T AT ES
AN D
.
”
and teas e h im
A n d yet some o f the vi c tims Of a n gina h ave
not found mental excitement to be the most serious ex c itin g
cause Th us in M r S umner s c as e
a sudde n turn in his
easy c h air w h ile quietly readin g at n ight w ould start up the
most tearin g ag ony w hile at oth er times an excitin g speech
i n the S enate a c companied w ith th e most forc ible and mus
c u lar g esticul atio n s w ould not cre ate e v e n t h e su gg estion o f
—
a pain
T
aber
Jo
h
nson
(
)
For some o f the w orst attac k s h o w ever neit h er muscular
action nor men tal emotion is respon si b le sin ce t h ey come o n
w hen the patient is q uiet an d at rest o r may w ake h im from
S leep
C old is an other excitin g cause particularl y i n t h e vaso
motor form but in the org an ic variety a cold w in d e v e n the
openin g o f a w indow in w inter or the cold sheets at ni gh t
h ave b e e n kn ow n t o brin g on an attack
I n almost every case in w hic h th e paroxysms recur w it h
fre q uency the patie n t la y s stress upon the condition o f th e
stoma c h E xertion immediatel y after a full meal the eatin g of
cert ain articles of food an d espe c ially of late suppers are very
apt t o cause attac ks ; and as I w ill mention later th ere are in
stan c e s in w hic h t h e dyspepsia is so marked a feature t h at t h e
I n some pa
c haracter o f t h e disease is entirel y overlooked
t ie n t s flatulency is one of the most common excitin g causes
—
In the report o f th e t w o cases w h ic h I read t o
S YMPT O M S
o u at the end of t h e last lecture I described t h e p h enomena
y
Th e ph y sician has not often
associate d w it h severe attacks
a n opportunity of w atc h i n g t h e onset and course o f a
ar o x
p
m
e
O
nl
y
once
that
I
remember
did
a
patient
have
attack
a
n
y
in my consultin g room Mr S t o w h ose case I h ave already
refe rred ( XX V I ) A s he sat q uietl y in th e c h air just after
the completio n o f m y exa m ination h is eyes became fixed and
h e suddenl y grasped both h ands over t h e h eart For a moment
t h e face did n o t c h an g e ; th en it fl ush ed and the neck became
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AN GINA PEC T OR IS
VE R A
47
.
sw ollen and th e cervical veins full Th e face became very
muc h con g ested and tear s filled the e y es T h e respiration s
T he pulse
w hic h h ad b ee n 1 8 increased to 3 0 in the minute
w hich h ad b e e n 8 0 increased to 9 0 an d became smaller an d
harder C onsiderin g th e increase in the respirations an d the
con g ested state of the face and neck I w as surprised that the
pulse chan g ed so little H e remained immobile durin g the
entire attack w hic h lasted just a minute an d a h alf passi n g
f abruptly and h e at once be g an to put on his clothes
Of
Th ere are t w o chief elements in the p ar ox y sm : first the
—
ri bable feeli n g of
l
r
e c t or is
ain
and
second
the
indesc
d
o
o
p
p
—
an guish and sense of imminent dissolution a n gor a n im i
Th e resources o f the lan gua g e h ave b ee n taxed to describe
t h e pain o f an gi na pectoris
P atients speak of a han d of iron
graspin g t h e h eart or a band of metal encirclin g it an d bein g
gradually ti gh tened ; o r as thou gh an enormous w ei ght w as
compressin g t h e breastbone a g ain st t h e spine or as thou gh
the w h ole chest w ere c o m pre sSe d i n an ironcase I n other in
stances the p ain is associated less w ith pressure t h an w ith the
sensation o f stabbin g as t h ou gh a da gg er h ad tran sfixed the
h eart Wh ile t h e maximum intensity of the pain is substernal
n ce the name o f ste r n a l ia is derived
w
he
it
ma
y
b
e
i
n
the
(
g
)
upper o r low er part o f the breastbone or over the bod y and
apex o f t h e h eart
T h ere are c as es i n w h ic h the ch ief a gon y
is Opposite t h e poi nt o f t h e xiphoid cart ila g e in th e scro b i c ulus
cord is D urin g an attack t h ere may b e m arked ten dern ess
over t h e re g ion o f th e h eart o r the left breast or the nipple
may b e tender to t h e touch Th e pain may cease as abruptl y
as it be g an
O n e o f P arry s patients said th e transitions from
acute pain to a state o f ea se we re so sudden th at at times h e
felt bot h extremes at th e same moment
A feature noted by H eberden and all t h e early w riters
w as t h e radiation of t h e pain to ot h er part s
H e b er d e n says :
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AN GINA
48
P E CT
OR I S
AN D
ALLIED S T AT ES
.
"
I t likew ise very freq uentl y extends from t h e breast to t h e
middle of t h e left arm
Th e pain sometimes reaches to
the ri ght arm as w ell as to the left , and eve n dow n to th e
hands but this is uncommon I n a very fe w instances th e
”
arm h as at t h e s ame time b e e n numbed and sw elled
In
an instance reported by H eberden the patient h ad attacks o f
pain i n t h e left arm w ith out any affection o f the chest for fif
t ee n years prior to h is sudden deat h Th e pain most common
1y extends to t h e s h oulder t o t h e left upper arm and to t h e
neck of th e same side Wh en it extends to th e arm an d h and
it is alon g the inner surface O f th e upper arm an d in the low er
arm on th e uln ar side in the distribution o f t h e ulnar n er v e
Th e feelin g is one of numbness and ting lin g o r o f pins and
needles T here may be h yperae st h esia o f th e skin V e ry
often the c h ief pain is in th e region o f the elbow or t h ere
may be as in a case I have already narrated to you a band
like sensation around the w rist S ometimes th e radiation o f
t h e pain is more marked i n the ri g ht arm and i n t h e ri ght side
o f the c h est
" u ain states that D r Morison h as reported a
c ase in w h ic h diseas e o f t h e ri g ht side o f t h e h eart w as ac
companied by symptoms o f an gi n a affectin g t h e correspond
in g side o f th e c h est an d arm C uriously enou gh as noted
by H eberden th e pain in t h e arm may precede th e an gina
attacks fo r years Blackall in t h e interestin g appendix upon
A n g ina to h is w ork o n D r op sie s refers to th e account w h ic h
L ord C larendon gives o f his father s sudden deat h evidently
”
from an gin a
w it h out o n e minute s w arn in ge or feare
t h ou gh th e pain is said t o h ave b ee n only in th e arm A s
this case i s often referred to I w ill give y ou th e extract from
th e L ife M r Hyde w as i n c h urc h and found himself a
”
little p ressed as h e used to be
G oin g t o h is h ome
the
pain in th e arm seizing upon h im , h e fell dow n dead w ith out
”
t h e least motion of any limb
I n some cases th ere is se n
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ANGINA
50
2
P
E CT ORI S AND ALLIED S T A T E S
.
I n an g ina pectoris the p ain may be re f err ed in addi
.
tion alon g the fifth sixth seventh and e v e n the ei gh t h and
nint h dorsal ar eas and is alw ays accompanied by pain in c e r
”
tain cervic al areas
A v er y rem arka ble feature is t h e motor disability w hich
may follow a severe attack Th e left arm may not only b e
numb but for a time almost pow erless Blackall sa y s th at h e
h as s ee n instances i n w h ich t h e muscles o f the arm and c h est
w ere n o t only painful but w ere affected w ith a t w itc h in g
noticeable by th e patient and Visible t o th e Observer B W
R ic h ardson
says the voluntary muscles s ee m t o b e affected
”
an d ri gi d
S till more extraordinary is t h e fact noted by
E ic hh orst f o f atrop h y o f t h e muscles o f t h e h and supplie d
by th e ulnar nerve
V o n D usc h in his admirable L e hr bu ch d e r H erzkr a n k
he ite n (w h ich rema ins o n e of t h e be st w orks o f its kind in t h e
literature) refers t h e h iccou gh th e occasional difficulty in
sw allow in g the g lobus an d uneasy feelin g s in the t hroat and
t h e g ast ri c symptoms t o sympath etic involve ment of th e
p h renic and va gus nerves
Va so m oto r dist ur ban ce s are almost constant in th e attack
A sudden pallor o f th e face may b e th e first indication and
vaso constrictor in fluences prevail in th e se Ve re
as a r ule
paroxysms A cold sw eat breaks o ut upon th e fore h ea d an d
upon th e arms and le gs I n recurrin g attacks I h ave s e e n th e
Skin Of th e h ands like t h at Of a w asherw oman from constant
soakin g in perspiration A s in C ase XXXV th ere may b e
gre at pallor and coldness w ith out sw eatin g Th ou gh rarely
absent in th e or ganic form o f th e disease t h ese vaso constrictor
disturbances ar e often more pronounced in th e h ysterical an
gina Th e countenance is expressive of th e deepest an guish
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A
sc lepi a d , v o l. x i
.
l
o
fl
d
b
h
d
r
s
i
l
e
P
a
t
h
o
i
e
5
t
A
u
a
e
u
l
n
a
n
c
e
ec
e
e
H
,
g
g
f
p
k
‘
ANGINA PEC T ORIS
VE
RA
51
.
and may assume a deathli k e a she n hue I n other instan ces
as in C ase XX VI the face is suffused or e v e n deeply c o n
g ested at the outset an d the vei n s o f the nec k may st and out
prominently More common ly in a fatal parox y sm there is
i
w
allor
at
first
w
h
ich
s
follo
ed
b
y
g
reat
lividit
y
as
noted
b
y
p
P ow ell in a man w h o died in his co n sultin g room
C omplaints of coldne ss and of sw ellin g of the extremities
are more fre q uent in the hysterical form
I n man y cases of true an g ina the pai n alo n e is experienced
—
but in severe paroxysms the other factor the me n tal element
—
i
th e an gor a n m i is also present L atham w as the first t o dis
t in gu ish clearly these t w o features of the attack :
T h e sub
i
e
c
t
s
f
of
an
na
pectoris
report
t
h
at
it
is
a
su
ferin
g
sha
r
p
as
j
g
as any th at c an b e conceived i n the nature o f pa in and that
it includes moreover somethin g w hich is beyond t h e nature
”
—
A nd he adds the d y in g sensa
o f pain
a sense o f dyin g
tion I h ave more fre q uen tly found to surpass th e pain than
t h e pain th e dyin g se n sation
Th e one is in rea lity a physi
the oth er a mental phenomenon and w as described by
c al
H e b erden s unknow n corr esponde n t as t h e sensation Of a
universal pause in the Operations of N ature or a sen se of im
minent and immediate dissolution T his feature o f th e attack
w as cert ainly referred to by S eneca ( q uoted by G air dn e r)
A s compared w ith any oth er disease it is lik e
w h en h e sa y s
th e difference betw een bein g si c k merely and g ivin g up the
”
gh ost
A ssociated w ith this sensation there ma y b e a feel
m g o f a ir h u n g er o r as one patie n t expressed it to me th e
same sensation th at one h as after h oldin g the breath for as
lon g as possible ; yet t h e attack is not necessarily associated
w ith any special respiratory disturbance
Th e a t tit ude durin g an attack is best described by th e
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P
o e
rac tit i n r , v ol
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l
i, p 2 5 4
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.
ANGINA PEC T ORIS
52
w ord
ALLIED S T AT ES
AN D
.
immobile I f seized on the street the patient grasps a
lamp post or le an s ag ai n st a w all u n able to stir until th e a g ony
h as passed o ff The attac k usua ll y comes on duri n g some
sli ght exertion w hile the patie n t is in an erect posture H e
may b e quite un able to sit do w n I n other cases w hen the
attack com es o n at night the patie n t usually assumes the sit
tin g posture or h e finds sli ght relief b y pressin g a firm pillow
t o the chest o r by pressin g firmly ag a inst t h e back of a chair
I mmobility how ever is not a constant feature o f a par o x
D
of
true
an
g
ina
I
n
C
harles
S
umner
s
ca
se
r
T
aber
m
s
y
Jo hnson notes that h e w ould at times g et ease by w alkin g the
fl oor quite u n conscious o f an y increase in t h e ag ony by t h e
exertion In others the erect posture is assumed w ith th e
h ead and shoulders th row n back O n e patient as sured me
th at in moderate att acks on the street by a stron g effort of
the w ill he could con tinue t o w alk and the pai n gradu ally
subsided T his is like the gi g antic farmer of w h om Forbes
tells w h o th ou gh t h e could r ule the disease as h e did h is
horses
—
S T A T E OF T H E H E AR T A N D P UL S E
H e b er d e n states t h at
the pulse is at least sometimes not disturbed by th is pain
”
conse quentl y the heart is n o t affected by it
P a r ry is more
positive as to the occurrence of c h an g e h oldin g that w h at
e v er may be the state o f th e pulse as to re gularit y I believe
w e sh all al w a y s find it become more o r less feeble accordin g
to the Violence Of th e paroxysm
Th e questio n is on e about
w hich very diverse Opinions are held and you w ill find in v o l
i o f th e L a n c e t 1 8 9 1 several interestin g letters w hic h passed
betw een P rofessor G airdn e r an d D r H arrin gton S ainsbur y
I t is q uite evident th at there are g ood auth orities w h o accept
the statement th at i n some cases at least th e paroxysm is not
associated w ith special ch an ge i n th e pulse and conse quently
n o t in t h e a ction of t h e h eart
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A NGINA P E C T OR IS
VE R
A
53
.
Th e opportunities for Observin g the paroxysm do not com e
ve r y Often and w he n they do the condition of th e patien t is
suc h that our efforts are directed rather tow ard his relief than
to th e study o f special points i n the case I n an attack of
moderate severity such as Mr S ( C a se XX V I ) had in my
consultin g room the pulse w hich had b ee n 8 0 in c re ased to
The ten
9 0 in t h e min ute and became smaller and harder
sion ce rtain ly became increased but I h ad not time to do more
than count t h e radial beats for h alf a minute an d to listen
hurriedly to th e h ear t sounds before the attack w as over I n
C ase XXX I I in th e first p ar ox y sm in w h ic h I saw h im Janu
ary 3 d t h e state of the pulse thre w me a little o ff my guard ;
it w as full and re gular an d did not chan g e muc h if at all
I am not certain t ha t it w as an inte n se attack as h e th re w h im
self about on th e bed th e face w as flush ed and there w as a g ood
deal o f commotion S ubse quently the pulse became feeble
and irre gular 1 1 5 a minute T hen on the day before his
sudden deat h th e pulse w as soft re gular w ith out special ten
sion and 9 0 a m Inu t e In C ase XX III the pulse fell in the
paroxysm to 4 2 in th e minute and became small an d soft
Fo r days t h e ran g e h ad b ee n about 9 6
For seve ral hour s
after th e paroxysm th e beats at w ri st and at heart ran g ed
from 4 0 to 5 0 a minute S ubse q uently the heart be ats b e
came more numerous than the pulsations at the w rist ran g
in g from 6 0 to 7 0 a minute I n C ase XXXV I I did not se e
t h e patient in his first parox y sm but three hours later the
pulse w as 9 0 o f fair volume re gu lar an d w ithout in cre ase
of tensio n O n succeedin g da y s as the attac k s i n creased in
fre q uenc y th e pulse became small feeble and at times could
n o t b e felt
Follo w in g a se ri es o f severe att ac k s the pulse
ma y b e persistently small and irre g ular as i n C ase XXXV
—
I n C ase IV th at o f a man a g ed fort y fiv e admitted to th e
U niversity H ospital , Philadelp h ia Feb ruary 2 4 , 1 8 8 7 I had
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ANGINA
54
P E CT OR
I S AND ALL IED S TA T ES
.
several Opportunities of feelin g the pulse durin g th e parox
m
s
2
5
h
t
O
n
the
the
pulse
0
re
g
ular
small
and
a
w
s
8
a
n
d
y
th e respirations 3 4 D uri n g an intense parox y sm t h e pulse
became more and more feeble and at last c ou ld n ot be c oun te d
Th is s e n t e n ce I fin d underlined in my notes
O sg ood h as c alled attention
t o a remarkable difference
in t h e radial pulse of the t w o s i d e s T h e cas e w as o n e Of hys
t e ric al an g ina i n a youn g g irl
Huch ard ( p 5 2 4 ) refers to its
occurrence in tru e an gi n a both in the attacks an d in the in
t e r va ls
Th e h e art s action i n s e ve re spe lls is probably al w ays
disturbed the force of the impulse w eak ened and the rhythm
altered T here are t w o chan g es w h ich h ave b ee n most com
—
r
i
mon in my expe ence namel y the shorteni n g of t h e lon g
pause and t h e occurrence Of g allop rhythm Whatever may
b e t h e mec h anism of t h e production of these chan ges they
bot h I t h ink mean th e same t h in g w eake n in g of the v e n
t ric u lar systole from dila tation and debility o f t h e muscular
w all
Th e case w h ic h called m y attention to the foetal h eart
rhyth m follow in g an gin a I saw w ith D r U nderw ood at Pitts
in Febru ar y 1 8 8 9 T he patient C ase V I a g ed
t on P a
sixty h ad w ell marked sign s Of m y ocarditis w ith cardiac
asthma and severe p ains a b out the h eart and dow n t h e ar m
I saw him sh ortly
so t h at h e h ad t o take morphine freely
after an attack ; t h e pulse w as 1 04 w eak and irre g ular A t
apex and base th e sounds w ere c lear rath er rin gin g i n quality
and all distinction betw een the t w o seemed lost
T h ere w as
a sh ortenin g of the pause betw een th e second and the first
sounds so that th ey follo w ed each ot h er i n a uniform series
”
as i n the foe tal h eart be at
This so called emb ryo cardia w as
a most persistent feature in C ase V and w as present also i n
C ases X I X XX IX XXXV and XXXVI
Th e gallop
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A m e rican
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Journa l of th e M e dica l S ciences Oc tob er
,
,
1 8 75
.
AN GINA PEC T ORIS
VE RA
55
.
rhyt h m is I think met w it h q uite as Often and w as present
after attac k s in C ases X I X III X I X XXX I I
I t does not fall to the lot of m a n y physicians to w itness
a sudden death i n an g ina but t h ere are Obse rv ations to sho w
that the pulse beats ( and the heart ) stop abruptl y P otain
an d in the case of our
mentioned a case t o Huchard ( p
g ood friend Mr H C ase XXXV D r T hayer w h o w as pres
—
n
ent tells me t h at the deat h seemed instan ta eous th e pulse
ceased a t on c e an d t h ere w ere no further heart beats
o f deat h resem
N
ote
C
I
before
remarked
t
h
e
mode
A
s
)
(
bles t h at produced by Kronecker s hear t pun cture
A S the su bj ects Of an g ina pectoris present very fre q uently
th e S i gns o f arte ri os clerosis an d increased tension y ou w ill
Often find a ringi n g accentuated aortic second sound A n
aortic diastolic murmur is muc h m o re common than my fi g
ures w ould indicate A s I h ave alre ady mentioned mitral
valve disease is rarely present T here is a very interestin g
feature in certain cases of an gina w it h recu rring attacks
Viz th at w it h t h e development of a mitral s y stolic murmur
the attacks have ceased as th ou gh a relief o f t h e in t rav e n
t ric u l ar pressure had b e e n e ffected by the establishment of a
relative mitral insuffic iency M y attention w as called to this
*
point by Musser w h o h as had several illustrative cases and
L
Broad b ent h as dw elt particularly upon this po in t )
—
A
P E R IC R D IT rs
D uri n g a severe attack pericarditis may
develop from t h e involvement of t h e epicardium in a soften
in g infar ct ( Ke rn ig) i D ock h as described th e onset o f
pericarditis in a case Of th rombosis Of t h e coronar y artery
due to the same cause H ood records a case in w hich the fric
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Tr a n sa c t ion s
ocia tion
f
f A m e r ican P hysicians,
I B r itis h JIIe dic a l ou rn a l, 1 89 1 , i, p 747
" u o ed in L a n c e t , A ugust 20, 1 892
3* M ed ic a l a n d
S u rgica l R epor ter , 1 89 6
t
1
4
L
e
a
n
c
88
5
,
,
, p 20
[I
o
t h e A ss
o
J
t
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i
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x,
5
8
p
.
.
AN GI N A P E C T OR IS
56
ALLIED S TA T E S
AND
.
tion developed t w enty four h ours after the attack and sub
se quently there w ere signs o f effusion I n the discussion
w hic h follo w ed D e H H all mentioned a similar case
—
R E S P I RA T O RY F E A T UR E S
W e h ave h ere to consider se v
—
eral important poin ts the s y mptoms i n the attack the rela
tion Of cardiac asthma to an gina and the interestin g group
o f cases o f c h ronic pleuro pulmonic affections in w hic h an gin a
like attacks of grea t intensity occur
a
I
n
the
attack
except
sli
g
h
t
acceleration
in
t
h
e
move
( )
ments t h ere may b e no special c h an g es You w ill remember
i n readin g John Hunter s case th at as he expressed it h e
felt as thou g h he had forg otten to breath e ; and a patient may
feel some sort of relief from t h e p ain by voluntarily fixin g
t h e c h est at th e full inspiration o r by makin g a very forced
expiration and h oldin g t h e breat h I n a let h al attack th e
respiration may become slo w ed and si gh in g and a fe w g asps
follow the abrupt cessation o f th e h e art s action O n e Of th e
most remarkable features Of th e attack to w h ich th e attention
w as e arly called is t h e development of a bronc h ial as th ma
—
E rasmus D arwin called th e disease painful asth ma a sthm a
—
d olor ificu m w it h out so far as I can s e e from his account
any justification O n aus c ultation on e hears o v er th e ch est
numerous sibil ant Tale s and th e breath in g may become
lab o red an d expiration muc h prolon g ed Huchard likens it
to a condition o f acute emphysema In C ase XXXII w h ic h
I g ave you i n full at th e last lecture the attacks o f sh ortness
o f breat h w it h pipi n g r a les formed a very distressin g feature
i n th e case Th e expectoration w as muco purulent ; Cursc h
m ann S spirals w e r e n ev er found Th rou gh out th e illness
w h ic h persisted for several w eeks t h is condition continued
and w as t h e cause Of much annoyan ce Th ou gh H eb erd e n
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Z oonom ia, th ird c d
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1 8 01 , p 41
.
.
AN GINA
58
P E C T OR
I S AND ALLIED S TA T E S
.
patient m ay die D re sc h fe ld reports the case of a w oman
a ged forty nine year s w h o w hen young er had b e e n h y s
S uddenly o n e ni gh t
t e ric al and later very neurastheni c
sh e w as seized w it h s e ve r e dyspn oe a w it h out any cardi ac pain
A w eek later sh e h ad a second attac k ag ain w ithout pain and
in a third attack the follow in g ni gh t sh e died T here w as
a fibrous myocarditis at apex o f left ventricle and the left
coronary artery w as greatly narro w ed by an atheromatous
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Ch eyne S tokes breat h in g is met w it h in t h e interval s b e
t w een very s e v ere attacks as i n C ases XXIII and XXX II
o r is o n e of t h e manifestations of an advanced arterio s clerosis ,
as i n C ases V X I an d X III
0
ri s h as b e e n
T
he
term
r e sp ir a t or
m
f
an
g
ina
pecto
or
O
()
yf
applied to cases of cardiac ast h ma su c h as the one repo rted
by D re sc h fe ld I th ink the term more appropriate to t h at
interestin g group o f cases i n w h ic h the subjects o f ch ronic
l
r pleural disease have a g onizin g p aroxysms o f
u
monary
o
p
pain about t h e h eart evidently Of th e nature of angina and
w h ic h may prove fatal
L e t me mention several illustrative cases :
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C A S E I X On F eb ru ary 1 2 1 8 9 1 I was consulted b y a
h ealth y Vi gorous loo k i n g man a g ed thirt y three y e ars w ho
c ompla i ned o f shortnes s O f b reath and attack s o f a g on i z i ng
pain in the chest
I n 1 8 7 6 he h ad pleurisy o n the ri ght side for wh i ch he was
tapped repeatedly The e flu sion b ecomin g puru lent opened
spont aneou sl y and the fi stula took a lon g t ime t o heal H e
graduall y got stron g and w ell an d rema i ned so for nearl y ten
y e ars I n 1 8 8 7 he b e gan t o h ave attack s O f short nes s o f b reath
at n i ght wi th pain i n the chest A t fi rst there was no short
ness o f b reath durin g the day excep t on active exertion I n
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P rac titione r,
VOI. xl iv.
ANGINA
P
E CT ORI S
V
ERA
59
.
the year 1 8 8 8 the atta c k s r e cu rred at i n terval s I n 1 8 8 9 an d
1 8 9 0 he w as v er y mu ch i n c ap ac i t ated b y th e m as there was
gre at p ai n an d short n e ss o f b reath o n attempt i n g any extra e x e r
t i on The atta c k s c am e o n w i th a f eel i n g o f great oppre ssi on
in the c hest an d a sen se o f overpo w eri n g co n stri ct i on an d u n
easin es s i n the re gi on o f the h e art The pai n s never ext e n de d
do wn the arms b u t th e y p asse d u p t h e nec k t o the he ad O f
l ate they have recu rre d at n i ght w i th great re gulari ty so th at
he dreads t o go t o b e d H e g oes t o sleep qui etly dreams a
g ood deal but al ways pri or t o w ak i n g i n pai n there is great
exci tement i n the dre am s an d he feel s pressure o n the eyeb alls
an d f orehead
wh i c h gradu ally i ncre ase s unt i l it aw ake s hi m
Then he aro u ses i n terri b le agon y in b oth the che st and h e ad
and the sw eat po u r s fro m h im The p aroxy sm last s from five
D ur
t o ten m i n u tes an d he h as o f t e n h ad t o tak e c hloro f orm
i n g these noct urn al atta c k s there is n o shortn es s o f b reath onl y
the a g on i z in g p ai n in the re g i on o f the heart an d passi n g up
the neck t o the head
O n examinat i on the p atient sho w ed an extreme grade o f
contraction o f the ri ght si de w i th lateral curvature O f the spin e
flatten i n g i n the mam mary an d axi ll ary region s w i th scar ri n g
i n the seventh ei ghth an d n i nth space s w here the em pyema
h ad per f orated
O n perc u ssi on ther e was flatness everyw here
o v er th i s side ; the l e ft si de w as hyperre son an t T h e apex b eat
was n o t vi s i b le ; t h e h e art i m p u l se could b e f elt w i th moderate
f orc e at the lo w er stern um The heart sounds were perfe c tl y
clear and quite n at u ral The pu l se was re gular ; the vessels
were n o t scl e rosed Th e r e w as n o t r ac h e al tu ggi ng an d t h e
O n rap i d exert i o n the f ace
m anub rium w as cl e ar o n perc u ssi on
b ec ame a l i ttle fl u sh e d b u t n o murmu r developed ove r the
The uri ne w as cle ar The ab domen was di stended the
he art
ri ght costal b order w as c u ri o u sl y everted from contra c t i on o f
the che st an d the liver was d raw n u p very far A short t ime
a fter h is vi si t t o me the p at i ent di e d su dd e nly i n a p aroxysm
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Th e follow in g case illustrates a much less severe form :
A
April
cler gyman
2 0, 1 89 2 ,
ged forty four years came under my care
w i t h s i gn s O f local di s e ase at the apex o f the
,
a
-
,
ANGINA PEC T ORIS AND ALLIED ST A T E S
6O
ri ght lun g H e
h ad tub erculo si s
.
a vi go rou s w i ry loo k i n g m an wh o had
fo r several y e ar s; b ut the f e at u re w h i ch i nca
i
a
a
c
t
e
d
h
i
m
f
t
o
r
r
n
w
or
k
the
o
u
re
ce
d
r
i
n
g
ex
i
tement
as
u
c
w
c
c
p
a n d e spe c i all y w h e n pre ach i n g
o f att ac k s o f i nde scr i b ab le dis
tress ab out the he art w h i c h o n sev eral o c casi on s almost caused
h im t o f aint I t w as n o t a sharp pai n and there was n o radi a
t i on b ut he de sc ri b e d i t as a f eeli n g as thoug h the he art w oul d
b urst o r b re ak an d an ent i re i mpo ssi b i l i t y t o pro c e e d w i th his
sermon o r w i th h is addr e ss I t w as n o t accompan i ed w i th an y
shortness o f b reath
an d thou g h the si gns Of tub erculos i s and
o f some compen satory e m ph y se m a w ere quite mark ed y et it was
this spec i al sympt o m for w h i ch he sou ght reli e f as b y i t he w as
i ncapac i tated
The apex b eat w as n o t vi s ib le
The heart
sounds were clear ; there w as n o si g n O f h ypertrophy and the
aort i c second sound w as n o t accentuated The arteri es w ere
sclerotic and the pulse tensi on was consi derab l y i ncreased
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Th e condition w hic h th is patient described thou gh prob
ably n ot true an gina is o f interest in connection w it h this
subj e c t P ublic speakers an d others w h o h ave to address
audiences n o t infre q uently complain o f a peculiar sensation
in the re gi on o f the h eart sometimes only an exa ggeration
o f t h e ordinary embarrassment w hich so many o f us feel but
in other instances there may be w ith an increased peripheral
vaso —
motor contraction q uite evident in t h e pallor of the face ,
a summation Of cardia c distress w hic h becomes a lmost u n
bearable I know o f one profession al friend w h o rarely can
g et up to speak i n a meetin g w ithout considerable cardiac
pain
C ases o f c h ronic pleurisy tuberculous o r oth erw ise are
very apt t o h ave s e v ere an gina like attacks I h ave called
your attention in t h e w ards to M ary C a ged t w enty four
ye ars w it h ch ronic bilateral pleurisy w h o came under our
care first i n D ecember 1 8 9 0 w ith an effusion o n t h e ri gh t
side S h e h as h ad lately s e v e re attacks o f pain i n and about
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AN GI N A P E C T ORIS
V
E RA
61
.
the h eart w h ic h h ave come paroxysmally but h ave n eve r h ad
th e intensity of true ang in a I saw this w inter a w oman
a g ed th irty six yea rs w h o had had a pleuris y on the ri g ht
side o f thirtee n years duration w ith chronic disease o f both
apices and considerable enlarg ement of the heart S he had
h ad shortness o f breath an d occ as ional pain about the h eart
S he died in an attack of acute dilatation of the
o n exertion
h eart associated w ith a g reat deal of substernal pain muc h
pallor and sw eatin g
—
N au s ea n o t infre q uentl y
G A S T R o I N T E S TI N A L S Y M P T O M S
accompanies the attack and the patient may vomit H eber
den notes that persons w h o h ave persevered in w alkin g till
the pain has returned four o r five times have then sometimes
”
vomited
A s an attack ends th e patient may belc h quanti
ties of gas or pass flat u s from th e bow el bot h w ith apparently
great relief
Flatulency w as re garded by Butter as t h e most obvious
”
and the most re g ular excitin g cause
Parry too laid g reat
stress o n th e in fluen ce of eructations in miti gatin g t h e pai n s
”
produced by mal or g an i z ation o f the larg e vessels an d
quotes Morga g ni to the e ffect that the vul g ar and e v e n the
p hysicians thou g ht t h e disease ori gin ated in the flat u le n c y
Th ere is a n other important relation Of the g astro inte stinal
features o f an g i n a pectoris When the pai n is situated in the
scrobiculus cordis and associated w ith eructation s an d d y s
e
i
a
a
s
t
h
e
di
g
nosis
of
g
astral
g
ia
ma
y
b
e
made
T
here
are
p p
several very interestin g papers on this q uestion in the litera
ture L eared described a series of cases Of dis guised dis
ease of t h e h eart i n w h ic h th e h eart affe c tion w as so
stran g ely masked b y t h at o f th e stoma c h that noth in g in the
st atements O f the patients h ad any bearin g on the primary
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M e dica l Tim e s a n d G a ze t te, 1 867, i
.
AN GI NA
62
disease
Bari e
’
P E CT OR
I n several
IS
AND
ALLIED S TA T E S
.
f his
cases sudden deat h follow ed
h as w ritten an elaborate pa per on t h e car dio pul
m o n ary features o f g astro h epatic disorders
T he attacks of
pain i n some O f his cases simulated closely angina Huc h ard
h as a special section o n w h at he called the p se u do gastr a lgic
form of a n gina
I n only t w o cases i n my series w ere th e g astric symptoms
of suc h intensity that the affection w as at fir st th ou gh t to be
in the stomac h
I n C ase X IX t h e pains w ere at first alto g et h er in t h e upper
p ar t Of the abdomen and as th ey w ere of sufficient intensity
to cause vomitin g sh e w as thou g ht to h ave gastral gia I t
w as n o t until dyspn oea came on and t h e pains became centred
about t h e heart and extended t o th e neck and ar m t h at th e
dia g nosis of an g ina w as made
I n t h e follo w in g case t h e patient a most intelli g ent man
insisted that t h e entire trouble w as i n h is stomac h
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C A S E XXV II — M r W a mer c hant from N orth C arolina
was re f erred t o me b y D r Wh i tehead O cto b er 2 6 1 8 9 3 c o m
pla i n in g o f severe att ack s o f pa i n i n the ab domen and lower
part o f the ch e st H e w as sixty seve n y ears o f a ge and o f ex
A ll h is l i fe he had had occasional at
c e lle n t f am i l y h i story
tack s Of i n di gesti on
O n the 1 7th o f Ju ne 1 8 9 3 a fter helpin g a se rV
an t t o carr y
a heavy tru nk upsta i rs he f elt a sen sat i on at the p i t o f the
stomach as i f he had wrenched h imsel f b adly A fe w day s later
w h i le w al k i n g up a h i ll the se n sat i on O f pai n i n the stomach
return ed and a w ee k later w h i l e w alkin g fast t o catch a train
he had v ery severe pa i n and short n ess o f b reath The ta kin g
feren c e t o the pain b ut he had a
o f f ood appare n tl y made n o d i f
g ood deal o f b el c hi n g o f w ind and he insisted upon regardin g
the con di t i on as alto gether du e t o h is stomach D r Whit e
head in descri b in g the ca se st at e d th at the pa i n b egan in the
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R evu e
de m é decine
,
1 883
.
.
AN GINA PEC T ORIS
VE RA
63
.
epi gastrium and passed directly t o the backb one ; i f very s evere
it Spread over the thorax ; asthm a comes o n ; th e re is t in gl ing
sen sat i on i n the le ft hand and violent pa i ns are felt i n the arms
”
The ag on y is simply terri fi c
H e n e v er h ad any nausea o r
vomi t i n g i n the attac k s The pat i ent was a ver y well preserved
m an ; the rad i als were fi rm t e n sio ri w as i ncrea sed an d the
radial pulse was anastomot i c There was n o exce ssive cardiac
impulse the area o f dullness was n ot i ncre ase d b ut the sub
cutaneous fat was very excess ive W i th the except i on O f a
so ft apex sy stol i c murmur auscultation gave n o i ndi cati ons
The second sound over the aort i c re gi on was o f medium in
tensi ty The exami nati on o f the ab dominal organs was nega
tive There was n o di latat i on o f the stoma c h an d the gastri c
j ui ce was normal The note w h i ch I made wi th re fere nce t o
the nature o f the case at the t ime was as f ollo w s : Though the
possi b i li t y h as b ee n entertai ned th at Mr W h as gastralg i a due
e i ther t o ulcer or can cer i t seems t o me mu ch more l i k ely that he
”
H e w as ordered iodide o f pota ssium ;
h as an gi na pectoris
and throughout the winter o f 1 8 9 3
he d i d v ery w ell and
he could wal k a distance O f t wo o r three b lock s wi thout suffer
in g pain
O n July 2 1 8 9 4 a fter eat i n g a much he artier dinner than
usual he went o u t to pay a Vi si t and o n leavin g the door o f
the house fell f orward on the verandah and died in a fe w
moments
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A not h er
by no means uncommon and often very distress
in g s y mptom is persistent h iccou gh
A symptom described by some w riters h as b e e n the c o n
—
—
stant desire to urina te urina spastica an d there may be a
v er y lar g e amount of urine passed G riffiths an d M assey
profess t o h ave separated a special leucomaine from the urine
passed durin g th e attack
—
N E RV O U S A N D P S Y C H I C A L S Y M P T O M S
T h e mental an guish
h as been described A s e n s e o f fai n tness almost invariably
.
.
.
.
Comp tes
e du s
r n
,
A
ca
d
.
des
e e
sci n c s,
1 89 5 , 1 1 28
.
ANGINA P E C T ORIS
64
AND
ALLIED S T A T E S
.
accompanies s e v er e attacks and actual loss o f con sciousness
syncope may follow upon w hich feature I have already
d w elt
Th ere are interestin g psychical manifestations i n
an g ina pectoris upon w hich you w ill not fin d much in t h e
literature T h ey are features of the myocarditis rather than
o f t h e an g ina and develop w it h the pro g ressive w eakness o f
th e h eart I n C ase V t h e patient had delusion s Of a most
painful nature for nearl y six w eeks durin g w h ich time h e
h ad an exceedin g ly feeble h eart w ith g allop rh ythm
H e re
covered and lived for three years I n C ase V I I I the patient
thou gh t th at he w as in a stran g e h ouse and be gg ed constantly
to b e taken to his h ome You remember th at in C ase XXXII
t h ere w ere occasional delusions
T rousseau believed that t h ere was a close relationship
betw een an gina pectoris and epilepsy :
I n some cases and
perhaps in a pretty g ood number Of instances accordin g to
my experience an gina pectoris is an expression o f t his cruel
and fearful complaint and is a variety o f th e verti ginous
—
f
form o t h e disease in ot h er w ords it is an epileptiform
n eural gia
I ts invasion is as sudden its pro gress as rapid
and it s disappearance as sudden and as I have already told
you it is not of very uncommon occurrence to find persons
w h o h ave in former years su ffered from an g ina pectoris b e
come subj ect afterw ard to epileptic fits just as in ot h er in
stances an g ina pectoris h as b e e n preceded by w ell ma rked
”
L
epileptiform seizures
" uite recently R ic h ar dso n } has
urg ed that an g ina pectoris is a special disease o f a paroxysmal
n ature
as distinct as epilepsy an d partakin g in many w ays
o f its features— a sort o f epileptic counterpart in t h e sym
pathetic s y stem T h e t w o diseases ma y c o exist W e h ave
to distin guish bet w een th e attacks Of nervous palpitation w ith
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Clin ic a l M ed icin e
f A sc lepia d
,
v o l. x i.
.
N ew
S yd enh am S oci ety edition
,
v o l.
i, p 662
.
.
AN GI N A
66
P E CT OR
I S A ND ALLIED S T A T E S
.
such as w alki n g fast up hill o r mental excitement w ill cause
severe pain exactly under th e left nipple often of great
severity I n M arch of this year w hile w orkin g in a stable
h e felt a sudden a g onizin g pain in the h eart became g iddy
an d fell to the fl oor unco n scious
H e did not bite h is ton gue
and so far as w e know h e did n o t w ork t h e muscles or
foam at t h e mouth O n June 1 7t h h e h ad a second atta c k,
w it h very muc h more pain about t h e h eart w h ic h lasted fo r
five or t e n minutes before h e became unconscious O n t h e
2 4 t h h e w as w a lkin g on the street felt a s eve re pain and great
Oppression about th e h eart and t h en fell unconscious and w as
brough t to t h e hospital by t h e police patrol The loss Of c on
H e h ad no attacks w h ile in
sc io u sn e ss lasted several h ours
the w ard and it seemed impossible t o determine precisely th e
—
nature of the case w hether t h e so called cardiac epilepsy or
an an omalous type o f angin a pectori s N ew ton h as re
ported an interestin g case in w hic h very probably both the
epilepsy and the an gina w ere associated w it h syphilis
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M edica l R
ecor
d
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1 89 3 , i
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L E CT UR E IV
A L L IE D
A SS OC IA T E D COND ITI ON S
AND
.
I Sync ope angino sa —II T h e A d am s Stok es syn d ro m e —III Angina
d olo e —IV Card iac asth m a
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r
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S in e
to call your attention i n this lecture to several in
t e re st in g conditions closely allied to true an g ina w hich may
either develop in the course o f an attack or w hic h occur spon
t an e ou sly i n t h e subj ects O f heart disease or arterio s clerosis
—
I S yn c ope a ngin osa You remember that P arry called
an gina sy n c op e a n gin osa and this feature o f fa in tn e ss may
det ain us for a fe w momen ts The distin guished old Bath
physician from w h ose mono g rap h I have S O Often quoted
says : Th e angina pectoris i s a mere c ase of syncope or faint
in g diffe ri n g from th e common s y ncope on ly in bein g pre
”
ceded by an unusual de gree Of pain in t h e re g ion o f the heart
T his i s t oo stron g a statement a s in a majorit y o f the par ox
m
s
s
thou
g
h
t
h
e
pallor
and
ot
h
er
va
o
motor
p
h
enomena
of
s
y
a fa in t may b e present consciousness un h appil y for the poor
victim is not lost In lookin g over the histories of my cases
I do n o t find fa in t in g as w e usu all y u n derstand the term to
have b ee n a common s y mptom There is o f course the s y n
—
cope Of a fatal parox y sm S le talis as " uain terms it D u r
in g a s e v ere attack t h e patient may lose consciousness Mr S
C ase XXV I w as once pic k ed up on the street In C ase
XX V mentioned i n connection w ith an gina and epilepsy
w e could not determine t h e nature Of t h e attacks o f loss
W I SH
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67
ANGINA
68
P E CT OR
I S AND ALLIED S T A T ES
.
consciousn ess A nother feature of w hic h I h ave no illus
t rat iv e example is thus referred to by Broadbent :
A pa
tient w h o has ceased t o suffer w it h attacks of an gina may
h ave attacks of w h at h e calls faintness in o n e of w h ic h h e
ultimately dies T hese w h ic h h ave lost the title to th e name
”
an gina h ave an e qually serious si gnifican c e
A n d lastly
an individual subj ect all h is life to faintin g spells may present
remarkable attacks of th e nature Of G airdn e r s an gina pe c
toris si/n e dolore about w h ic h I sh all speak shortly
of
.
C
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C A S E XXX I V T J J
a ged sixt y o n e y e ars s ee n with
D r Kin g M ay 1 1 1 8 9 5 compl ai nin g o f curious attac k s w h i ch
occu r on the street wh i le wal k in g
The p at i ent h as b een a v ery vi g oro u s healthy man h as
n e v er h ad syph i l i s an d h as b een ab stemi ous H e h as had t wo
atta c k s O f sc i at i ca in the p as t ten y ears the last a severe o n e
H e h as had an
t wo y ears ago ; he has had n o j o i nt affect i ons
exceptionall y healthy li fe F rom b oyhood ho wever he has
b ee n liab le t o f ai nt on v er y tri flin g pr ovocation such as a vomi t
in g att ac k a Sl i ght sho c k the si ght o f b lood o r the extract i on
From any o f these c auses he would drop i nstantl y
o f a tooth
in a fa i nt H e h as n ot had a spell O f thi s kind fo r more than
H is present attac k s date from e i ghteen months ago
t w o y ears
The first o n e occu rred w hen w al k in g from the U ni on S tat i on
H e had a t i n gl i n g feel i n g in the h an ds and
t o N orth Aven ue
then a sudden faint i n g sensat i on as tho u gh he was g oi n g t o die
The attac k pa ssed O ff in a fe w moments H e
H e had n o pain
too k the street c ar and then w al k ed t o his home havi n g a se c
S ub se quentl y he had these attac k s at
o n d attac k o n the w a y
intervals al w ay s when w al kin g on the street
O n N ovemb er 2 2 1 8 9 4 he had t wo very severe attac k s an d
he then con su lted D r Kin g I n e v ery i nst ance the y have come
H e does n o t th i n k that g oin g up h i ll
o n w h i le he is w al k in g
o r w alk i n g a ga inst the w i nd ma k es an y di fferen ce H e has n e v er
had an attack at his place o f b u siness or i n h is home an d he
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B ritish M e d ica l
Journal
,
1 89 1 ,
i
,
747
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ANG I NO S A
S YN CO P E
69
.
ab le t o go up three o r fo u r fli ght s o f sta irs quick l y an d readi ly
w i thout the sli ghte st emb arrassme n t
The y come on w i th
ab ru ptnes s b e g i n n o w every t i me w i t h a f e e li n g o f n u m b n e ss
an d t i n g li n g i n fi n g er s and h an d s w h i ch som e t i m e s ext e n ds u p
the arms and w hich is n o t more on o n e Si d e than the oth e r
H e h as n e v er vomi ted i n an att ac k ; there is no c ough an d there
H e turns o f an ashen gray color sw e at s pro
is no dy spn oe a
fu se ly and f eels i n each on e as thou g h he w o u l d S i n k aw ay
and die I t is th i s sensat i on o f impendin g di ssol u ti on wh i ch
H e h as n e v er had the sl i ghtest se n
h as alarmed h i m so much
sat i on O f pai n D uri ng an attac k he i s n ot immob i le b ut he
The day b ef ore ye sterday fo r example he
h as t o move S lo w l y
h ad an atta c k b e f ore he rea c he d h is hou se an d was ab le t o g et
up the step s into the por c h and close the door ; b u t he h ad
then t o sit do w n and he w as f ound there b y h is son i n a c o n
diti on o f exhaust i on and s w e at i n g pro fusely
H e was a healthy loo kin g m an w i th iron gr ay ha i r and
H e w as n o t
moustach e ; n o arcus; the pup i ls were normal
stout b ut wel l nouri shed The pul se was 72 and re gu l ar the
Vessel wall n o t spec i ally sclerot i c and the pulse coul d b e c o m
pressed readily
T here w as a sl i ght thro bb i n g i n the vessels o f the n e c k
The v en u l es w ere mark ed alon g the course O f the di aphragm
O n auscultat i on there was a short sh arp some w hat ro u gh m u r
mur heard o n ly i n the apex reg i on an d as far as the mi d ax i lla
The apex b eat was n ot vi si b le b ut was palpab l e i n the n ormal
si tuat i on in the fi fth space j ust b elo w the n ipple The h e art
impulse was felt also b elo w the ensi form c art il age ; th e re was
no thri ll The dull n e ss b e gan on the fourth co st al c art i lag e
The perc u ssi o n on
an d d i d n o t extend b e y on d the n i pple l i ne
the manub rium was clear The aort i c se c on d so u n d was n o t
accentuated
B oth sounds w ere clear in the ve ssels o f the
neck ; the seco n d w as a l i ttle loud at the S tern al not c h
The lun g s w ere clear P osture made n o di fference in the
heart sounds o r i n the apex murmur
The l iver was n o t enlarged ; Sp l ee n n ot enl arged
A fter dressin g and in the erect postur e the pulse was 8 8 a
minute
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AN G I NA
70
P E CT OR
I S AN D
ALL
I ED STA T E S
.
He h as
Jun e 1 4 1 8 9 5 I heard o f th i s patient
had n o attack s fo r a month
The pat i en t was se en t o da y
H e had a
M ay 2 9 1 8 9 6
severe att ac k i n A pri l o f thi s y ear o n e o f t h e w orst he h as ever
Ther e
h ad A f ter a h e art y d i nn er he w as att ac k e d in the street
all g o n e
f e e l i n g as though
w as n o shortnes s o f b re ath b ut an
he w ere g oin g t o exp ire b ut th e re w as no p ai n w i th i t ; sw eat
rolled o ff h im H e was w ell that e v e n i ng H e h as had i n
the year ab out ei ght mild attack s H e had an atta c k y esterday
They oc c ur nearly al w ay s after meals
t o day
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II The A d am s S tokes S yn dr o m e Th ere is a most in
t e r e st in g g roup o f s y mptoms associated w ith m y ocardial
chan g es and sometimes w ith an gina to w hich R obert A dams ,
and w h ic h S tokes sub se
o f D u b lin , first called atte n tion
q uently desc ri bed more fully M ost o f the text book s re f er
to a pseudo apoplexy in connection w ith fatt y o r fibrous m y o
carditis a condition in w hi c h w ith a perman entl y slow pulse
t h e patient h as tran sien t vertig o o r falls i n to a d ee p coma
Huchard h as g iven
w it h or w ithout convulsive movements
it th e name m a la die d A da m s o r S t oke s A dam s A s it is al
’
w ays pleasant and profitable t o h ave the aut h or s first h and
description o f any sym ptom o r disease , I w ill g ive y ou an
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abstract of the case recorded in the D u blin H ospita l R ep or ts
A dams I may remind you w as one of that distin
v o l iv
n cludin g C he y ne C olles R
i
h
d
e
u
band
Of
men
i
W
S
mit
h
s
g
G raves S tokes and C orri g an w h o g ave suc h renow n t o th e
D ublin school in t h e first h alf of t h is century
H e is b e st
know n throu gh h is superb w ork o n rh eumatoid arth ritis
A dams s patient w as a man a g ed sixty ei g ht years w h o h ad
had in s e v e n years n o t less th an tw enty apople pt ic attacks
eac h o f w h ic h w as preceded fo r a fe w days by h ebetude and
loss o f memory Th e pulse w as permanently slow and at the
time Of th e attacks became S low er Th ere w as n e v er any
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AD AM S S T O KE S S Y ND RO M E
71
-
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paralysis
P ost mort em t h e
D eat h follo w ed an atta ck
h eart w as fo u n d t o be excessively fatty There w as n o note
about the coro n ary ar teries R W S mith also no t e d the
con dition O f ver y slow pulse w ith fatt y heart an d S to k es de
L
scribed it more fu lly j and su gg ested the nam e false or pseudo
apoplexy H e laid stress o n the s y ncopal ch aracter of the at
tacks t h eir fre q uenc y the absence Of paral y sis an d th e g ood
e ffect of a stimulant rather than a depletin g plan of treat
m e n t Th e first case w hich h e gives is very remarkable and
is w orth y of a brief abstract as recent A n glo A me ri can au
t h ors h ave not dw elt specially upon his symptom g roup : A
man ag ed sixty ei gh t years w as suddenly seized w ith a faint
in g fit w hi c h recurred several times in the da y For th e
three years before he w as admitted to t h e Meath H ospital
h e h ad n e ve r b ee n fr e e from the attacks fo r any len gth Of
time and h ad h ad at least fifty such seizures A s u dd e n e x e r
tion o r a di st en d e d sto m ac h w as most apt to cause an attack
H e h ad no convulsions nor w as there e v er anythin g like pa
r al sis
r five minutes
H
e
perfectly
insensible
for
four
a
o
w
s
y
Th e pulse w as 2 8 per minute and the arteries w ere in a
state o f perm an ent distention t h e temporal arteries ramify
in g under th e scalp just as they are s ee n in a w ell injected
”
subject
There w as a soft br u it w ith th e first sound T he
t h reatenin g s of attacks h e could reco gnize and he had often
w arded o ff a seizure by turnin g o n h is h ands and knees and
keepin g th e h ead low
I n passin g I may remark th at y ou w ill find in this paper
S tokes s ori ginal description o f t h e Ch eyne S tokes breathin g
w h ic h th ou g h fuller is not a w h it b e tt er th an Ch eyne s ac
count publish ed th irty years before
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Jou rn a l ix
" O b se rvatio n s on so m e Case s of
"uar terly Journ al 1 846 p 73
D u blin
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P e rm anently
S lo w
P ulse
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D u blin
AN GI NA
72
P E CT OR
I S AND ALLIED S T A T ES
.
P ermanent slow ness of the h eart action and verti g o or
syncope are the t w o distin guishin g features Of th is syndrome
D o n o t forg et t h at slow n ess o f heart s action is the spec i al fea
ture not simply a diminished number o f pulse beats at the
w rist
I n myocarditis i n mitral valve disease and as an
e ffect of di g italis the radial pulse ma y appear very slow — 3 5
—
t o 4 0 per minute
w hile t h e heart beats are exactly double
I n th e bi g eminal t y pe of h eart beat t h e second pulse w ave
very Often does not reac h th e w ri st and may lead a novice
into th e serious error o f supposin g tha t there is an extreme
A dams s disease
bradycardia In
the pulse rate ma y
fall to 3 0 o r 2 0 per minute o r in extreme cases e v e n to 1 0
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or
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Th e patients are usually advanced in years and sh ow
often an extreme g rade of arterio s clerosis the arteries feel
ing as S tokes remarked bot h full an d h ard
Th e cerebral s y mptoms are th ose to w h ic h naturally chief
attention h as b ee n paid V erti g o is the most common , and
is usually t ransient and o ft repeated A ctual syncope of
three o r four minutes duration resemblin g closely th e syn
c op e a/ngin osa and doubtless Of t h e same nature h as b ee n t h e
special feature in some cases ; w h ile in oth ers t h e attack h as
b ee n apoplectoid in its character, Of lon g er duration , and h as
b ee n complicated b y convulsions Huchard re g ards t h e slow
pulse as a result o f c h an g es in the va gi centres due t o disease
Of th e arte ri es o f th e medulla H e calls t h is form of art erio
sclerosis th e c ar dio bu lbar
T ransient disturbances in th e
cerebral circulation so common in th e subjects of advanced
art erios clerosis are responsible for th e syncope and the apo
attacks
h
ic
h
remind
o n e o f t h e tempora r y h emi
w
l
e
c
o
i
d
t
p
r monople gias t h e ap h asias and the transient para
l
o
i
e
as
p g
h
ic
h
t
h
ese
atients
are
subject
i
l
a
t
o
w
e
s
p
p g
T ypical cases are n ot common Th e most remarkable
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ANGINA
74
~
P E CT OR
IS
AND
ALLIED S TA T E S
.
no dy spepsi a b ut o f l ate h as b e c om e very n e rvo u s ab out him
self H e h as t o w al k slo wly an d o n g o i n g up the sli ghte st in
c l i ne he f eels the sense o f oppre ssi o n i n the chest
H e h as no
c ou gh
no palp i tat i on Ab out a y ear ago i t was noti c ed th at
h is p u lse was v er y slo w an d i n the earl y morni ng i t h as on se v
eral occasi ons b ee n counted as l ow as 2 0 per mi n ute
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The pat ient was a health y lookin g man with iron gray hai r ;
there was no arcu s ; the p u lse was 3 4 t o the min u te ; t h e ten
s i on was pl u s the u p stro k e a l ittle lab ored an d the pulse wave
The c hest w as large ; the cardi ac i m pulse
was w ell s u sta i n ed
w as n o t vi sib le ; there w ere no areas o f ab normal p u lsati on ;
the aorta was n o t p alpable i n the sternal not c h ; there was no
increase i n the area o f dulln ess ; no apparent h ypertrophy ;
no shoc k at the b ase ; n o thri ll
O n auscultat i o n the so u n ds i n the apex re g i on w ere cle ar
o v er the b ody o f the heart there was a ro u gh i sh systolic b ruit
heard also at the aort i c cart i lag e transmitted feebly t o the v e s
sels o f the neck The second aorti c was heard but was n ot
speci ally a c centu ated ; there was no accentuat i on o f the pul
m o n ary second
There was n o enlarg ement o f the liver or
spleen
I heard f rom th i s pat i ent i n A pri l 1 8 9 6 H e h as b ee n a
great deal b etter H e sti ll h as the b rachy cardia but the ver
ti g o Is n ot so troub lesome
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P
e c t or is
—
i
n
s
e d o lo r e
III A n gin a
Th e th ree elements
—
in an attack th e pai n th e s e n s e of an guish and the abrupt
—
e n di n g o f life may b e di ssociated T here ma y b e o n l y the
severe pain there ma y b e a se n se of a n gor an d oppression
—
—
a n gin a sin e d o lor e
w ithout any pain
o r death may occur
w ith out a moment s w arn i n g
T he reco g n ition of a group of cases in w hich th e eleme n t
as made by P rofessor G airdn e r
i
is
su
b
sidiary
w
H
i
s
of
a
n
p
brief description is as follo w s :
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ANGINA PEC T OR IS SIN E D OL ORE
75
.
A part
from w hat h as b ee n variousl y termed cardiac
asthma d y spn oe a o r orthop n oe a w hic h in man y c ases receives
its clear expla n atio n from the associated states either of the
pulmonar y circulation o r o f the lun g s b ronchi and ple u r w
as disclosed b y ph y sical si g ns
t h ere is Often an element of
subjective abnormal sensation prese n t in cardiac dis ea s e s
w hich w hen it is n o t locali z ed throu g h the coi n cidence Of
pain is a specially in de fin ab le an d indescribable se n sation
almost al w ays felt to b e such by the patient himself I make
this remark deli b erately as the result o f experience and
w ell kno w in g that it is liable to b e brou gh t into question i n
particular insta n ces ; that in fact a larg e part o f w hat has
b ee n described under the titles g i v e n at the commencement
o f this para g raph has b ee n i n extric abl y confounded b y sy s
t e m at ic w ri ters w it h the sensation o r g roup of sensations to
T 0 this group of sensations w hen not dis
w hic h I refer
t in c t ly accompanied b y local p ai n I ha ve i n various insta n ces
g iven t h e nam e o f a n gin a sin e d o lo r e re cogn i zin g thereby
w hat I believe t o b e its true dia g nostic and path olo gical si g
and its allia n ce w ith the painful a n g i n a of H e b er
n ific an c e
d e n ; the pain in w hic h how ever as w e h ave already see n
i s an exceedin g ly variable eleme n t bot h i n de g ree and in
”
kind
L e t me read you t h e h istories of several cases of th is
variety
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C A S E X III — M r H merchant a ged fi f t y years wh o had
su ffered repe atedl y f rom att ac k s o f g o u t c o n su lt e d me on O cto
b er 2 1 1 8 9 2 com pl ai n i n g o f O ppre ssi on an d p ai n i n t h e che st
and bron c h i t i s Throughout the summer he had h ad at t imes
ve ry se v ere p ai n i n the reg i on o f the h e art an d d o w n the l e f t
arm When fir st se en he was a n aemi c wi th a di l ated h e art an d
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R e yn o ld s s
S
y st
em of M e dicin e
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art
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ina P e ctoris
A ng
.
AN GINA
76
P E CT OR
I S AND ALLIED S T A T ES
.
an enlarged l iver With re st and i ron he did v ery well I saw
h im at i nterval s through the w i nter ; the attac k s O f pai n ceased
but he h ad severe card i ac asthma at n i ght wh i ch trou b led hi m
very much I sub se qu ently saw h im i n several atta c k s which
f ollo w ed the exert i on o f w al ki n g from the street c ar t o m y house
in wh i ch the feature o f dyspn oe a was sub si di ary and that o f
great oppre ssi on i n the c hest the m o st i m portant I n th e se at
tack s the color chan ged he b ecame p ale look ed v ery di stressed
remain ed mot i onle ss the f orehe ad covered wi th
an d ha gg ard
sweat the h an ds c old the p u l se f eeb le an d irre gular A fter
the attack he expre ssed h imsel f as havin g had a f eel i n g o f in
There was no dyspn oe a
de fin ab l e d i stre ss w i thout actu al pa i n
The att ac k s at n i ght w ere somet imes v ery severe an d he dreaded
Thou gh in the
t o go t o sleep lest he sho u ld b e r o use d i n on e
summer o f 1 8 9 2 he had had repeated att ack s o f what seemed t o
b e true an gi na yet he sub se quentl y had on l y attac k s o f the kind
j ust descri b ed
I n the spri n g o f 1 8 9 3 he b ecame much w orse ; there were
s i gn s o f di latat i on o f the heart wi th the gallop rhythm and a
so f t apex sy stol i c murmu r H e had cardi ac dy spn oe a as well
as attack s o f se v ere oppres si on and in on e o f these he turned
on his Si d e an d di ed suddenl y
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attack of an a n gin a sin e
indication of c ardiac trouble
An
dolor e
may b e t h e very first
.
A n intimate fri end a man o f ab out fift y six years o f a g e
n t ha b i t s and g reat e n ergy while o n a Vi si t
f
C
ase
V
o
excelle
(
)
t o E n gl an d w al k i n g on e S un da y a f ternoon w i th the l ate D r
H ac k Tuk e up a Sl i ght accl i vit y felt as he expres sed i t a se n se
o f intolerab le d i stress a b out the heart
turned pale vomi ted
an d for a f e w m i nutes could n o t move from the place at wh i ch
he was att ack ed H e recogn i z ed the seri o u s ch aracter o f the
paroxy sm an d s aid that had there b een the seve re pain he
w ou ld have called it an gi na
The attack was the startin g
po i nt o f a seri es o f v ery di stressi n g se i zures culminatin g i n a
protra c ted condi t i on o f cardi ac d ilatat i on wh i ch k ept h im
i n h is b ed in Paris for several mo n ths O n h is return he was
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ANGINA
wonderf ull y
P
E CT ORI S SINE D O L ORE
77
.
b etter too k u p h is w ork b u t s oon had anoth e r
b re ak do wn be gi nn in g w i th att ack s o f a ngin a sine dolore I n
o n e o f these w h i c h I saw the p al lor w as extre m e the e x t r e m i
t i e s w ere cold a c lammy persp i rat i on b athed the foreh e ad an d
face the p u l se was e xtrem e ly fe e b l e an d I thou ght an y m om e n t
that he w ould di e A ft e r a pro tracte d att ac k O f c ardi ac di l ata
t i on persi stentl y feeb le irr e g u l ar p u l se w i thout an y drop sy
but w i th the mo st re m ark ab le p sy c h i cal man i fe stat i on s he re
covered and w as ab le fo r more th an three y e ars t o atten d t o
Then he h ad a s u dde n m ore rap i d b reak do w n
h is dut i es
wi th c ardiac d i l at at i o n an d he d i e d b et w een three and f our
years from the date o f his fir st att ac k I have already sh o wn
n ary art e ri e s in h is c ase wh i ch w ere
ect
i
ons
f
rom
the
coro
o
u
s
y
scleroti c and the myoc ardium was fib ro i d i n pl ac es
C A S E XXX — E H aged fift y f ou r years seen J u l y 1 1
1 8 9 5 co m pl ai n i n g o f att ac k s o f oppress i o n i n the che st t o
wh i c h he h ad b ee n sub j e c t fo r five ye ars
The pati en t w as a rem ark ab ly healthy look i n g m an of g oo d
color of medium s ize w i th i ro n gray h ai r Th i rty years ago he
had syphil i s b u t was thoro u ghl y treated at Kre u znach an d he
has had n o troub le some symptoms H e marri ed ei ght o r te n
years ago and h as he althy ch i ldren H e h as b ee n a v ery heavy
smo k er from h is e ighteenth year ; otherwise temperate ; he h as
n e v er d on e heavy w ork
F ive y e ars ago he n ot i ced th at w hen mak i n g an y extra e x e r
tion he had a se n sati on i n the chest w h i c h com pell e d h im t o
stop
A fter re st in g fo r a momen t o r t w o he co u ld then go
on
There w as no pa i n w i th i t H e w as smok in g exc e ssive
ly at t h e t i m e an d af t e r stopp i n g the tob ac c o the a t t ac k s b e
cam e less fre quent ; b u t for t w o years they troub led hi m a good
deal
Three years ago he r e t i red from b u si n e ss an d sp e n t a ye ar
When there he h ad h is fi rst se v e re att ac k Whi le
in E urope
g oi n g hom e aft e r a heart y d i nn er w i th a fri e n d he w as se i z e d
w i th a sen sat i on i n the che st h ad t o stop in t h e stre e t an d w as
The feeli n g in t h e ch e st w as as i f eve rythin g
t ak en t o his ho t e l
in i t w as b e i n g dra w n to g e ther an d t i gh t en e d b u t w i tho u t an y
sharp pain H e was v ery pale he persp ir e d and the attack
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AN G INA
78
P E C T OR
I S AN D ALLIE D S TAT E S
lasted unt i l the nig ht A fter the at tack he h ad great d e pressi on
o f sp i ri ts
The onl y other severe att ack he h as e v er had w as six w e e k s
ago
H e h ad b e e n f eel i n g v ery w ell b u t b ef ore s i tt in g d o wn
t o d i nn er an an n o y i n g c i r c u m stan c e d e veloped and w h i le st i ll
u n der the i n fl u e n c e o f t h e i rri t at ion he sat d o wn and ate he art i l y
I mm ed i at e l y a ft e r di n n e r he h ad an attac k o f terri b le oppre ssi on
in the c hest f eel i n g as he e x pre ssed i t as thou gh the l i f e w as
b e i n g squ eez ed o u t o f him The sl i ghtest movem ent w ould
increase the oppr e ssi o n
I n the attac k ab solute qu i et i s w h at
he de si res H e do e s n o t e v e n w i sh t o b e spok en t o b ut f eels
The i m m ob i l i ty is evi den tly a
t hat the m i n d m u st b e at r e st
v er y characteri st i c f e ature Wh e n the sen se o f co n stri c ti on
a n d dra w i n g is upon h i m he sa y s he c ould n o t f orce h imsel f
In these se v ere att ac k s the pulse b e c omes
t o b u d g e an i n c h
very slow
The sensat i on is i n the b rea st b one in the mi d
dle
In describ i n g h is sen sat i o n s d u ri n g a conv e rsation o f at least
t hree qu arter s o f an ho u r he d i d n o t u se the w ord p ai n once
an d states expre ssl y t h at i t i sn t an y th i n g l i k e pa i n b u t an in
A S he s ay s
de sc rib le se n sat i on o f c o n stri ct i o n an d oppres sion
he feels as i f the e n d o f ev e rythi n g had come
at the same
t ime he f eels so h e althy th at b eh i n d i t as it w ere there i s a
”
f eel i n g that he st i ll h as a lon g t ime t o l ive
I n the t w o se v ere att ac k s a f eel i n g e x t e n d e d into the mus
cles o f the arms n ot i nto the sk in he say s but there was a
sen se o f stra i n an d soren e ss i n them
The small atta c k s as he c alls them recur with grea t fre
qu e n e y and almost an y d ay he h as w h at he c alls a hin dran ce ;
an d i f he ma k es an y exert i o n o f m ore t h an u su al e ff ort he h as t o
stop short and w ai t a f e w momen t s u n t i l the s e n sat i on pas se s a w a y
Thi s may recu r t w o or three t i m es an d then i f he t ak e s i t
he c an sub se qu e ntl y w al k t w o o r three mi les w i thout
slo w l y
an y di stress
T w o other ci r c u mst anc e s w hich will b ri n g o n an attack
are an unu su all y fu ll m e al an d an y mental worry H e n e v er
h as the att ac k s at n i ght
The pul se was 7 2 when he was at rest ; after his runnin g
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AN GINA
P E CT OR
I S SINE D OL ORE
79
.
upstairs and do wn 1 04 ; the tens i on was n o t i n c re ase d ; the
superfi c i al vessels w ere n o t sclerosed
The apex b eat w as onl y j ust vi sib le i n fi fth i n t e rsp ac e with
The S hock o f t h e first s o un d was f e lt n ot
in the n i pple l i ne
O f the second A rea o f su perfi c i al du ll n ess w as r e du ce d b y e m ph y
se m a B oth s o u n d s o f the he art w ere c l e ar ; first a l i ttle fl app in g
an d valvul ar ; no accentuati on o f aort i c second so u n d The e x
The l ive r w as n ot
ami nat i on o f t h e heart was enti rel y ne g ative
e n l arg e d
July 1 2 t h The pat i ent stay e d i n to wn unt i l I c ou l d se e
hi s cond i t i on i n an attac k H e had had t wo t o day on e qu i te
li ght i n the morn i n g H e w al ked into the room somewhat
deli b eratel y talked clearly an d w ell a n d h ad n o t ch an ged i n
color H e sai d he had a sen se o f great di stres s j ust b en eath
the b rea st b on e The pu lse w as small a n d har d 1 03 a mi nute
with d i sti nctly increased tensi on A fter si tti n g d o w n fo r a
f ew mo m ent s h is ski n b ecame moi st b u t he di d n o t b ecome
pale I n the course o f a few mi n u tes the attac k p asse d o ff w i th
a f eel i n g o f g lo w
A fterw ard there was a v ery deci d e d c han g e
noti c eab le i n h is p u lse wh i ch w as so fter an d fu ller an d o f
decidedly lo w er tensi on
H e w as advi sed t o stop smo k i n g an d o r d ere d a course o f
n i trogl yceri n I heard from h i m i n S e ptemb er an d o f him i n
”
Ma y
H e still has the smaller attack s as he calls
them
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T h e attacks may altern ate w ith t h ose in w h ich a g on i z in g
pain is present o r th e y m ay e n tirely supplant the severer
t y pe S ome Of the milder parox y sms indic atin g the b e g in
n i n g as it w ere o f th e trouble appear to be Of this kin d
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A n iron gra y health y lookin g m an aged sixt y four years
o f g ood hab i ts a n d exc e ll e nt h i st ory
con su lt e d me M ay 2 5
1 8 9 5 ab out c urious sens ations i n the c h e st
In O c tob e r he
not i c ed th at when w alk i n g fast th e r e w as a p e c u l i ar sen sati on
ab out the heart as he sai d an aur e ol e wh i ch spre ad up h is
”
neck and head and w ent ou t t o the h ands
I f he stopped for
”
a moment the sensation would recede l i k e a glo w
if he
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ANGI NA
80
w ent
P E CT OR
IS
ALLIED STATES
AN D
.
it w ould culmi n ate i n a pa i n wh i c h would compe l
h im t o stop There was no sense o f fai ntne ss no dy spn oe a a n d
he di d n o t sw eat They have al way s f ollo we d exert i on an d
he h as had as man y as f our o r five att ac k s in a day H is arteri es
w ere a l i ttle st i ff but the aort i c seco n d sound was no t ac c e n t u
ated The t op o f the p i n n a o f the le ft ear was calc i fied H e
had n e v er had gout I heard from this patient on F eb ru ary
6 t h o f th i s y e ar
The attack s con t i nue though l ess f re quent
—only t w o o r three a week They are characteri z ed b y t h e s ame
spre adi n g glow b e gi nni n g at the heart a n d lately the curi ous
sensation h as passed d o wn the ri ght arm alone
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IV
Car dia c
—
A sthm a
H eberden I n s ist ed th at in t h e
paroxysm o f t ru e an g in a there w as n o shor tne ss of bre a th,
and yet w e find a fe w ye ars after h is description t h e term
u
a sthm a applied to t h e condition : A sthm a d o lor i
c
m
D
a
r
(
fi
w in) A ar thr itic u m ( S chmidt ) A con vu lsivu m ( E lsner)
In rea di n g the reports O f t h e cases published w ith in t h e
first h alf century after H e b er de n s paper, it is very evid e n t
t h at muc h confusion existed and nearly all forms Of cardiac
distress w ere termed an gina D esportes emp h asized t hi s on
t h e title pa g e Of h is mono grap h ( 1 8 1 1 ) o n a n gi n a , w h ic h h e
said w as a malady pres que toujours confondue a vec asth
ma
T h e earliest a n d the latest as it is the most ur g ent
symptom in heart disease is dysp n oea w h ich t h e older w riters
c h ara cteri zed as a sthm a ; and as it forms a common feature
in cases of angin a pectoris it i s n o t surprisin g that more o r
less confusion prevailed E v e n S tokes d o e s not seem t o h ave
h ad a very clear con ception o f the distinctions betw een these
states since h e sa y s that the disease w h ic h most o ft e n g ets
t h e n a m e o f an g in a pectoris mi ght b e more properly de sig
”
n at e d a s cardiac asth ma
Wh at t h en is th is condition " G O into th e w ards and ask
th e patients w ith valvular disease o f the h ea rt as to th e very
With scarcely an exception
fir st symptom of t h eir trouble
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AN GI NA
82
P
E CT OR I S AND ALLIED S T A T E S
.
able to the w orkin g Of all the accessory muscles of respiration
S li gh t cyanosis is usuall y present a n d in severe p ar ox y sms
a cold sw eat breaks o u t in the face a n d limbs
T he pulse
i s feeble often irre gular a n d very small and o n ausc ul tation
o n e h ears either g allop rh y thm o r the foe tal t y pe of heart
beat D eath may occur in the attack as in D re sc h fe ld s case
the history o f w hich I g a v e y ou in L ecture III T his form
o f cardiac as thma occurs w ith great fre q uency i n some o f t h e
subj ects of an g in a pectoris as in C ases V a n d X II
A n d lastly the type Of breathi n g k n own as Che yn e
S toke s is sometimes a form o f cardiac asthma a n d it is not
uncommon in an gina pectoris T he curi ous pause in his respi
ration Of w h ich John Hunter spoke w as probably a period
I t w as
o f apn oe a in a paroxysm o f C heyn e S tokes breathin g
first descri bed b y Ch eyne in a ca se o f fatty h e art and y o u
w ill find it mo re fre q uently associated w ith chronic m y o c ar
dit is t h an w ith any other form o f heart diseas e
Th e follow in g case presen ts features of G airdn e r s an gin a
sin e d olor e w it h characteristic cardiac ast h ma :
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X,
Mr
a g e d si x t y seven seen March 9 1 8 9 5 with D r C lari
b el C on e compla i n i n g o f atta c k s o f terrib le oppress i on i n the
chest a n d a se n se o f i m pendin g death
The patient was a v ery large framed w ell nouri shed Vi gor
o u s loo kin g m an
H e had b een al w ays a v er y active b usi ness
man tem perate b u t a heavy smok er ; he b egan i n h is ei ghteenth
y ear an d h as u sed as man y as ei ght ci gars a day
F o r several y ears he h as occasi onall y b ee n roused from h i s
sleep w ith a feelin g of oppres sion i n the c he st b ut it h as n e v er
b ee n v ery se v ere F o r the pa st t w o o r three w eek s he h as b ee n
v ery short O f br e ath and h as had p aroxysms o f gre at oppres sion
in the chest wi th dy s p n oea f eeb lene ss o f the c i rculat i on cold
clammy sw eat an d a se n se o f i mpen din g di ssoluti on D uri n g
these attack s there is n o actual pa i n Mental exc i tement or
muscular exert i on w i ll b ri n g on the oppressi o n and dy spn oe a
H e came t o day however in the street c ar an d walk ed hal f
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CARDIAC AS T H M A
83
.
a b lock w ithout much di ffi c u lty D u rin g the exam i nat i on h e
h ad w e ll m ark e d C h e yne S to k e s re sp i rat i o n
The p u lse w as 1 04 o f moderat e t e n si o n e asi ly obl i t e rat ed ;
the vessel w all was a li ttle st i ff The ap e x b e at w as f e e b l e j u st
at the m am i ll ary l i ne ; there w as no S hoc k o f e i th e r so u n d t o b e
felt ; there w as gallop rhyth m at the apex b u t no m u rm u r The
se c o n d aort i c s o u n d w as a l i ttle accent u at e d
T h e l i ve r w as n o t
e nl arg e d
A t 1 1 P M o n the 9t h the p atient had a v ery se ve re attac k
o f terri b le oppress i on in the b re ath w i th drench i n g cold sw e at
w h i ch so aked the cloth in g D uri n g the att ac k t h e pul se was
1 04 an d re gul ar
The C heyne S to kes b reath in g b e c am e ag
r
e
a
va
d
ur
i
n
g
the
ttac
k
a
t
d
g
I n thi s pat i ent the attac k s w ere more than ordi nary c ar
di ac dyspn oe a In addi t i o n t o a sen sat i on o f a wf u l oppre ssi on
i n the che st there was a sen se o f i mpendi n g d e ath a n d the cold
c l amm y s k in sho wed pro f o u nd i nvolvement o f the vaso motor
sy stem
Fo r several wee k s th i s pat i e nt seemed v ery i ll
There w ere
t wo i n terest i n g po i nt s i n h is tre atment
T h e di gi t al i s s e emed
t o have helped h im very much w hen t h e p u lse t e n s i on w as l o w ;
su b se quently he go t a great deal o f rel i e f from the fu ll d o ses o f
n i tro glyceri n Thro u gh the w i n ter o f 1 8 9 5
he remai n e d
pretty w ell though sub j ect t o occasional attack s
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I can n o t leave th is q uestion o f cardiac dyspn oea o f e qu al
importance patholo gically a n d clinically w ithout re ferri n g
brie fly to certain recent w orks upon it A Frae n k el in the
third edition o f th e R e a l E n cyc lop adie under A sthma h as
a full a n d clear statement o f t h e condition R osen b a c h s
H erz kr a n kh e ite n has the most exhau stive discussion o n the
w h ole subject full Of su g g estive idea s but not e asy readin g
apparentl y not e v e n to his country me n as P rofessor Martius
speaks o f the L e hr bu ch as in ein er etw as dun k len S prache
”
g eschrie b ene
The esse n c e o f R osen b ach s view s o n the
re l a t i o n s Of cardiac ast h ma and an g ina may be g athered from
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AN G INA
84
P
E CT OR I S AND ALLIED S TA T E S
.
D ass nur e i n e V e r an d e
the follow i n g se n tence ( pa g e
run g i n der A rt der M u sk e lc o n t rac t io n die die S t arke der
Mus k elleistun g durc haus nicht z u b e e in flu sse n braucht w ohl
aber b e e in flu sse n kan n I m pul se fiir die se n siblen B ah n e n
liefert d i e j e nach der E rre g bark eit dersel b en und der B e
fe n h e it d er betro ffen en Bah n e n
d i e verschiedenen
sc h af
Formen von S chmerz u n d A n g st au l se n die w ir als S teno
cardie bezeich nen w ahrend die V e ran de ru n g im Muskel die
zur L eistun g ss c hw a che fiih r e n das H auptsymptom d e s A sth
”
ma cardiacum de n w ahren L u h t h u n ge r hervorruft
Or a s
h e sa y s i n an other place
die w ahre S tenocardie ist e i n
blosses Z eichen der R e gu l at io n sst Oru n g das A sthma cardia
”
ru n g
c u m ein Z eichen de r C o m pe n sat io n sst O
h ave e n dea v o re d t o sh ow th at
V o n Basc h a n d h is pupils
w h enever either from spasm or w ea k ness of the left ventricle
t h e blood pressure i n the auricle i s raised cardiac dyspn oea
follow s in association w ith t w o important chan g es i n the lun g s
L u n ge n sc hw e llu n g
sw ellin g and diminished elasticity
v iz
Th e sw ellin g w hich may e v e n b e de
u n d L u n ge n sta r r h e it
t e rm in e d b y percussion results directly from the overdi e
tention of th e c apillary netw ork i n the air cells an d t o th e
same cause von Basch attributes th e lessened elasticity T he
ratio betw een the respiratory w ork an d the i n t ak e of air is
reduced ; a n d as Z e rn e r remarks ( S tu die n B d iii) th e pe
c u liar it y o f cardiac d y spn oe a is in this respiratory i n su fficiency
T he ex
n o t in the rapidit y and depth Of the breathin g
of the lun g s is lessened and the amount
c u r sio n sfah igk e it
of air inspired i s not proportion ate to the w ork d o n e Frae n
kel also refers t o the in fluence of th e v e no u s en gorg ement
a
s
t
h
e
mucous
membrane
Of
t
h
e
finer
bronchioles
limit
f
o
in g the freedom o f in gress a n d e g ress Of the air to the alveoli
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K lin ische
iii, 1 89 6
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und
e ape r im e n te lle
S tu dien, i, ii,
and
tic ularly
iii, par
Bd
.
CAR DIAC AST H M A
85
.
W h en w e recall to mind the features of th e attack in
cardiac asthma an d in cert ain ang inal se iz u r e s the similari ty
as H uch ard remarks to a n acute e m ph y
o f t h e condition
sema t h e vie w s o f v o n B as c h appear to possess a t least a
reasonable probability
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L E CT UR E V
-
P S E UD O A N G I N A
P
‘
I
.
.
E C T O R IS
.
Neurotic grou p : (a) H ysteric al and n e urasth e n ic c ases ; (b ) Angina pe c
toria aso m oto ria ; (c ) Reflex angina —II T ox ic angin a : form s of h e art
pain f ro m t ob ac c o
v
-
.
.
AN
an gina n otha false an gina w as first described so far
as I c an ascertai n b y J L atham in a paper ( 1 8 1 2 ) o n certain
symptoms usuall y b u t not al w a y s denoti n g an g ina pec
”
toris
A ccordin g to Huchard th e term pseudo an gin a w as
introduced by L arti gue in 1 84 6 W alshe called attention
particularl y t o this co n dition statin g that g e n u i n e an g ina
pectoris is undoubtedl y a ver y rare affection O n the oth er
h a n d I a lm ost da ily meet w ith a form of complaint c o m b in
i n g in a mi n or de gree man y of the characters of an g i n a ;
a n d to this imitation o f th e true disease I propose to g ive the
name Of pseudo an g in a I believe that herein lies th e ex
planation of L aennec s notion ( so discordant w ith th e e x pe ri
e n ce of E n glish observers) that an gin a pectoris is of v er y fre
”
quent occurre n ce
T he term w hich h as come i n to g eneral
use a n d i s Of no little value has not passed w ithout criticism
Balfour ( T he S e n ile H e a r t) says : T he term pseudo an
gi n a is Often applied to an ginous pains occurrin g before
middle life especially in the female sex and y et w e see that
fatal an gin a ma y occur in o n e w h o is still but a g irl T o talk
ho w ever a mark o f i gnorance rath er
o f p seu d o a ng i n a is
t h an of refinement o f dia gnosis ; for a n g in a is but a symptom,
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86
PSEUD O ANGINA
-
P
E CT ORI S
87
.
a n d if w ell marked it should n o more b e stigmatized as
pseudo because it occurs in youth than th e lesion w it h
w hic h it i s sometimes a ssoci ated should b e called functional
”
because it h appens to b e curable
A nd y et not t w o pag es
Off he sa y s :
But in w h at w e m ay term— for w ant Of a
—
better e xpression false an g ina w e h a ve only to d ea l w it h
”
the pain, the d a n g er Of w hic h d e p e n d s u po n its cause a n d
in r e ality he subse quently acknow ledg es the w isdom of
Walsh e S division
Burney Yeo says :
I do n o t admit a pseudo an g in a O f
some authors
H y sterical imitative an gin as how ever cer
t ain ly occur
But
t h ere is simply a gradation Of se
verit y a n d curability b e tw ee n the S O called c ases of ps eu d o
”
an gina a n d t h ose of t rue a n gina
*
M orison t oo i n a recent pa per
q uestions the correct
n e ss o f the term :
A case o f true a n g ina i s o n e in w hi c h
t h ere is n o doubt a b o u t the an gin a an d th ere i s n o mistake
about th e reality of t h e pain o r breast pan g in man y so called
functiona l cases
Th e id ea o f spurious a n g i n a i s only per
missible in so far as the an gina is not as sociated w ith d e m o n
”
an d t e n d s to g et w ell H erein lies the essence
st rab le lesion
—
th e symptoms o n the o n e h a n d indi
o f t h e w h ole matter
cate the existence of a grave org anic usually incurable
malady a n d o n t h e oth er a condition very distressin g it is
true but rarel y serious an d usuall y curable The a d v a nt a g e s
in thus reco gn i z i n g a functional g roup far out w ei g h any
t h eoretica l o b je c tion s a n d in a se ri es of cases th e forms are
w ith fe w exceptio n s fairly w ell defi n ed
I h ave no t es o f some t w en t y cases of pseudo an gin a pec
toris cases in w hi c h there w ere recurrin g paroxysms of se v ere
e v e n a g oni z in g cardi ac pain o f ten w ith radiation Th e ab
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d in bu rgh H ospita l R eports
,
Vol
.
iii
.
AN
88
GINA PEC T OR IS
AL LIED S T A T ES
AND
.
—
im i
—
ment al element
a n or M
n d t h e exis t
a
s e n c e Of t h e
g
ence of collateral features aetiolo gical o r s y mptomatic served
to separate th em f r o m the forms I h a v e previously c o n sid
ered I have only taken ca s es in w hich the seizures w ere
parox y smal and i n t e n se ; if o n e counted all t h e sli gh t c ar
diac disturbances in h y ste ri cal a n d neurasthenic patients as
pseudo an gina the list could b e g reatly extended
A t t h e outset let m e emp h asize t h ree points o f special
si gnificance :
,
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,
You
f
f
member that in the series Of or g a n ic or coron ary a n gi n a there
—
—
the only instance
w as only o n e w oman
a mitral val ve case
o f t r u e a n g i n a that I h a v e s ee n i n a female
O f the tw enty
cases Of pseudo an gina tw elve w ere in w omen I f w e ex
there w ere only six in
e lude t w o cases o f tobacco an gi na
stances in ma l es In my seri es it w as muc h m o r e common in
married w omen ; t h ere w ere only t w o g irls eac h a g ed tw enty
W e can say th en th at ps eu d o a n gi n a i s almost as much
two
a special disorder of w omen as true an gina i s o f men
S e c on d It occ u r s in y ou n ge r p erson s
T he a v erag e a g e
o f th e subj ects o f spurious a n gi n a is muc h low er t h an i n the
—
other form t h irty ei ght years i n my s eri e s th e extreme s
bein g tw enty t w o a n d sixty years t h e latter a w oman w h o
h ad h a d attacks for tw ent y or more y e ars
T hir d T he p a t ie n ts do n ot die
Wh ile fi fteen o f t h e
subjects o f true an g in a o n my list are d ea d every o n e o f th e
t w enty patients w ith pseudo an gina is alive ; o f several of
t h e cases Of true an g ina I ha v e lost track
T w o main groups o f functional a n gi n a may b e reco gn ized
—th e neurotic a n d th e toxic
—
U
I NE R O TI C T h e cases in th is group p re s e n t a g ood
m any m i n o r differences eith er in t h e c h aracters o f t h e attack
or i n t h e circumstan ces w h ic h fa vor its onset
and
base
d
;
F ir st P
.
se u d o a n
-
i
i
n
a
s
g
an a
e c t ion o
w om e n
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AN GINA
90
P E CT OR
I S AN D ALLIED S T AT ES
.
S he is a w om an o f a g ood de al o f character and de
termi n at i o n and o f exec u tive sk i ll an d d o e s n o t g i v e o n e the
i m pre ssi o n o f b ei n g o f a neu rot i c h ab i t S he h as al way s b een
a b le t o d o a gre at de al o f w alk i ng an d has n ot su fl e re d spec i ally
w i t h short n e ss o f b reath
Fi ve y ear s ago sh e had a n attack of
appendi c i t i s from wh i ch sh e recover e d wi thou t operat i o n I n
the spri n g o f 1 8 9 3 w he n ret u rn i n g from C olorado a n d after
a g oo d d eal o f m en t al w o rry sh e had an att ac k o f very sever e
p a i n in t he che st I t c ame on a fter exert i on an d e xpo su re t o
t he w ind i n w alk i n g T he pai n was O f terri b le severi t y ex
tended u p the n ec k an d do wn the arms; b ut she was ab le t o
move ab out i n it a n d w as a g ood deal exc i ted S i n ce that at
tac k she h as b ee n at i ntervals a l i ttle short o f b reath o n e xe r
tion S he h as ha d t w o o f the severe attac k s s ince ; o n e la st su m
mer at the sea si de w hen w al k i n g on the sand the o t her t wo
months a g o B oth o f t hese w ere o f great severit y ; t he p ai n
w as a g oni z i n g ; she be c ame gra y and cold and exhau sted a n d
the s k i n was c overed wi th a clamm y persp i rat i on S he states
t o o th at she ha d a sen sat i o n as t h o u g h sh e co u ld no t l i ve
t h r o u g h i t O n e o f the se atta c k s was f ollo w ed b y a transi ent
f aci al paral y si s L ast A u gust fo r the fi rst t i m e i n her l i fe sh e
b ega n t o ha v e hea d aches wh i ch ha v e recu rred as O f ten as t wo
T he y are o f the type o f mi graine and
o r three times a w ee k
c om e on with di stu rb ance o f vi s i on ; sh e somet imes sees fi gures
and queer thin g s ; on ce sh e had hemi anop i a The attack s pro s
trate her v er y much
Ab ou t the middle O f D ecemb er her feet a n d an kles b e g a n t o
s w ell part i cul arl y a t n i ght A t fi rst ther e w as l i ttle o r n o
pitt i n g but n o w t he y are someti mes s w ollen t o the kn ees T he
ur i n e h as b ee n normal i n qu an t i t y and w i thout al bumi n o r tub e
casts
T he p atient was a w ell nourished health y loo k i n g w oman ;
pulse 8 0 re gul ar w i thou t i n crease in ten sion a n d the ve ssel
w as n o t sclero se d T he thyro i d gl a n d w as n o t en larged an d
there w as no pu ffin e ss o f the f ac e o r ab ov e the clavi cles T he
f eet and ankle s at t h e t i m e o f examin ation were n o t oe dematou s
T he examination o f the heart and other organs was entirel y
ne gative
sc io u sn e ss
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PSEUD O —ANGINA
P
E CT OR I S
91
.
h opeful pro gn osis w as gi v e n i n the case based o n the
vie w th at the attacks thou g h s e v ere w ere proba b l y pseudo
an g ina The occurre n ce Of mig rain e w ith w hich pseudo
and the sw ellin g of the f ee t
an g inal attacks ma y alternate
w it h out evid e n ce of h eart or re n al disease w ere corroborative
features I h a v e h eard o f this case se v era l times ; sh e g ot
better a n d the pain f ul heart atta c k s w hen I last saw her
husband six mont h s ag o had not recurred
A
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II M rs F R
CA S E
a g e d f orty t wo y ears see n April 9
1 8 9 4 compl ai n i n g Of att ac k s o f a g o n i z i n g p ai n i n the ches t
The p ati en t comes o f a very n ervo us fami ly a n d on e si ster
is i n a l u natic as yl u m
S he w as well a n d stron g u n t i l t wo y ears ago ; sh e has ha d
five ch i ldren the y o u n g es t S i x years o l d S he h as n e v er ha d
an y spe c ial i llne sse s
S he w as n o t sp e c i ally nervo u s as a y o u n g
g irl an d had no c ryi n g spell s o r hy steri c al att ack s H er d om es
tic relat i ons are c on g en i al an d sat i sfac tory
T he pres e n t troub le b e gan t w o y ears ago last F eb ru ary w h e n
on e morn i n g she had an att ac k o f se v ere p a i n i n the c hest I t
b egan i n the p i t o f the stom ac h b ec ame m o st i n ten se under the
left b reast an d extend e d roun d the S h o u l d er A s sh e expr e sse d
it sh e thou ght death ha d c om e S he got cold b rok e o u t i nto
a pro fuse persp i rati o n an d du ri n g the atta c k was c om pl e t e l y
helpless The atta c k l asted fo r ab ou t an hou r a n d l e ft h e r mu ch
prostrated D u ri n g t he succeedi n g y ear sh e ha d ab ou t f ou r at
ta c k s e ac h Of gre at severi t y and i d e nt i cal i n charact e r In the
pa st y ear t hey ha v e b e c om e more fre qu ent ; thus sh e has ha d
t wo in the p ast month
T he last att ac k w as on t h e l st o f Apri l
S he felt comfort ab le i n the morn in g whe n she go t up but after
breakfast felt a l i ttle dro w sy an d hea v y an d lay d o w n o n the
so fa The att ac k c am e wi th the greate st rap i di t y a n d w as s o
sev ere t hat she could n o t ri se The b re ath get s short ; sh e f e e ls
a sen sation O f deathl y coldness ab o u t t h e heart an d t h e c h i ef
p ai n is u n d er t h e l e ft b reast S he can n o t mov e ab ou t an d whe n
the pain is at it s h e i ght she c an n o t b e ar t o b e tou ch e d A s
it c ome s on she loosen s her clothi n g b u t as the att ack in c re ases
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ANG I NA
92
P E CT OR
I S AND ALLIED S TATE S
.
verity sh e i s qui te b es i de hersel f tosse s ab o u t an d is as
S he s ay s almo st dead
S he groans a great d e al an d i n some
o f them h as cri ed o u t v er y loudl y
H er husb a n d wh o is a
traveller h as o n ly seen her i n t w o attack s b oth o f w hi c h came on
w i th great su dd e nn ess S he go t very c old the fa c e b ecame
p i n c hed and d ra wn at fi rst a l i ttle con ge sted a n d then pale
T wice sh e vomit e d in the att ac k T he durat i on has b ee n from
a quarter o f an hour t o an hour S he h as had t o h ave m o rp h i n e
hypodermi cally on sev eral occasi on s A fter the y p ass a way sh e
f eels mi serab le and is wretched fo r t w o o r three day s S ome
t i me s the w h o l e b ody is sore after an att ac k
S he kne w o f no sp e c i al c i rcumst an c e apt t o i nd uce an at
t ac k
S he was lo w sp i ri ted at times and not i ced that she h as
b ee n a l i ttle d es p on d e n t pri or t o the i r on set S he has n o t b ee n
S hort o f b reath on g o i n g upst ai rs o r uph i ll ; n o t more than
might b e expected i n a stout w oman
E xert i on h as n e v er
b rou ght on the attac k
T he pat i ent w as a larg e stout health y loo k i n g w oman
There w as no arcus ; the c olor was g ood ; the tongu e clean ;
the temporal art e ries n o t sclerosed ; puls e 8 4 readi ly c om
pre ssed ; the vessel wall w as n ot sc lerosed There was sl i ght
throbb in g i n the ve ssels o f the nec k P ercussi on was clear on
manub ri um T he c ardi ac d u ll n e ss b e gan on the fourth ri b
A t fi rst ri ght i n terspace there was a so ft sy stol i c murmur and
the aort i c sec on d sou n d was here a l i ttle acce n t u ated T he fi rst
s o u n d was loud and clear upon sternum ; th e re was no murmur
at the apex T here w as no pain o n fi rm pressure over manu
b riu m o r ad j acent parts
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Th e soft bruit at t h e aortic area and the a ccentuation
of th e second s o u n d ma d e m e a little suspicious o f t his case
thou gh the g eneral features o f the attack w ere rather those
The subse quent history as o btain ed from
o f pseudo an gina
D r G W N orris a n d from h er h usband o n O ctober 2 7 1 8 9 4
a n d July 7 1 8 9 5 sho w s th at sh e steadily improved and th e
attacks h ave n ow ce ased
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ANGINA
94
t i on
P
E CT ORI S AND ALLIED S TA T E S
.
t he heart was ne gat i ve the aort i c sec on d sound w as rin g
T he p up i l s w ere e qual ; she ha d no arcu s
in g an d accentuated
sen i l i s
of
,
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.
Th ere see m e d v er y little doubt th at th is w as a pseudo
a n g i n a , a n d I reassured her upon the q uestion o f sirdde n
d ea th I heard of this patient o n July 1 3 t h a n d o n D ecem
S he has not had a severe attack sin ce February ;
h e r 3 0t h
”
for a f e w months sh e had threate n in g s as sh e calls th em ;
since July sh e has b ee n q uite w ell
T he follow i n g ca se is Of i n terest from t h e i n ten sity Of the
paroxysms and the h y peraesthesia o f the left arm S h e h ad
b ee n alarmed t oo by t h e serious Vie w w h ich h ad b ee n t a k e n
o f h er condition :
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s
C S E I V Mi s C a g e d twent y t wo y ear s re f erre d t o m e
S ep t e m b er 2 9 1 8 9 1 b y D r C l ark o f S k an eateles co m pla i n
in g Of remark ab le atta c k s i n the re g i on o f the heart
T he fam i ly h i story is g oo d an d sh e h as hersel f al way s e n
j o yed very g oo d health S he is evi dentl y a h i gh strun g nervous
girl wh o h as stu di ed h ard
When qu i te y ou n g ab out the
t w el fth y ear she h ad fo r a ti m e pai n i n the le ft s i de ab out the
hear t and se n sat i on s o f coldnes s
T he presen t complai nt has persi sted fo r b etween t wo a n d
three years S he d e scri b es a pai n mo re o r le ss c onstant i n the
lef t front o f the ches t w h i c h somet i m es g oes do w n the arm
w h i c h b ec om es n u m b S he says she is n e v er w ithout th i s p ai n
T he n sh e ha d
an d that i t somet i m es k eeps her f rom sleep i n g
su dd e n spell s i n w h i ch sh e h as a terri b le sens ati on O f spasm
i n t he re gi on o f the he art as thou gh someth i n g h ad g ra sped her
I t di ffers alto g ether from the other pa i n I n severe attac k s i t
has l asted all n i ght a n d sh e h as ha d t o g asp fo r b re ath S he
d o es n o t persp i re T he le ft arm b eco m es num b O ften t in gl e s
a n d in severe att ac k s t he numb n e ss extends to the le ft le g The
left arm feel s almo st p aralyz ed a n d i s ten der an d she c an n o t
use i t i n the at t ack s There m ay b e headache s but sh e is n e v er
S i c k a t t h e stomach
S he n e ver h as a ny speci al coldness of
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PSEUD O AN GINA PEC T ORIS
95
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the extremities S he h as only h ad f o ur o f these very seve re
paroxy sm s w i thi n the ye ar D u ri n g th e m sh e t ak e s chloro form
They ha v e n ever b ee n b ro u ght o n b y e x e r
a n d n i tri te o f amy l
t i o n an d sh e h as b een a bl e t o play t e nn i s quite act ively E x
c it e m e n t a n d e mo t i on most f re que n tl y c ause them
The patient was evi dently very neurot i c S he ha d n o heart
di sease no increased ten si on a n d no sclero si s o f the vessels
A n i nteresti n g feature was the g reat sensi tiveness o f the left
ha n d a n d arm S he j umped at on ce w he n I tou c hed the wrist
in order t o feel the p u lse T he Vari ous forms o f sensat i on in
it w ere perfe c tly normal Though sen si t ive t o the tou ch she
feels i t nu m b an d heavy The sensi t iveness di d n o t extend t o
the sk i n of t he chest
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Th e condition h ad b ee n the cau s e of a go o d deal o f alar m
to h er fr i e n d s an d a dia g nosis h a d b ee n m a d e b y on e of h er
physician s o f a tumor pressi n g i n th e re g io n O f the h eart
S he w as gi v e n a v er y favorable pro g nosis
I saw t h is patient fo r a fe w m o m e n t s abo ut a y ear a go
S h e h ad e n tirely recovered from h er a ttacks a n d th o u g h
n er vo u s s ee m e d very w ell
H y sterical an g in a in th e male is usuall y a very w ell
ch aracteri z ed afl e c t ion T he follow in g cases ar e th e m ost
typical w hich I h ave s ee n :
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C A S E V — W H seen w ith D r P u rv i s o f A lexan dri a aged
th i rty t w o years compl ai n in g o f seve re attac k s o f p a i n ab ou t the
heart
T he patient comes o f e c e llent G erma n sto c k H is moth e r
is al i ve an d h i s b rothers an d si sters are well an d stron g ; there
ar e n o special ne rvous troub le s i n t he f ami l y
T h o u g h a n hot e l
k ee p er he h as b een v er y ab ste m i o u s i n the u se o f al c oh o l H e
h as n e v er had syph i l i s
H e h as b een n ervo us fr o m b oyhood
When ab o u t fi fteen he had a fri ght aft e r wh i c h he ha d nerv ou s
spell s called fit s fo r several ye ars From h is de script i on they
A t the age o f t w e nt y
were e vi d e n tl y se v ere h y sterical attac k s
t hree he h a d scarlet f ever a nd di phtheria a n d n e ar l y lo st his
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ANGINA PEC T O RIS A ND ALLI ED S T A T ES
96
.
li f e F or the past s ix y ears he has had a great deal o f mental
w orry and f or nearl y two y ears a go o d dea l o f extra fi nanc i al
stra i n D uri ng th i s t ime he has had at i nterval s what h e call s
nervous attac k s He w oul d g et numb i n h i s f eet and then i n h i s
l egs and a sensat i on w ou l d ri se i n hi s b od y li k e a w ave mak
i ng h i m co l d and f ai nt
D r P urvi s who has seen h im i n the spe ll s say s they are evi
de n t ly h y ster i c al
He does not l ose consc i ousness
F or the past three months he has had d i fferent attac k s con
s i st i n g o f very a g on izi ng pa i n ab out the hea rt exten ding to the
shoul ders and down the am even to the fi ng ers very f re quent l y
on l y to the i ndex fi nger and thumb o f the l e f t hand The y have
come on most fre quent l y wh il e wa l ki ng He catches h i s b reath
and has fre quent l y had to si t down on a doorstep He descri b es
the pa i n as very agon izi n g b ut he ma k es no ment i on o f any
sensat i on li k e that o f i mpendi ng death H i s hands get co l d ;
somet i mes the f eet are co l d and he has at t imes bro k en out
i nto a pro fuse persp i rat i on The attac k s have recurred wi th
reat
f
re
q
uenc
y
He
has
had
as
man
y
as
f
our
i
n
the
t
w
ent
y
g
f our hours W orry overexert i on and on severa l occas i ons a
f ull mea l have caused attac k s The y have i ncreased rather
than d imi ni shed duri n g the past month
The pat i ent was a heal thy l oo ki ng w e ll nour i shed man
o f g ood co l or o f fa i r ph y si que wi th b l ac k ha i r and e y es The
p ul se was qui et ( 8 0 a m i nute ) tensi on not i ncreased He fl ushed
eas il y and there was the most mark ed f act i t i ous urt i cari a and
dermatograph i a The apex b eat was not vi s i b l e and not pal pa
b l e The superfi c i a l c ard i ac dull ness was not i ncreased The
sounds at the apex w ere c l ear There was no accentuat i on o f the
aort i c second and there w ere no murmurs There w ere no
pai n fu l spots ab out the prae cord i a The pat i ent sub se quentl y
entered the pr ivate ward o f the hosp i tal w here he had severa l
attac k s o f the character ab ove descri b ed
C A S E V I — Ou M ay 2 3 d I saw at the R ennert Hote l D r
R a g ed th i rt y three y ears a ph y s i c i an f rom one o f the N orth
ern c i t i es who had had a seri es o f most severe attack s dat in g
from M ay 1 5 th
The p at i ent a man o f very h igh strung nervous or gani z a
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ANGIN A PEC T O RIS
98
S TA T ES
AN D A L L IE D
.
The ph y si ca l exam i nat i on was ent i re l y negative The pulse
w as qui et wi thout i ncrease i n tens i on The heart sounds were
c l ear wi thout accentuati on o f the aort i c second The vaso
motor s y stem was extreme l y l a b il e and the sli g htest scratch w as
f o ll o wed by an act ive reacti on
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,
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,
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—
p seu d o angi n a
T he p ersistence of
is sometimes v er y re
mar k able I n 1 8 8 8 I w as consul t e d in P h i ladelphia by an
ol d fr i en d a ph y sician from the P rovince of " uebe c w ho
had very se v er e heart d isease While I w as visitin g him late
one evenin g at the L afay ette H otel he as k e d me to ste p
into the next room and see his w ife a w oman sixty y ears of
a ge
w hom I found prostrate on the be d w ith her han d s
clasp e d over her heart roc k in g herself from si d e to side in
an ag on y of p ain H e r han d s an d feet w ere col d the face
some w hat flushed the pulse small an d rap i d I coul d n ot
g et an ans w er from her but w h en I returne d to the room
t h e d octor said not to w orr y ( I seeme d anxiou s about her)
t h at she w oul d reco v er in a little w hile H e assure d me that
for more th an thirty y e ar s she ha d been subj ect to these at
tac k s part ic u larly w h e n overanxious or w orrie d S he w as a
v ery nervous w o m an h ad been h y sterical w hen y oun g an d
thou g h at first h e r husban d an d other ph y sicians thou gh t
the attac k s v ery serious the y p asse d o ff so q uic k ly part ic u
larly under the in fl uence of a hot w hisky p unch that h e h ad
ceased to re g ar d them as in an y w a y d an g erous
a
se m o to r A n in a
aso
motor
phenomena
are
6
V
V
( )
g
rarely absent in attac k s of true an g ina but the y are even
more p ronounce d in t h e nerv ous an d h y sterical subj ects
N oth na g el has d escribe d a special t yp e an g ina p ectoris va so
96
m otoz ia
In the four cases ( all men ) the sym p toms con
siste d of peculiar sensations in the extremities or on one si d e
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D e utsc he s A rch ie
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f
.
klin M e dicin , B d iii, 1 867
.
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ANGINA PEC T O RIS
VAS O
-
M O T O R IA
99
.
of the bo dy w ith coldness and somet i mes liv i dity of the
h a n ds and feet and s w eat i n g
With this there w ere pa l p i ta
t i on of the heart terrib l e pr ae cord i al anxiety or pa i n and
sometimes feelin g s of fa i ntness A strik in g feature in these
c as es w as the ten d en c y of the attac k s to occur in the c old
or on w ashin g the hands in col d w ater N o t h n age l re g arded
these vaso motor phenomen a as the p rimary features and
the car d ia c embarrassment an d d i stress as secondary to a
wi d esp rea d v aso constrictor in fl uence throu ghout the arterial
sy stem
A g oo d d eal of discussion has ta k en p lace upon the p ro
rie t
of
reco
g
ni
z
in
g
th
i
s
as
a
special
t
yp
e
and
cons
i
der
i
n
g
p
y
—
the fre q uenc y of vaso motor chan g es in b oth org anic an d
function al forms it does seem d oubt f ul ; an d y et the cases
are w onde rfull y w ell ch ar acteri z e d an d in t h e most pro
I th i n k of the funct i onal variety
n o u n c e d de g ree al w a y s
—
In a larg e proportion the vaso constrictor influences dominate
I remember but one in
an d there is pallor w ith c oldness
stance in w hich the v as o d ilator p henomena alone w ere
mark e d
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saw ( Case V II) i n Toronto a l ad y aged th i rt y
five y ears stout w e ll nouri shed the mother o f five or s i x ch il
dren wh o had b een the sub j ect at i nterval s o f very pu zzli ng
and d i stressi ng attac k s Wi thout an y spec i a l re f erence to the
menstrua l peri od an d f o ll owi ng p art i cul arl y w orry or exc i te
ment she w oul d experi ence a f ee li ng o f d i stress ab out the heart
amount i ng to actua l pai n and the vesse l s o f the f ace and o f
the extremi t i es w oul d b ecome congested and she f e l t co l d and
numb B ut much more d i stressi n g than these were the sensa
t i ons o f great pa i n i n the b ac k o f the head and neck The at
tac k s woul d l ast f or tw ent y f our hours or more and w ere some
t imes very al armi n g I coul d not gather from her that the pai ns
a b out the heart were ever o f a very a g onizi n g character b ut
the y w ere al way s severe I was ask ed to see her to determine
In 1 8 8 7 I
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ANGINA PE C T O RIS AND ALL IE D S T A T ES
1 00
.
the presence or a b sence o f a heart l es i on B oth sounds seemed
perf ect l y c l ear and there w ere no s igns o f organi c d i sease I
was much i mpressed wi th the neurot i c cond i t i on o f the pat i ent
and suggested h y steri a I saw the pat i ent i n an attac k evi dent
ly h y ster i ca l ; she was great l y prostrated l a y wi th the e y es
c l osed qu i te livi d i n the f ace and the hands and f eet were pur
s a b out
i
n
co
l
or
and
co
l
d
S
he
comp
l
a
i
ned
o
f
g
reat
d
i
stres
l
i
s
h
p
the heart and a gon izi ng pai n i n the b ac k o f the head and neck
The sub se quent h i stor y has b orne out the v i e w ta k en o f her
case Wi th i n a y ear or so she g ot perf ect l y we ll and has re
ma i ned so not havi ng had an attac k f or nearl y e i ght y ears
.
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,
M uch more commonly there is p allor w ith the col d ness
.
I n w omen the attac k s are a p t to recur at or before the men
st ru al p eriod
.
ag ed f ort y y ears consul ted me i n
1 8 9 0 a b out attac k s o f severe pa i n i n t h e re g i on o f the heart
wh i ch had recurred at i nterva l s f or ei g ht y ears s i nc e the b i rth
o f her l ast ch il d The y were part i cul ar l y li a b l e to come on dur
i ng the menstrual peri od or whenever sh e was sub j ect to any
spec i a l menta l strai n or worr y The pai ns w ere very severe im
med i ate l y und e r the l e f t b reast an d passed up the nec k and
down the l e f t arm S he d i d not fl ush wi th them but on the
contrar y g ot pal e and f e l t very co l d part i cul arl y i n the hands
and f eet wh i ch somet imes sw eated The pai ns w ere not con
t inu o u s b ut recurred at i nterval s extend i n g over a per i od o f
severa l da y s D i et she th i nk s had no spec i al i nfl uence S he
s l ept b ad l y and dreamed a great deal The pat i ent was a stout
—
w e ll nour i shed w oman o f g ood co l or ; the pul se w as regu l ar
a b out 8 0; the arteri es were not sc l erot i c There w as no he art
d i sease
M rs
C
ase
III
V
(
)
R
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I n w omen as y ou w ill have notice d in the reports I h ave
read the features of col d ness of the extremities w ith numb
ness an d p allor are v ery common I n men this ty p e may occur
in a most mark e d d e gre e , an d t h e d ia gnosis may be for some
t h e in d oubt
,
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.
ANGINA PEC T O RIS AND AL L I E D S T A T ES
1 02
.
very great stress upon the sensat i on o f co l dness i n the arms
an d l e g s and sa y s that on one occas i on he too k a w arm b ath
and even thou gh the water was qui te hot he st ill had a f ee l ing
o f g reat co l dness and numb ness i n h i s l e g s I n one attac k the
face and nec k b ecam e very red and con g ested and the nose b l ed
pro f use l y There i s i nvari ab l y pa lp i tat i on o f the heart and he
has b een to l d by h i s doctor th at the pul se at the wr i st b ecomes
scarce l y percept i b l e I n a paroxy sm seven y ears a g o he th i nk s
he l ost consc i ousness f or a moment He stagg ered and f e ll
I n one attac k at th i s t i me he had vert i g o
A s the paroxy sm
passes o ff he b e l ches a great dea l o f wi nd
I n severa l spe ll s
there has b een a good dea l o f itch i ng o f the sk i n and i n one
or two a mark ed twi tch i n g o f the musc l es The durat i on o f
the ent i re p aroxy sm vari es f rom two or three to ten or fif teen
mi nutes He fi nds that a strong dri n k o f wh i sky will somet imes
cut short an attac k I n the two months si nce the y recurred
he has had on an avera g e ab out f our i n a w ee k The y have not
all b een severe He has b een much al armed a b out them and i n
several o f the attac k s b oth he and h i s wi f e have b een great ly
terri fi ed
P at i ent was a tall w e ll grown heal th y l oo k i ng man There
The
was no arcus sen ili s ; the pup il s reacted read il y to li ght
pul se was so f t and f ull regul ar tens i on l o w The apex b eat
was j ust wi th i n the n i pp l e li ne not f orc ib l e ; sli ght thro bbi ng
i n the vesse l s o f the nec k The percussi on note was everywhere
c l ear ; there was no i ncre ase i n the area o f heart dull ness
The
heart sounds were c l ear ; the aort i c second was not accentuated ;
the b reath sounds w ere e qua l on b oth s i des ; there was no dull
ness i n e i ther i nterscapul ar re gi on and no b rui t i n the course
o f the descendi n g aorta ( a d i a gnosi s o f aneury sm had b een
made ) The cervi ca l gl ands w ere not en l ar g ed The exami na
t i on o f the a b domi na l organs was ne gat ive The k nee j erk s
w ere norma l There was no R omb erg s s ymptom and the pup il
re fl exes w ere act ive
The pat i ent s wi f e came to day to speak
Januar y 1 1 8 9 6
a b out her husb and s cond i t i on S he say s that l ast summer he
had a f ew sli ght attac k s S he ment i ons several f eatures o f in
F or exampl e
t e r e st part icu l ar l y the suddenness o f the onset
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PSEUD O ANGINA PEC T O RIS
1 03
-
.
he will aw ak en f rom a perf ect l y sound s l eep i n a most a l armi ng
paroxy sm and h i s hands an d f eet will b ecome co l d ; the f ace
i s usua ll y pal e and the heart will thro b most f orc i b l y Wi th i n
a mi nute or tw o h i s hands will b ecome as wet as thou g h the y
had b een d i pped i n water S he rememb ers two or three attac k s
i n wh i ch the f ace b ecame qu i te con g ested and f ull i nstead o f
pal e He i s great ly terri fi ed and a lway s f ee l s that he i s g o i n g
to d i e What has reassured her a l way s i s the f act that wi th i n
ten or twe lve m i nutes somet imes l ess he i s l au gh i n g and tal k
i ng qu i te f ree f rom pai n S he does not th i n k that he has b een
a very nervous man an d he has not had an y spec i al worri es
A pr il 1 1 8 9 6 F or the past two months th i s pat i ent h as
b een very much b etter and as he te ll s me has a l most recovered
from h i s attac k s
He has not had an atta c k f or nearl y f our month s
June 1 st
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.
A
i
n a — A nd
g
lastl
y
in
d
dition
to
the
purel
y
a
()
fl
—
h yste rical an d vaso motor forms there are c ases in w hich
the an gina ap pears to be excite d r e fle x ly either from pe
ri h e r al or visceral irritation
Y
ou
w
i
ll
fi
n
d
an
interestin
g
p
chapter in H uchard d evote d to these re fl e x pseudo an ginas
an d he h as collecte d a number of cases from the literature
There are instances of an ginous attac k follo w in g a cerv i co
brachi al neur al gia of either traumatic or spontaneous origin
You remember in the histories of the c as es of true an gin a
h ow insistent man y p atients w ere as to the in fl uence of d iet
There is also a so calle d g astro intestinal form of pseudo an
gina in w hich attac k s follo w in di g est i on The fo l lo w i n g is
the only instance in m y list in w hich the visceral irritat i on
appeared to in d uce the paroxy sms or to sp eak more cor
re ct l
:
in
w
hich
the
t
w
o
conditions
w
ere
associate
d
y
R
0
e
ew
n
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A
—
C S E XII M i ss A
a g ed t went y two y ears seen A pril 4
comp l ain i ng o f severe attac k s o f pai n i n the regi on o f the
1 89 3,
-
.
,
,
,
heart
S he b e l on g s to a nervous f amily and she has never b een
.
,
ANGINA PEC T O RIS AND ALL I E D S T A T ES
1 04
.
very strong S he den i es havi ng had h y steri a S everal t imes
as a ch il d she had s li ght rheumat i sm and three y ears a g o she
was l a i d up wi th a more acute attac k S evera l memb ers o f her
f am ily have a l so had i t F or y ears she has b een su b j ect to dy s
i
e
s
a
part
i
cu
l
ar
l
y
a
f
ter
eat
i
n
g
too
man
y
s
w
eet
th
i
n
g
s
F
or
a
p p
y e ar or more she has had occasi ona l attac k s o f pa i n i n the chest
com i ng on part i cul arl y when she has i nd i g est i on The pai ns
are ne uralgi c i n character ch i e fly ab out the l o wer part o f the
chest y et someti mes to use her own express i on the y fl y a ll
”
L ate l y she has b een much a l armed by the occur
over her
rence o f tw o attac k s o f great sever i t y the fi rst ab out t wo month s
ag o and the second a month ago There was a gon izi ng pa i n
in the re gi on o f the heart wi t h shortness o f b reath B oth w ere
severe enough to re qui re h y poderm i c i nj ect i ons o f morph i ne
The pai n so far as she coul d l ocaliz e i t was i n the l e f t
s i de i n the regi on o f the heart not i n the ab domen O n b oth
occas i ons though the severi ty o f the pai n was only as
she sai d for a n hour or 3 0 y et f or tw o or three day s after
she had more or l ess pain and d i stress O n b oth occasi ons
she had d y spepsi a b ut she had not b een spec i a ll y nervous
or run down S he does not k now whether she got pal e dur
i n g the attac k s b ut she sweated a f ter them S he tak es a great
deal o f exerc i s e b ut has never had an attac k b rought on by
exert i on
S he l oo k ed a nervous gi rl an d fl ushed eas il y T h e examina
t i on was negat ive wi th the except i on o f s light dil atat i on o f the
stomach
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II T o x ro A N G I N A T he secon d d ivision of functional or
p seu d o an g ina embraces cases due to the abuse of tea coffee
an d tobacco substances harmless in themselves but w hich
if tak en in excess may d isturb the action of the heart M y
experience w ith this form is extremel y limite d ; In tea or
coffee drin k ers I have ne v er seen attac k s of car d iac pain w hich
coul d be calle d an gina ; th ou gh p aroxy sms of severe p alpitation
with d istress about t h e heart an d g aspin g resp iration are not
T obacco ,
u ncommon in nerv ous w omen much a dd icte d to tea
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PEC T O RIS AND AL L I E D S T A T ES
AN GI N A
1 06
an attac k of tobacco an g ina
t ra t iv e case :
.
T he foll owin g is a g oo d illus
.
a g ed tw ent y n i ne y ears seen M arch 2 4 1 8 9 6 com
p l a i n i ng o f pa i n i n the re gi on o f the heart j ust b e l o w the ni pp l e
The fi rst attac k w as f our or five y ears ago and i t has recurred
at i nterval s ever s i nce S hort l y a f ter the onset h i s phy s i c i an
suggested that i t m ight b e due to to b acco ; and w hen he gave
up smo k i n g the attac k s d i sappeared a l to g ether S ince he r e
sumed the ha bi t the y have recurred and f or the past year he has
had them more f re quent l y The attac ks occur at n ight j ust
a f ter he has f a ll en asl eep He i s awa k ened wi th a severe pa i n
i n the re gi on o f the heart wh i ch a l most tak es h i s b reath awa y
and ma k es h i m cry out at once I t rare l y l asts more than a
m i nute or tw o The heart s act i on i s not i ncreased He never
has had an y s weat i ng and does not change i n co l or nor do h i s
hands and f eet b ecome co l d He has never had any pai n down
the arm I t i s a l wa y s o f the same character sharp and stab
b i ng j ust b e l o w the n i pp l e and i s i ntense enough to cause h im
to cry out He has had as man y as f our or s ix attac k s i n the
twent y f our hours I n the day t i me the pa i n i s not so severe
and the spe ll s are more transi ent He has never had an attac k
f o ll o wi ng exert i on and ne i ther emot i on nor errors i n d i et have
an y i nfl uence upon them
He was a memb er o f a very nervous family He was h i mse l f
a hea l th y vi gorous man He had smo k ed f rom h i s b o y hood
three or f our strong c i gars and when trave li ng five or s i x
c i gars a day He f e l t h i mse l f that the to b acco was respons i b l e
f or the pa i n He was a hea l th y l oo ki ng man a li tt l e pa l e The
pul se was 7 6 regul ar and wi thout i ncreased tensi on The apex
b eat was i n norma l s i tuat i on ; the heart sounds were everywhere
c l ear
The second aort i c was perhaps a li tt l e accentuated
There was no pai n on pressure and no h yperaesthes i a
He was advi sed to stop smok i n g a l to gether
I
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3
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T obac c o
A
n
i
n
a
g
— I have seen but t w o cases in w hich
th e se v ere p aroxy sms of card iac p ai n a pp eare d
the abuse of tobacco
.
to
be d ue to
T OXIC AN GI N A PEC T O RIS
1 07
.
of
aged th i rt y fiv e years consul ted me A pril
1 3 1 8 9 1 comp l a i n i n g o f severe pa i ns i n h i s chest and o f numb
ness i n the l e f t arm The pat i ent has a very g out y h i story on
b oth si des He h as b een a hard worki n g pract i t i oner has b een
a moderate dri nk er and has used to b acco to excess b oth sm o k
ing and che wi ng F our y ears a g o when he had b een smo ki n g
very heavil y he had an attac k o f pa i n ab out the heart and
do wn the arm f or wh i ch he consul ted D r P epper He ha d
very li tt l e troub l e a gai n until s i x or seven months a g o when
the attac k s recurred He then consu l ted D r D aCo st a who
sai d that he was g outy and wi t hout or gani c d i sease o f the heart
L ate l y the attac k s have b een very severe ch i e fl y under the l e f t
margi n o f the sternum and reach i n g down the arm wh i ch b e
comes numb and t i n gl es He has never had an attac k i n wh i ch
there was a sense o f imp end i n g d i sso l ut i on The pati ent was
a hea l th y loo k i n g man ;
the pul se was 78 the tensi on a li tt l e
p l us, b ut there was no sc l eros i s o f the arteri es The exami na
t i on was ne gat ive wi th the except i on that the aort i c second
sound was perhaps a li tt l e sharper and c l earer than norma l
He was to l d that he had no heart d i sease and he was urged to
l ive a temperate li f e to gi ve up to b acco and ordered ten gra i ns
o f i odi de o f potassi um three t i mes a da y Af ter see i n g h im the
fi rst da y I d i ctated the f o ll o win g note :
I n th i s case the g out y h i stor y and the accentuated second
sound are perhaps su ggestive o f true angi na O n the other
hand he has b een a very heav y smo k er i s evident l y nervous
and worri ed a b out h i s cond i t i on b oth o f wh i ch f actors mus t
”
b e ta k en i nto consi derat i on
Dr
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I have seen this pat i ent at intervals d urin g the past five
y ears H e lay s very g reat stress upon tobacco as the cause of
t h e attac k s and an y indul g ence is apt to be fo l lo w ed b y severe
pain On February 1 7 1 8 9 4 in a letter he la i d stress a g ain
u p on the part pla y ed b y tobacco ; in a letter rece i ved recentl y
h e g ives a very sat i sfactor y account of himself thou gh he still
smok es an d still h as attac k s There is a feature in th i s case
upon w hich H uchar d lay s a g reat d eal of stress in tobacco an
.
,
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A NGINA PEC T O RIS
1 08
—
g ina
AND
S T A T ES
AL L I E D
.
namely the occurrence of certain nocturnal sp ells al
most li k e sy ncop e The patient states in the recent letter that
the s t ran g est sy mptom of all is that j ust as I lose m y self and
am about to drop to sleep and often j ust a f ter losin g conscious
ness I cho k e sit up q uic k ly and f ee l for the moment as if th e
g ame w as u p
There i s no pa i n no exc i tement of the heart
and y et th i s often occurs after havin g a cho k in g fullness an d
distention in m y throat as if I w as try in g to force a g reat
”
H e adds
volume throu g h a small space
S u dd en inhala
tions of to b acco smo k e still g i ve me p ain a b out the heart last
”
in g for several minutes
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T W ag ed f ort y fiv e y ears seen wi th D r G o l dsb orough
June 1 2 1 8 9 5
The pat i ent was a very vi g orous heal th y l oo k i ng man and
has en j o y ed uni f orml y good heal th I n N ovemb er 1 8 9 4 he
h ad i n fl uen z a and was wretched f or t w o months a f ter i t
He
h ad b een a heavy smo k er s i nce h i s f ourteenth y ear
S ome y ears
ago he g ave up the ha b i t f or tw e l ve m onths as he had attac k s
in b ed i n wh i ch he f e l t as thou gh the heart had stopped and he
woul d have to j ump o ut o f b ed and gasp f or breath He got
we ll and has smo k ed heavil y ever s i nce
O n the 6t h o f January he had a sudden severe paroxy sm
to wh i ch he attri butes h i s present nervous cond i t i on He had
b een smo k i n g on an avera g e twe lve stron g c igars a da y The
attac k b e gan wi th a peculi ar f ee li n g i n the chest not exactl y
pai n b ut great d i stress
He turned pal e b e l ched gas con
persp i red was co l d coul d not li e down and f e l t as
st an t ly
thou gh he was g o i n g to d i e He had no agonizi ng pai n b ut he
f el t a sense o f terri b l e oppress i on and had num b ness i n b oth
hands and wri sts The heart s act i on durin g th i s attac k was
scarce l y percept i bl e the pul se very f ee b l e and fl utteri ng I t
l asted a l together tw o or t hree hours and a l armed h i m ver y
much F or several da y s a f terward he f e l t prostrated and w ea k
and f or a month he had a sort o f f a i nt f ee li n g part i cul arl y
a f ter eatin g These fa i nt attac k s have d i stressed h i m very much
T h e y w ou l d come on at i nterva l s and he w ou l d turn pa l e an d
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A N GI N A P EC T O RI S
110
AND ALL I E D S T A T ES
.
mia or sy ncop e atta ck s of p al p itation w i t h extreme irre gu
larit y o f the h e a rt (fo lie c a r d ia qu e d e l ir iu m c o r d is)
4
T he attac k s of an gina are o f t en very p ainful and
co m p lete in t h e i r intensity and in the ra d iation of the p ains
But i t i s in an g i na f rom to b acco that one sees parti cu l arly the
imperfect and abortive forms cons i stin g of dy spn oe a w ith
sli g ht p rae cordial anx i ety or simp ly o f a l i ttle sense of u n e asi
ness behin d the sternum w ith the sensation of stopp in g of
the heart an d the fear of impe ndin g d eath
A n g ina from tobacco sho w s g enerally sp ontaneous
5
p aroxy sms ; the y ma y also be p roduced by exerc i se or e x e r
tion
I t has then the clinical characters of an g ina from
coronary artery d i sease
6
The paroxy sms of fu n c tio na l to b acco an g ina d ue to
s p asmodic contractions of t h e coronaries disappear rapi d ly
after the com p lete sto p pin g of tobacco a clin i cal feature
common to almost all the sy m p toms of tobacco p oisonin g
w ithout lesions
T his is not tr u e of the paroxy sms of orga n ic tobacco
7
an gina du e to or g anic contract i on of th e coronaries ( throu g h
T his form is more resistant ; it
n icotine arterio sclerosis )
disappears but slo w l y or may be pe rmanent ; it is w orth y
o f treatment w ith io d ide of potassium
T here exists another form of stenocar d ia the most
8
beni g n of a ll ; it is du e remotely but not imme d iately to nico
tine ; it follo w s d y spepsi a p ro d uced by the abuse of tobacco ;
it is cured b y th e remo v al of tobacco an d the d isapp earance
”
o f t h e dy sp e p sia
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LE C T UR E V I
.
T
HEOR I E S
OF
A
N G IN
A
.
T h e im po rt anc e o f c o ro n ary art e ry d ise ase — n t e rm it e nt c lau d ic at io n
t a t e o f t h e h e ar t m u sc le in an at t a c k — e at an d c ause o f t h e pain
.
S
V aso m oto r c h an g e s in
-
A
an
I
S
t
g ina —Re lat io n s o f spurio u s an d t rue
.
A R T ER Y D I S E A S E
A N G IN A
an
.
.
gina
.
— It
w ou l d be
impossi b le to discuss even brie fly all of the theories w hich
from time to t i me have been o ffere d in explanat i on o f this
H uchar d has tabulated
remark able grou p of sy m p toms
sixty one o p inions un d er six main theories " U n der these cir
c u m st an c e s it w ill be w ise to start out w ith the statement of
—
a g enerall y accepte d fact vi z that in an immense propor
tion of all cases a ngin a p e c toris c e r a is a ssocia te d w ith dise a se
h
o
t
e c or o n ar
r te r ie s an d o
a
h
T
his
y
ou
t
e
m
m
o
ca
r
i
u
d
f
y
f
y
w ill reca l l w as J enner s ori g inal su gg estion w hich he
enounced in the letter I rea d to y ou in L ecture I V ery
shortly a f ter the appearance of H eberden s pap er the first
reports of coronary artery d isease in an gina w ere made b y
—
Fothergill the g reat Fothergill w hose frien d ship w ith R ush
an d w hose interest in th e medical affa i rs of the A merican
colonies en d eare d his name to the profession on this side of
the A tlantic In t h e fi rst case w hich he reports there is no
note upon the coronary arteries b ut on the out w ard mus
onlar part
of
th
e
heart
near
the
apex
w
as
a
small
w
hite
spot
(
)
”
as bi g as a S ixpence resemblin g a cicatrix evi dently a patc h
of fi broid m y ocar d itis In another case (wh ich seems reall y
C OR ON
RY
AN D
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111
A N GI N A
112
PEC T O RIS AND ALLIED S TA T ES
.
to have been one of an gin a sin e dolor e ) the patient , w ho ha d
a difficulty or i ncapacity to w al k u p a mo d erate ascent d i ed
i n a sudden transport of an g er J ohn H unter w ho made the
d i ssect i on found the t w o coronary arteries from the i r ori
g in to man y o f their rami fi cations up on the heart w ere b e
”
come one p iece of bone
The ol d er reports w hich cor
r o b o r at e d the Opinion of J enner
are to be foun d i n P arry s
mono g raph ; w hile the full statist i cs on the q uestion have
been collecte d w ith great pains by H uchar d In a supple
mentary chapter to his w or k y ou w ill fi n d a summary of 1 4 5
autopsies in cases of an gina g athere d from the l i terature
In 1 7 cases there w as mention only of a lesion of the coro
naries w ithout further speci fi cation ; of 1 2 8 there w ere 6 8
w ith lesions of both coronary arteries 3 7 of the left v essel
1 5 of the ri g ht an d in 1 2 the seat of the lesion w as not stated
In the 1 2 8 cases obliteration or stenosis of th e vessels ha d
occurre d and of th ese in 1 2 1 there w as atheromatous nar
ro w in g or thrombosis in 5 embolism an d in 2 com p ression
Fatal cases are on recor d in w hich the coronary arter i es have
been foun d normal ; most of these are instances of adherent
p ericardium or valvular d isease T here are also fatal cases
of tobacco an d p ost febrile an gina in w hich the anatomical
c on dition is state d to have been ne g ative
N othin g i s easier
than to overloo k m y ocar d ial chan g es particularl y in the ol d er
metho d s of examination an d a h eart may p resent extensive
fi broid disease w ith obliteration of arteries w hich to the u n
traine d e y e loo k s h ealth y or w h ich ma y not Sh o w an y coarse
les i ons of the aorta or of t h e main branches of the coronary
v essels Or a g ain Kre hl s metho d of serial section may S ho w
w ith ch an g es in the smaller arteries
e xtensive m y ocar d itis
in a h eart apparentl y normal S pasm of the coronary arteries
,
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M e dic al Observa tion s
an d
In quirie s,
v o l. v ,
1 774
.
PEC T O RIS
AN GI N A
1 14
ALLIED S T A T ES
AN D
.
a clot or w hen both hind le g s have been involve d the
ab d ominal aorta has contained a thrombus
C harcot w hile an interne in the service of R ay er d e
scribe d in man a con d ition correspon d in g to this intermittent
clau d ication in the horse H e say s that one d ay a p ati ent
in the service told him that he w as not able to w al k for more
th an a q uarter of an hour w ithout bein g ta k en w ith cram p s
in the le g s A fter res tin g a w hile he w oul d g et better and
w oul d be able to resume his w al kin g an d then a crisis re
curre d A t the autopsy C harcot foun d a ball enc y ste d in the
n ei g hborhoo d of the iliac arter y an d a traumatic aneury sm
w hich ha d obliterated the art er y in its lo w er p art The cir
culation w as carried on b y collateral channels w hich w ere
am p le to maintain the nutrition w hile the patient w as quiet
an d for a short perio d durin g exertion but after a time w hen
the limbs w ere fati g ue d by the movements the q uantit y of
blood w hich reached them w as insufficient causin g a relative
isch aemia w ith tin glin g cram p s an d im p ossi b ilit y of w al k
in g
H e refers to the fact that the con d ition is often p re
liminary to g an grene an d narrates a case in w hich a p atient
w ith t h e affection ha d his le g am p utate d for gan gr e n e j
T he cre d it of pointin g out t h e analo gy bet w een this con
dition an d an g ina pectoris w hich is ascribe d usually to P otain
but w hich is maintaine d b y Weber i; to be d ue to
Brodie
belon g s in reality to A llan Burns w hose 0b
w ith
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S om e
se r r a t ion s o n
f
e a se s o
th e H
f
o
t he
1
09
8
(
)
e ar t
M ost F r e qu e n t
is a w ell kno w n storehouse of inter
T
C
ph e n o m e n o n h ad
e n c o re re n c o n t r , c h o se
ab l e a
So c ié t é d e
B io lo g ie ,
’
.
.
c o m m u n ic at io n o n so re m ark
v
n o t re c e i e d an y at t e n t io n
é
n e st
Imp or ta n t D is
-
o m e i, p 45
L egon s da M a r d i
h arc o t se e m s t o h a v e fe l t h urt t h at h is
.
an d
singul iere , c a r
o
u
r
t
a
n
t
p
as
p
He
.
sa
é
Je
é
n ai
é
pas
a la
m o n m m o ire d e 1 8 56, pr se n t
c rit e n c h in o is, il m e
parait c rit
é
é
’
fran cais, pre squ e e n b o n fran cais, j e n ai pas re nc o n t r
”
c in q u i a it t e n u c o m pt e d e m e s o b se r v a t io n s
d is
-
,
j
M e dica l S cie nc e s, M ay, 1 8 9 4
é
e , u n se ul
.
m
ri c a n Jou r n a l of t h e
A
e
;
1
ys :
’
.
en
m ede
T H E O RY OF INT E R M I TT EN T CLAUDICA T I O N
115
.
estin g facts S i nce so far as I k no w this distin g u i she d w ri t
er s connection w ith th i s supposed ne w theory h as not been
p ointed out ( except in the secon d edition of m y P r a c t ice )
I w ill read to y ou in full w hat he say s on the subj ect :
S uch
a st ate of the arteries of the heart [ referrin g to atheroma ]
must imp a i r the function of that org an I t has been lon g
kno w n that althou g h the heart is al w ay s full of blood y et
it can not ap p ropriate to its o w n w ants a sin gle particle of
fl uid contained in its cavities On the contrary li k e every
other part it has pecu l iar ves sels set ap art for its nourish
ment In health w hen w e excite the muscular sy ste m to
more energ etic action than usual w e increase the circulation
in every part so that to support this increase d action the hear t
an d every other part has its po w er au gmented If ho w ever
w e call into vi g orous action a limb round w hich w e have
w ith a mo d erate d e g ree of ti g htness applie d a li g ature w e
fi n d that then the member can onl y sup p ort its action for a
very short time for no w its suppl y of energy an d its e x pe n di
ture d o not balance each other ; conse q uentl y it soon from
a d e fi cienc y of nervous in fl uence an d arter i al bloo d fa il s an d
sink s into a state of q uiescence A heart the coronary ves
sels of w hich are cart ila ginous or o ssifie d is in nearl y a s i m i l ar
condition ; it can li k e the limb be girt w ith a moderatel y t i gh
lig ature d ischarg e its functions so lon g as its act i on is mo d
Increase ho w ever the act i on o f the w hole
e r at e an d e q ual
bod y and alo n g w ith the rest that of the heart and y ou w i ll
soon see exempli fi ed the truth of w hat has been sa i d w i th this
d ifference that as there is no i nterruption to the action of the
car d iac nerves the heart w ill be able to hold out a little lon g er
than the l i mb
I f a person w al k s fast ascen d s a steep or mounts a pair
of stairs the circulation in a state of hea l th is hurr ie d an d
the heart is felt beatin g more fre q uentl y a gainst the ribs than
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A N GI N A
1 16
PEC T O RIS AND ALLIED S T AT ES
.
sual I f ho w ever a person w ith the nutrient arteries of
the heart d i sease d in such a w ay as to impede the pro gress of
the blood alon g them attempt to do the same he fi nds that
the heart i s sooner f at ig ued than the other parts are w hich
r e ma i n health y When therefore the coronary arteries are
o ssifie d
every a g ent capa b l e of i ncreas i n g the action of the
heart such as exerc i se passion and ardent spirits must be a
”
source of d an g er
Burns di scusses also w hether the p aroxy sm w as d e p en d
ent on a state resemblin g p aral y sis or on a spasmod i c con
traction of the fib res of the heart H e hardl y think s that t h e
vie w of sp asm is corr oborate d b y any analo g ous f acts in the
animal econom y H e say s : D o w e ever after the Operation
for aneury sm see the muscles in a state of r i gi d action ; or
w hen w e appl y the tourn i q uet onl y so ti g ht as to impede t h e
circulation d o w e ever observe that the member is affecte d
w ith spasm " In both cases w e w itness an in d uction of an
extreme d e gree of debil i t y an d w e h ear the person complain
in g of an unusual pain f ul feelin g in the limb but still its
muscles are in a state of inactivity I f these be the phenomena
resultin g from a de fi cienc y of arterial bloo d in the muscular
s ystem in g eneral w h y S hould the heart be an exce p tion "
We k no w that this or g an is p rincipall y composed of muscle
and w e have therefore reason to believe that it is re gulate d
”
b y the same la w s w hich g overn other muscles
I w ill rea d y ou this intermittent claudication theory as
formulate d b y P otain in 1 8 70 and y ou w ill see ho w com
a Ch a r it e has been
L
the
d
istin
g
uishe
d
clinician
of
l
e te l
p
y
anticipate d b y the ol d G las g o w p rofessor : I f one consi d ers
the p ainful se n sations the di sorders o f the cardiac action
w hich constitut e an attac k of an gina pectoris ; if one but
remembers that these paroxy sms occur al w a y s after fati guin g
—
o
movements muscular efforts or emoti nal d isturbances that
u
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AN GI N A
118
PEC T O RIS
AND
ALLIED S T A T ES
.
tions is the p ain associated an d w hat relation h av e the p ains
of p seu d o an g i na to those of the an g ina vera " What p art do
vaso motor chan ge s p lay in t h e proc e ss " T hese are amon g
the q uestions w hich must be as k ed and ans w ered before w e
can accept the int erm i ttent claud i cation or in d eed any
other theory We may d iscuss these points under three hea d s :
the state of the heart muscle the seat and cause of the p ai n
an d the vaso m o tor ch an g es in the d i s e ase
—
E
I T H E S TA TE OF T H E H A R T M U S C L E
D urin g an attac k
t h e or g an has b een supposed to be either in spasm or in a
con d ition of p araly sis from imperfect blood supp ly or over
d istention H eberden and many since have re g ar d e d the
heart in a p aroxy sm as in spasm or cramp ; but A llan Burns
an d after him Bro d ie ( as q uote d by Weber) ur g e a g ainst this
vie w that the muscles in the con d ition follo w in g bloc k in g of
arteries are not in spasm but rather the o pp osite ; an d w hile
not absolutel y p araly z e d are as Bro d ie say s i n a state ap
r o ac h in
to
it
Wit
h
this
the
clinical
features
of
the
attac
k
g
p
are in accor d for althou gh it has been note d in exceptional
instances that the p ulse beat has n o t been feeble or the car
d iac rh y thm d isturbe d the g eneral experience is that the left
v entricle is w ea k ene d an d the sy stemic arteries imp erfectly
fi lle d
T he con d ition of the heart muscle in the attac k is prob
abl y not al w a y s the same For exam p le in a patient w ith
ten or fi fteen p aroxy sms d ail y w e can not su p pose that any
serious org anic ch an g e as an ae mic necrosis develo p s in each
attac k In such as A llan Burns say s the suppl y of energy
an d expen d iture d o not balance each other
a h eart w ith
the coronary arteries c artila g inous or o ssifie d can d ischar g e its
functions so lon g as its action is mo d erate an d e q ual but if
t h e circulation is h urrie d the p ro gress of the bloo d alon g t h e
nutrient arterie s of t h e h eart is im p e d e d an d t h e heart b e
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T H E S T A T E OF T H E H EA R T M USCLE
119
.
”
comes fatig ue d
A transient p aresis from insufficient su p pl y
of oxy g enated blood ( and p oss ibly as has been sugg ested ,
fro m a sor t of auto intoxication w ith the products of imper
fe c t metabolism) explains the cardiac w ea k ness and the tend
enc y to sy nco p e but a ffor d s not the sl i g htest cle w to an ex
—
p lanation of the main feature of the attac k the pain V ery
d ifferent to this r e la t ive isc haem ia o f the card i ac muscle must
be the condition follo w in g the bloc k in g of a larg e branch by
a thrombus or an embolus T he resultin g an aem i c in f arct
if at all extensive must cause not alone g reat w ea k ness of
t h e cardiac muscle but at the site of the les i on the smooth
uniformit y of the w aves of contraction must be seriousl y
interrupte d T his car d iomalacia may lea d to rupture of the
wa ll of the v entricle ( ele v en cases in H u c h ard s collection of
auto p sies ) or may cause p ericarditis While the an aemic in
farc t is a w ell reco g ni z e d lesion in fatal cases of an g ina p ec
toris it must be remembere d that a paroxy sm of p ai nis really
a rare com p lication of this not infre q uent chan g e I t is in
t e re st in g to note that the scars of infarcts have been foun d
y ears after recover y from attac k s of an g ina C urschmann in
the d iscussion at the C on g ress f innere M e dic in alrea dy re
ferre d to mentione d t w o cases one a man of se v enty fiv e
ye ars the other a w oman of sixty both of w hom some t w ent y
y ears before d eath ha d h ad severe attac k s of ang ina fro m
w hich the y recovere d with bra dy car d ia There w ere foun d
Old fi broi d chan g es in t h e m y ocard i um w ith obliteration of
branches of the left coronary arteries We may say then
that the e vi d ence such as it is favors the vie w that the heart
muscle in the attac k is in a state of paresis T his ho w ever
ma y not be g eneral ; it ma y be con fine d to the left v entricl e
or to a part of its w all ; but w eakness in itself o ffers not t h e
sli g htest cle w to th e cause of the p ain
Th e vie w of H eber d en th at t h e h eart muscle d urin g t h e
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P E C T O RIS
AN GIN A
1 20
ALL IE D
AND
S T A TE S
.
ttac k is in a state of s p asm h as been supporte d b y man y
w riters notably by L atham T he existence of spasm of the
heart d urin g l i fe can not be i nf erre d from the empty an d
contracte d con d ition of the left ventricle p ost mortem R ela
tive isch aemia in the territory of one coronary artery or of
its main branch st i ll more an area of an aemic necrosis might
rea d ily brin g about conditions favori n g cram p not necessaril y
in the affected re g i on ( very unli k ely in d ee d in an infarct ) ,
but in conti g uous muscular d istricts , the rh y thm of w ho se
motion w ould be interrupte d an d d isturbe d I d o not k no w
of cram p in the voluntary muscles p ro d uce d under analo g ous
conditions but I may remin d y ou of the horribly p ainful
cramps in the le g s in the exhaustion follo w in g the p rolon g e d
use of untraine d muscles an d the cram p s in the calves an d
feet in chronic arterio sclerosis P ain the sp ecial feature of
the an gina attac k is explained by the cram p theory T h e
most intense sufferin g w hich can be ex p erience d is associate d
w ith muscular contractions of t h e tubular structures as in
intestinal biliary an d renal colic an d in the contractions of
t h e uterus in p arturition
A n d observ e that this a g oni z in g
p ain is in p arts not endo w e d so far as w e kno w w ith v ery
acute sensibili ty Theoreticall y there is muc h in fav or of
the idea that in the most p o w erful muscular org an of t h e
bo dy irre g ular c ram plike contractions even if localiz e d mi ght
be accompanie d b y painful sensations w hich could attain
the maximum intensity present in an an g ina attac k But this
brin g s us d irectl y to a d iscussion of
II T H E S E A T A N D CA U S E OF T H E P A I N IN A N G I N A
T here is one inexp licable feature w hich baffles all su gg estion
an d g iv es us p ause in an uneasy ap p rehension lest w e shou l d
k no w e v en less than w e su pp ose I refer to the extraor d inary
variability in the incidence of attac k s in car d io v ascular lesions
a pp arentl y most favorable W h y sh oul d true ang ina p ectoris
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A NG IN A PEC T O R IS
1 22
‘
ALL IE D
AN D
S TAT ES
.
the cases w ith fre quently recurrin g attac ks in w hic h one can
n o t p ossibly su p pose infarcts to be present thou g h the scars
o f course p ersist
T he analo gy w ith p ainful sp asm in other
h ollo w or g ans , usually v ery insensitive is also su gg estiv e
—
H
n
a
d
T hat eber d en
L atha m still masters in I srael— stan d
sp onsors for this vie w an d that so acute a mo d ern observer
as R osenbach , S houl d
conclude that the pain is due to
”
chan g es in the form of muscular contraction commen d it
stron g l y to our consi d eration
b
D
i
e
n
i
n
s
t
t
o
n
a
/
d S tr e t ching of th e Card iac Wa lls
( )
T raube hel d that the sy mp tom com p lex of an g ina p ectoris
r esulte d from a ra p i d l y increasin g d istention of the w alls of
t h e v entricle , w hich , in conse q uence of d efectiv e nutrition ,
w ere more y iel d in g Wh en o w in g to increase d p ressure in
the aortic sy stem , this d istention became excessiv e the nerv e
e lements in the heart w all became stretche d an d bruised
,
c ausin g the p ain
Y ou w ill fi n d a very careful elaboration of
t h is theory b y L au d er Brunton in the P r a c tition e r vol xlviii
A p ara g ra p h in a lecture b y T K C hambers also su gg est s
this i d ea : T he p ain has t h e same tearin g an d p aroxy smal
c h aracter that y ou fi n d a ccom p an y in g the d istention of hollo w
fi brous or g ans usually insensiti v e such as the stomach t h e
colon an d the bladder T he p ain is of the same nature as
that felt in o v erstraine d ten d ons or muscles w earied out b y
sustaine d effort ; it ap p ears associate d w ith the stretchin g of
us uall y insensitive fi bres an d is sometimes t h e most d rea d ful
a g on y the bo dy can bear as the inventors of rac k s and other
instruments of torture w ell k ne w 1 Of course this is a
p ossible explanation but it raises a pr oblem insoluble as t h e
—
ori ginal o n e w h y if extreme dilatation is a cause an gin a
d oes not occur more often T here must be surely som e a dd i
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G e sa mm e lt e B e itr age , Bd iii, p 1 8 3
L ec tur e s, c h iefly C lin ic a l, fo u rt h e dit io n, p 3 1 5
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SEA T AND CAUSE OF T H E PAIN
1 23
.
factor or attac k s w ould be of every day occurrence
The relation of an ge io spasm to the attac k s w ill be discusse d
later
—
n is in th e A r te rie s
e
a
i
h
A
l
l
an
Burns
s
p
o
k
a
P
0
h
t
t
T
e
( )
of the p ain follo w in g the ty in g of an artery an d the a ppl i ca
tion of a tourni q uet S ensory nerve en d in g s have b een dem
o n st rat e d in the arterial w alls an d it has been su gg ested fr e
q uently in recent discuss i ons on an g ina p ectoris that the
main element of the attac k may be c e sse l p a in due to either
—
There ma y b e there is not al
an ge io spasm or thrombos i s
—
w ay s g reat p ain in the bloc k in g of a larg e v essel artery or
vein by a thrombus or e m bolus The name p hle gmasia alba
d ole n s em p hasi z es a prominent character in the plu g gin g of
the femoral vein and as I have j ust said the pain after l i g a
tion of the femoral or the appl i cat i on of the tourni quet is
often ver y intense N othna g el refers also to the pain in the
head in bloc k in g of larg e cerebral vessels It is not u n re a
sonable to su pp ose that pain of the same na t ur e may occur
in bloc k in g of the coronary arteries thou g h I do not call to
min d the existence of special pain i n embolism or thrombosis
of arteries of the si z e of the coronary vessels in other or g ans
M oreo v er as I have alrea dy said w e can not sup p ose that in
each attac k a thrombus d evelops A n ge io spasm is a much
more lik el y cause of the pain an d it may be assoc i ated in
some cases w ith bloc k in g of a vessel There are the analo g ous
conditions of mi g raine with its vascular spasm an d intense
pain an d the v ascular c h an g es w ith pain in R ay nau d s d is
ease Bal four has an interestin g para graph u p on this ques
tion of pain in the arteries :
T h at isc h mm ia does g ive rise to p ain even of the most
atrocious character is sufficientl y atteste d by the a g ony that
attends compression of an arter y for aneur y sm especially at
t h e momen t the vessel becomes com p letel y occlu d e d ; the
t io n al
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AN G INA PEC T O RIS AND
1 24
L I ED S T A T ES
AL
p ains arisin g from a similar cause that p recede the a pp ear
ance of g an g renous p atches in a limb a ffected w ith sen i le g an
g rene ; and those w hich precede accompan y and follo w at
tac k s o f local asp h y xia ( R ay naud s disease ) There is every
reason to suppose that the arter i al spasm w h i ch is so evi d ently
the cause of local asp h y xia and w hich ta k es so prominent a
S hare in the production of an attac k of an g ina vasomotoria
o ccasionall y invades the heart either as part of a g eneral con
d ition or it may be as a distinctly local affection and that
this is a v ery p oss i ble cause of those an ginal attac k s w here
no other seemsobvious ( T he S e n ile H e a r t)
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T
h
a
h
e
d
t
t
P
)
(
a in
is a N
i
e
u
a
e
i
t
h
r
n
i
F
c
t
o
n
a
l
,
g
eural
or
du e
—
JVe u r itis
This most w id e ly hel d vie w re g ar d s an g ina
p ectoris as a form of neural gia or neurit i s a ffect i n g the nerves
of the heart H uch ard mentions t w enty t w o mo d i fi cations
of this theory w hich d ates from the earl y part of the century
w hen in 1 8 08 Baumes ran k e d the d isease as a retrostern al
neural gia ( sternal gia) L aennec g ave it his stron g su pp ort
and held that either the pneumo g astric or sym p athetic d ivi
sion of t h e cardiac n erves mi g ht be implicate d an d w ith
either of them the br achial plexus
C orr i g an R omber g
Bamber g er an d others h el d the same o p in i on T hen in 1 8 63
came the observations of L ancereaux on chan g es in the car
diac nerves an d g an glia w hich w ere con fi rme d by P eter an d
o thers
H uchard states ( secon d ed i t i on 1 8 9 3 ) that there w ere
onl y t w elve observations on neuritis of the car d iac nerv es
of w hich six w ere assoc i ated w ith d i sease of th e coronar y
arteries M ore recent literature so far as I kno w does not
furnish a d ditional cases an d the w hole question of minute h is
pathetic nerves an d g an glia in
t o l o gic al ch an g es in the s ym
v arious disor d ers must be revie w e d w ith t h e h el p of the n e w
techni q ue
A g ainst this theory ma y be urg e d t h e common observ a
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A N GI N A
1 26
PEC T O RIS
ALLIED S T A T ES
AND
.
lecture I sp o k e of a s p ecial typ e of pseu d o an gina in w hich
these features dom i nate d the scene The y pl ay a consp icuous
le bot h in the functional and org anic forms
rO
N aturally
one approaches a vaso motor pro b lem w ith a g oo d d eal o f
caution since it len d s itself w ith sin gular ap tness to theo
r e t ic al va g ar i es an d to all k inds of s p eculation
I t is w ell to
remember that as Foster remark s the vaso motor nerves are
servants not masters in the matter of re g ulatin g the calibre
of vessels and alterin g the blood pressure
I have alread y spo k en of the state of the arteries d urin g
the paroxy sm an d have g iven a summary of m y p ersonal
experience on this moot q uest i o n The g eneral op i nion is
that in true an g ina there is an earl y an ge iospasm w ith g reat
increase in the bloo d p ressure
S p h y g mo g raphic tracin g s
d urin g the attac k have not often been ma d e
L au d er Brun
ton s observation is p articularly interestin g and I S ho w y ou
here the trac i n g s w hich he gives tak en from the ra d ial pulse
before an d durin g an attac k I t can not be d oubte d I think
that in man y cases an im p ortant factor is as M itchell Bruce
exp resses it too much pressure ahead of the drivin g po w er ;
but this w i d esprea d p eripheral spasm is probabl y a secon d ary
phenomenon excite d re fle x ly throu gh in fl uences on the v aso
motor centre comin g from the heart itself or from other parts
M orison of w hose paper in volume i i i of the E din burgh H os
i
a l R e o r ts I have alrea dy spo k en g ives the notes of a
t
a
p
p
p
tient w ith aortic insu fficienc y in w hom d urin g an attac k t h e
pulse tension w as lo w an d he think s th at even in the org an i c
form there may be consi d erable variations more esp ecially in
the c aSe s w ith or w ithout insuffi cienc y of th e aort ic valve I t
ma y be q uestioned in d eed w h ether the tracin g in B run t o n s
case reall y represents a g reat increase in t h e tension or w h e t h
er it d oes not mean that the le f t ve n tricle w as in a con d ition of
feebleness or d ilatation an d the p ulse tension extremel y lo w
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VA S O
M O T O R C H ANGES IN AN GI N A
-
1 27
.
I sh o w y ou here b y w ay of contrast the tracin g s g iven b y
H uchar d, in w hich , as y ou notice the one in the interval b e
t w een the attac k w ith the lo w tension resemb l es very much
that of Bru n t o n s durin g the attac k w ith supp ose d hig h ten
sion
A maj ority of p atients w ith true an g ina hav e reache d an
a g e in w hich naturall y the bloo d tension is increase d an d in
almost e v ery instance the excitin g causes of t h e p aroxy sm are
—
th ose w hich raise the arterial p ressure mental emotion mus
an d d ilatation o f t h e
c u lar exertion , col d to the p eriphery
stomach Y ou w ill find in Bru n t o n s p ap e r an adm i rabl e
discussion of the im p ortance of these factors in raisin g t h e
blood p ressure an d in brin g in g about the ang inal p aroxy sm
Fav o rin g too this vie w of w idesp rea d an ge iospasm is t h e
’
circumstance that in certain cases of R ay nau d s d isease an
gina pectoris of a v er y severe typ e has occurre d , an d has eve n
p ro v e d fatal T he most interestin g case of thi s k in d in t h e
*
lite rature is re p orte d b y R ichar d C le e m an
A man ag e d
sixty t w o y ears, ha d from his fiftieth y ear se v er e attac k s of
R a ynau d s d isease , chie fl y in the hands w hich occurre d U S U
all y in the w inter season On e d ay h e ha d an attac k of a g o
n iz in g substern al p ain lastin g for t w o hours an d of such in
tensity that h e w as greatl y prostrate d T he p ains radiate d
d o w n both arm s D urin g a perio d immediate ly p rece din g this
he ha d had very p ronou n ce d attac k s of local asph yxia an d
local sy nco p e chie fly in the h an ds A w ee k later he w as
foun d d ea d in be d
T he association of mi graine w ith an g ina pectoris part ic u
—
larly the vaso motor form has been lon g reco gni z ed an d in
t w o cases in m y series the subj ects ha d been gr eat su fferers
w ith t h is d isease
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Tran sa c tion
ll
e
e
e
o
t
h
C
g
f
o
n
s
i
h
s
c
i
a
P
,
f
y
o
Ph ilade lph ia
,
1 89 2
.
PEC T O R IS
AN GI N A
1 28
S T AT ES
AL L I E D
AND
.
T here are t w o p ossible exp lanations of the v aso motor p he
n o m e n a of an gina pectoris
In the fi rst place a w id esprea d
vaso motor spasm exc i ted r e fle x ly b y cold , by emotion by
fl atulence etc thro w s a grea t stra i n upon the left ventricle
w ith as Traube tho u gh t d istention stretch i n g an d c o n se
q uent p ain Of course in th i s w id esp rea d an ge io spasm the
coronary vessels thems elves may participate an d it is not at
all im p robable that in the h y sterical and vaso motor variet i es
of an gi na the entire sy mptom complex may be vaso motor
The p ossibilit y of a local ( coronary) an ge io spasm may be
a d mitted in the toxic cases and in org anic d isease of the coro
nary arteries On the other hand the w i d esprea d constrictor
in fl uence in the sy stemic arteries in an attac k of true an gina
may itself be a vaso motor re fl ex H e g ar sho w e d e x pe rim e n
tally that a g reat increase in the g eneral b l oo d pressure coul d
be excite d re fle x ly on the inj ection of nitrate of S ilver into the
p eri p heral artery of a rabbit In the same w a y the p allor
col d ness s w eatin g and g eneral vaso c o n t ric t or in fl uences in
true an gina ma y be excite d re fle x ly by afferent imp ulses fro m
the coronary v essels themselves
—
On e other mat
R E L A T I O N S OF P S E UD O T o T R U E A N G I N A
ter remains for brief comment Wh at relation d o the p he
n o m e n a of s p urious an g ina be ar to those of the or g anic affe c
tion " H uchar d insists u p on the absolute separation of the
org anic form associated w ith coron ary artery d isease from t h e
v arious other typ es of car d iac pain H e say s : Il n g a p a s
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u sie u r s
l
p
d c p oitr in e
a n gin es
”
il
n
’
g
en a
u u n e se u le ,
g
’
l
’
an
ccor d in g to him the p seu d o an ginas
are neural g ias of the car d iac p lexus d ue to various causes or
—
t
a
va
o
motor
neurosis
I
t
must
be
ac
k
no
w
le
d
g
e
d
that
the
s
a
tac k s o f v aso motor an g ina an d of the form seen in nerv ou s
an d h y sterical w omen have many of the characters of a paro x
m
i
i
neurosis
resemblin
g
n
d
ee
d
in
certain
p
articulars
m
a
l
s
,
y
i
n
e
g
c or on a rie n n e
A
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A N GI N A
1 30
PEC T O RIS AND ALL I ED S T AT ES
.
stu dy the articles of P orter referred to in L ecture I, the im
*
H
e a r t S t u d ie s t
ortant
mono
g
raph
of
R
the
o y an d A dami
p
of E w art, von B asc h s w ork s and his recent brochure on G e
—
i
rst e dt
T
e
these
w
ith
a
a
ssstar r e ( A n gio rhigo sis) :t
as
g
f
sort of Baede k er w ill p romote his enl i g htenment T he less
ambitious w ill be content w ith the luci d account in S te w art s
P hysiology fa c ile p r in c ep s amon g manuals on the subj ect
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P hilosop hica l Tran sa c tion s, 1 892
1
4
n
L
o
d
o
n
89
,
f
i
1
.
.
Vie nna, 1 8 9 6
4* L e h r bu c h
.
d e r P hysiologic des K re islaufes,
L e ipsic
,
1 893
.
L E C T UR E V II
.
I
D A GN
OI
S S,
P R OG N OS I S ,
A ND
TR E A T M E N T
OF
AN G I N A
.
A no m alo us c ase s o f h e art pain —E le m e n t s in t h e diagn osis o f t rue an gin a
D iffe re nt iat io n o f t ru e an d pse ud o an g in a —P o gn o sis — T e a t m e n t o f
an g in a pe c t o s v e ra — T re at m e n t o f fa lse a n g ina — C o n c l usio n
.
r
.
ri
A
.
.
.
r
.
—On e
must be a professional U ly sses in craft
an d w isdom not sometimes to err in estimatin g the nature of
an attac k of severe heart p ain T here is no group o f cases so
calculated to k eep one i n a con d ition of w holesome humility
When y ou j ostle ag ainst a hal e v i g orous specimen o f human
ity w ho c lap s y ou on the bac k an d
T he d euce tak e
”
y ou doctors " I have scarcel y y et g ot over m y fri ght y ou
w ould li k e to forg et that five y ears before y ou ha d almost
si gne d his death w arrant in a very positive d i ag nosis of an g ina
p ectoris vera On the other han d M r X has left y ou w ith
the full assurance that his car d i ac pains are d ue to over w or k
or tobacco an d y ou have comfo rte d his w i fe an d lifted a
w ei ght of sorro w from both b y y our mo st favorable pro gnosis
With w hat sort of appet i te can y ou eat y our breakfast w h e n
a w ee k later y ou read in the mornin g paper the announce
ment of his sudden death in the rail w a y station " Or ta k e
—
another asp ect poor M rs D o e has g one so f t ly all these y ears
in the bitterness of her soul since y ou too k that grave vie w
of h e r vaso motor or h y steri c al ang ina "
A s a rule y ou will h ave little or no doubt as to the exist
ence of an g ina T he c h ief d ifficulty is in d eci d in g u p on t h e
DI
G N OS I S
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1 31
PEC T O RIS A ND ALLIED S T A T ES
AN GI N A
1 32
.
functional or org anic nature of the trouble T h e re are ho w
e v er extraor d inary cases of recurrin g p ain about the heart
of terr ible severity the nature of w hich may b e very obscure
The follo w in g is one of the most remark able cases of this
k in d w hich I have met :
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H
aged f ort y ni ne years seen A pril 2 8 1 8 8 7 com
p l ain i ng o f attack s o f terr i b l e sub sterna l pai n He was a l arg e
act ive man w eigh i ng a hundred and n i net y fiv e pounds Wi th
the excepti on o f a chancre at h i s fif teenth y ear wh i ch w as f o l
l o wed by an ul cer on the l eg e i ght months af terward and
t ypho i d f ever three y ears a g o h i s g enera l hea l th has b een good
T we lve y ears a go ( 1 8 7 5 ) he consu l ted D r W e i r M i tchell f or
the f o ll owi n g symptoms : E very morn i ng ab out one o c l oc k he
w as aroused f rom s l eep wi th severe pai ns i n the l ower part o f the
chest b eneath the sternum A t fi rst the attac k s occurred
every n i g ht and then at i nterva l s o f f our or five day s The pai n
w as not li k e a cramp or a spasm b ut du ll and severe i ntense
enough to ma k e h i m get up and wal k the room F or nearl y
ten y ears the attac k s made h i s li f e a b urden
They ceased
ab rupt l y i n 1 8 8 5 s i nce wh i ch date he has b een qu i te w e ll unt il
M arch 2 8 t h o f t h i s y ear He now has the attac k ever y da y a b out
He goes to b ed at ten o c l oc k and f all s to sl eep com
1 A M
fo rt ab ly
U sua ll y a b out 1 A M somet i me s at three or f our
o c l oc k he i s aroused by a fi xed pa i n b eneath the sternum b e
t ween the f ourth and fifth costa l cart il a ges I t i s never tran s
m itt e d do wn the arm ; he i s never dou b l ed up w i th i t nor does
he turn pal e or sweat He occasi onall y b e l ches wi nd dur i ng
the attac k The p ain at t i mes i s so severe that he has to tak e
A M
an an aesthet i c
Thus on the 2 9t h he awo k e at
in
terri b l e a g on y and had to tak e ether He sl ept unt il a fter five
o c l oc k when the pai n agai n came on and persi sted unt il noon
He say s he has noti ced that i t i s o f ten w orse a fter the rest o f S un
da y The exami nat i on w as ent i rel y ne gat ive The arteri es were
not st i ff; the heart s acti on was re gul ar ; the aorti c second sound
He wm c e d a li tt l e on deep pressure j ust
w as not accentuated
ab ove the ensi f orm cart il ag e The uri ne was normal
He had t ak en i od i de o f potass i um p revi ously wi thout h e
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ANGINA PEC T O R IS AND ALLIED S T AT ES
1 34
.
N e i ther d i et nor exerc i se seemed to mak e an y d i fference an d
,
she never had d y spn oea S omet i m e s the who l e o f the l e f t s i de
i nc l ud i n g the nec k w oul d f ee l st i ff and sore Thou gh she had
b een f ree f or a f ew da y s f rom the sensat i ons o f pa i n she had not
wi th i n the past y ear had a w eek o f comp l ete i ntermi ssi on S he
had evi dent l y w orri ed very much a b out i t and dreaded con
su lt in g a ph y s i c i an l est she shou l d b e to l d she had the d i s e a se
o f wh i ch her mother and husb and had d i ed
The pat i ent was a heal th y l oo k i ng w oman The pul se was
qu i et wi thout i ncrease i n the tensi on and the art eri e s were not
sti ff There w ere no si gns o f h ypertroph y or d il ata t i on o f the
heart ; the sounds w ere norma l The uri ne had a spec i fi c gra vi t y
of
and w as f ree f rom a l b umi n and tub e casts I h ave
seen th i s pat i ent on severa l occasi ons dur i ng the past t wo y ears
and her cond i ti on has i mproved very much
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T her e are cases too in w hich h y sterical an g ina occurs in
w omen w ith aortic v alve disease T he onl y instance of the
k ind w hi c h has come un d er my notice is the follo w in g :
,
,
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M
K
a ged th i rt y ei ght y e ars seen F e b ru ary 2 4 1 8 9 0
The pati ent was an unusuall y b ri ght ab l e woman who had f or
several y ears lived under a seri ous menta l stra i n S he had severe
rheumat i sm as a ch il d and she had b een to l d by severa l ph y si
c ian s— amon g others the l ate D r A ust i n F li nt and D r D a C osta
— that she had heart d i sease
The fi rst seri ous attac k o f pai n
ab out her heart was two y ears a g o at a hote l w hen S h e fai nted
D uri n g the past three months she had had e i g ht or ten attac k s
They usua ll y came on when she was w orri ed or very anxi ous
S he g ot co l d ; the pa i ns b e g an j ust under the l e f t b reast and shot
i nto the arm and up the nec k D urin g the attac k s her ph ys i c i an
s ai d she had o f ten b een qui te h y ster i ca l toss i ng herse l f ab out
and tal k i n g i n a very i ncoherent way The apex b eat o f the
heart was a li ttl e outsi de the normal posi t i on ; the aort i c second
sound was i ntensi fi ed and at mi dsternum opposi te the th i rd
costa l cartil a g e and a l on g the l e f t b order o f the sternum there
was a so f t d i asto li c murmur The pu l se was regul ar a li tt l e
jerky ; the vesse l wa ll was a li tt l e fi rmer than normal When
rs
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DIAGN O SIS OF ANGINA PEC T O RIS
1 35
.
her she was havi ng pretty fre quent attac k s and w as very
nervous and h y steri cal
A f ter remova l from her home sur
round in g s wi th rest and qui et and a course o f ton i cs she im
proved very great l y A f ter m y exami nat i on I m ade the f o ll o w
i ng note : D o the attac k s represent true or h y steri ca l an gi na "
That t here i s a strong neurot i c e l ement i s undoub ted b ut the
presence o f aort i c i nsuffi c i enc y a cond i t i on wh i ch had b een
reco gn iz ed by severa l ph y s i c i ans some y ears ago mak es the d i a g
”
nosi s a li ttle dub i ous
I have seen the pat i ent at i nterva l s
durin g the past six y ears and she has had no recurrences o f the
attac k s and h as b een i n exce ll ent hea l th
I
saw
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The extreme rarity of true an gina in w omen must al w ays
b e borne in mind and also the infre q uenc y of its assoc i at i on
as noted in L ecture II w ith mitral valve d i sease F lushes
an
d
various
nervous
or
h
y
sterica
l
manifesta
r ae st h e siae
a
p
—
tions an d p articularl y the v aso dilator t y pe of phenome na
su gg est stron g l y pseu d o an g ina even thou g h a lou d mitral
murmur be present I sa w w ith D r C lark of K in g ston
Ontario a very pu zz lin g case of this k in d the notes of w hich
I have unfortunatel y mislai d
I n men w hile true an g ina ma y coexist w ith apparently
normal car d io v ascular condit i on in a very larg e proportion
of all cases there are si g ns of greatl y hei ghtene d bloo d pres
sure Or of sclerosis of the arteries w i th a rin gi n g metallic
aortic secon d sound ; sometimes only the s i gns of a w ea k
heart In men under the a g e of forty the ex i stence of sy phil is
shoul d be suspected as a b y no means incons i dera b l e n u m b er
of cases result from an aortitis causin g great s w el li n g o f the
intima an d narro w in g of the ori fi ces of the coronaries
In men too the q uestion of tobacco has al w a y s to b e con
side re d as recurrin g parox y sms of reall y max i mum intens i ty
may be d ue to persistent smok in g or che w in g
In d eterminin g bet w een a true an d a false an gina t h e
ph enomena of t h e attac k offer must v aluable d ifferential cri
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AN
1 36
G IN A PEC T O RIS AND ALLIED S TAT ES
.
teria T he haracter of the pain in p seu d o an gina w hile it
may be very severe rarely has the a g oniz i n g qua li ty of true
an gina and i s seldom if ever associate d w ith the sensation
of impend i n g death P atients more often c omp lain of a sense
of ful l ness and d i stention in the heart The seat of the pa i n
ma y b e i n both identical an d I do not th in k that much stress
can be laid on the point th at in pseudo an g ina the max i mum
p ain is more over the heart and to w ard its apex w hile in the
org an i c d i sease the chief seat of the pain is to w ard the base
of the heart and over the aorta Y ou must remember that in
true an g ina t h e seat of the p ain may be entire ly a w ay from the
chest an d ma y be as in L or d C larendon s father at the inner
asp ect of the arm or about the w rist or in rare instances con
fin ed to the s i de of the nec k or even to one testis Wh ile in
both forms the pain may ra d iate to the si d e of the nec k an d
to the left arm in pseu d o an gina the associated nervous sen
There may b e
sat io n s are apt to be much more w i d es p read
numbness and t i n g lin g in both extrem i t i es or prior to the
onset th ere may be a feel i n g of p ins and needles in the hands
—
an d feet T he vaso motor phenomena are apt to be muc h
more p ronounce d in pseu d o an gina T he attac k may be pre
ce d e d b y flu sh e s b y a sensation of great o pp ression in the
bac k of t h e nec k or hea d an d then before the onset of the
car d iac p ain not with it or follo win g it there is col d ness of
the extremities an d sometimes a p ronounce d tremulousness
amountin g to w hat is p op ularl y calle d a nervous chill S w eat
in g co m bined w ith t h e p allor is not so comm on in pseu d o
an gina T he p aroxy sms of false an gina rarel y have great
abrup tness of onset but are prece d e d b y various ner v ous an d
h y sterical features
The attitu d e in an gina p ectoris v era is one of its most
characteristic features T he p atient rarel y can stir from t h e
sp ot in wh ich h e is attac k e d In the h y sterical an d n e uras
c
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ANGINA PEC T OR IS AND ALL I E D S T A T ES
1 38
.
ag ain but the p ain w as scarcel y so intense ; it w as d u
ller an d
more borin g in character H e suffered all nig ht and in the
mornin g ha d to ta k e a h yp o dermi c inj ection of morphine
H e had no faintness the circulation w as not involved and
there w as no se n se of im p endin g d i ssolution H e felt v ery
w ea k an d use d up for nearly a w ee k H e ha d no return w hat
ever o f the p ain until last October H e ha d been w ork in g
v ery hard and had lost a g reat deal of rest Then he ha d
the p ains at intervals w hile he w as drivin g at the table w hen
w al kin g or in be d T he y w ere never very severe and d i d
not interfere w ith his w ork T he y w ere chie fly abo ut the ap ex
of the h eart not beneath the sternum T he y radiate d d o w n
the arms particularl y the left but h e has ha d p ains in both
arms as far as the w rists w ith numbness and on several occa
sions he h as ha d p ain an d numbness in the left arm w ithout
the p ain about the heart T hese attac k s p ersiste d on an d off
all throu g h the w inter
until about t w o months a g o H e
t hen ha d an attac k of in fl uen z a w ith fever an d since then h e
has ha d a great d eal of nerv ous palpitation of t h e heart p ar
t ic u larly w ith emotion or if his stomach is full
H e d oes not
a p pear ever to have ha d a severe a g oni z in g attac k w ith sw eat
in g an d a sense of im p en d in g d issolution
C ertainl y in a man of o v er fifty thou g h his heart w as
n orm al an d his arteries not speciall y sclerotic an d the pulse
t ension ver y little raise d such attac k s w ere to sa y the least
su gg estive of true an gina ; But on g oin g into his case more
full y t w o circumstances d evelope d wh ich w ere I thin k of
much moment in d icatin g p robabl y that h e w as of a more
neurotic temperament th an he w as w illin g to confess B e
t w een three an d four y ears a g o w hen overw ork e d an d w orrie d
h e ha d extraor d inar y attac k s of sli gh t s p asm of the glottis
w hi c h w oul d come on wh ile h e w as tak in g foo d or at an y
time if he w as v ery excite d I t w oul d be relie v e d w ith a
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P R O GN O SIS O F ANGINA PEC T ORIS
1 39
.
d ee p noisy insp iration almost li k e chil d cro w in g T hese at
tac k s passe d a w ay an d he has not had them since But last
summer his wife say s that he ha d the most extraordinary
attac k s of sp asm of the g ulle t recurrin g at every meal f or
nearl y S ix w ee k s A t the fi rst attemp t at s w al l o w in g either
of li q uids or of soli d s there w ould be a sudden interrup tion
w hich he d escribes as a sort of spasm of the g ullet and he ha d
to w ait several m i nutes for it to p ass off before he could ta k e
another mouthful T his p atient w as very nervous and appre
h e n siv e that he ha d true an g ina and y et I thin k the exist
ence of w ell mark e d oe so p ha g ismus and of laryng eal sp asm
three or four y ears a g o are circumstances w hich su gg est a
d iagnosis of p seu d o an g ina
—
On e of the most d istin g uishin g features of
P R OG N OS I S
true an g ina is a consciousness on the p art of the patient in
his an guish of min d that the very citadel of life has bee n
a pp roache d In a severe lon g continued paroxy sm all de
sire of reco v ery may be absent in the d read lest he sho u l d
have a g ain to en d ure the a g ony S ubj ects of the disease may
truly be sai d to stan d in e o par dy every hour y et it is astonish
in g with w hat e q uanimity the affliction is en d ure d C harles
S umner sai d :
T his tre a che r ou s d isease pro d uces in m y mind
a p ositive uncertainty w hen I g o out of m y house w hether I
”
shall ever enter it a g ain a livin g man
T he duration of the
d isor d er is most uncertain ; there are notable cases such as
J ohn H unter in w h i c h th e attac k s have recurre d at in t ervals
for tw enty or more y ears
R eco v ery is q uite p ossible an d there are instances in w hich
the attac k s d isap p ear entirel y In J une o f last y ear in con
r
D
out
of
to
w
n
about
a
case
of
heart
disease
su lt at io n
mentione d to me his o w n case as one of exceptional interest
e
t
a
d
h
w
as
a
man
of
fi
ft
y
y
ears
of
a
g
e
an
d
been
in
v
er
y
ac
iv
He
practice T w enty y ears a g o he ha d been for nearl y a y ear
.
,
,
.
,
.
,
,
,
,
.
,
-
-
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,
,
-
,
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,
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.
,
,
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,
,
.
,
.
.
,
.
,
ANGINA PEC T O RI S
1 40
S T A T ES
AL L I E D
AN D
.
a terrible su fferer w ith an g ina H e w as un d er t h e care of
the late D r D onal d son w ho re g ar d ed the attac k s as g enuine
as there w as als o w ell mark e d aorti c insuffi cien c y T h e pa
tient has remained p erfectly fre e for t w enty y ears
.
.
,
,
-
.
.
saw i n N ovemb er 1 8 8 6 wi th D r J Willi am Wh i te a naval
o fficer aged f ort y Six y e ars w ho had had severe attac k s o f angina
assoc i ated wi th immo b ili ty and a sense o f great a ngor He was
a powerf ull y bu il t man who had lived w e ll and had t ak en a
great dea l o f heavy exerc i se The pul se tens i on was i ncreased
and the aort i c second was accentuated He had b een a he avy
smo k er b ut had not had syph ili s He had k ept a very accurate
account o f the attac k s and he had b etween O cto b er 1 1 1 8 8 6
and A ugust 1 1 1 8 8 7 two hundred and th i rty n i ne most o f them
sli g ht b ut some o f terri b l e severi ty F rom the date menti oned
to the present he h as rema i ned perf ect l y we ll and attri b utes h i s
recovery l ar g e l y to the use o f the i od i de o f potass i um
He
stopped smo k ing at the t i me o f the paroxy sms b ut has resumed
i t s i nce wi thout an y detri ment
I
,
.
.
,
,
-
,
,
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,
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.
.
,
,
,
,
-
,
,
,
.
,
,
.
,
.
In a d isease so notoriousl y uncertain as true an gina the
p ro gnosis must necessarily be most guar d e d Fortunately as
I have alrea dy sai d the character of the attac k is such that
the p atient is v ery w ell a w are of t h e extreme h a z ar d of his
state Of the imp ort ant elements in p ro gn osis the follo w in g
are to be consi d ere d :
T he fre q uenc y an d se v erity of the attac k s R ecurrence
at short intervals of p aroxy sms of great se v e rity in d uce d by
S li g ht exertion
is of ill omen particularl y if w ith them
there are mark e d car d iac arrh y thmia an d si gns of d ilata
tion
,
.
,
,
.
,
.
,
,
,
.
Th e
exi stence of val v ular d isease d oes not in itself
r iall
y a gg ravate the p ro g nosis A l ar g e maj o rity of the
cases of an gina sho w no si gns of val v ular lesions Th e
ence of aortic d isease ren d ers t h e p atient, of course
.
.
,
mate
w orst
exist
much
ANGINA PEC T O RIS
1 42
ALLIED S T A T ES
AN D
.
gether the l ast one seven da y s ago as he was gett i ng out o f b ed
O n each occas i on there has b een a s i ngl e att ac k ; morphine
a l one contro l s them
Ten y e ars ago he evi dent l y had an attac k o f cardi ac b reak
down wi th gre at shortness o f b reath S ub se quent l y f or three
years he too k ten drops o f the t i ncture o f d i gi tali s three t i mes
a day wi thout mi ssi ng he th i nk s a s i ngl e dose D uri ng the
attac k he f ee l s very b a dl y ; there i s i mmo b ili t y and agonizing
pai n i n the chest he f ee l s as i f he was go i ng to d i e and he s weats
pro f usel y
.
,
.
.
,
,
,
,
,
,
.
,
,
.
w or d or t w o u p on an ethical p roble m w hich is often
—
very p erp lexin g vi z W ha t is y our d uty in the matte r of tell
in g a patient that he is probably the subj ect of an incurable
d isease " I can g ive y ou no hard an d fast rule ; the temp era
ment of the indivi d ual himself his as sociations an d resp onsi
b ilit ie s y our o w n convict i ons as to the seriousness of the con
—
d ition all these must be carefull y w ei g he d T he q uestion is
some w h at theoretical since in reality the necessity d oes not
T he announcement has alrea dy been ma d e for
Often arise
no man suffers the an g uish of a severe p aroxy sm of angi n a
w ithout a consciousness of the nearness of the A n g el of D eath
We are sometimes I confess p lace d in p ositions of the utmost
d elicacy since a man may have not the sli g htest intimation of
his p arlous state an d y ou may become a w are of the urg ent
necessity that he shoul d ma k e p roper arran g ements to p rotect
In such a case a q uiet hint as to t h e
h is w ife an d c h ildren
uncertainty of the outloo k in heart an d artery d isease may b e
enou g h to set him a think in g ; or in the case of an even
”
balance d soul the w hole q uestion may b e d iscusse d fran k l y
On e thin g is certain : it is not for y ou to d on the blac k ca p
an d assumin g the j u d ic ial function tak e hope from an y pa
—
tient
ho p e that comes to all
an d y ou may d w ell with
advanta g e on t h e as p ects of J oh n H unter s case rath er th an
on th ose of T homas A rnol d
A
.
,
-
-
,
,
.
,
,
.
.
,
,
,
,
.
.
-
,
.
,
,
,
,
’
.
T R EA T M EN T OF T RUE ANGINA
1 43
.
The fir st an d great Obj ect of the prac t i
t io n e r on be i n g calle d o n to treat a ca se o f an gina w i l l be
to ma k e h i mself ac quainte d w ith its ind ividual character
Be ginn i n g w i th the early history of the d isease he w i l l trace
it to its present sta g e an d w ill endeavor from the narrative
of the pat i ent an d fro m t h e observation of the w hole p he
n o m e n a presented to him t o for m a c lear j ud g ment respect
i n g the local condition of the org ans in w hich the characte ri st i c
sym p toms have their site an d the state of all the other parts
of the sy stem w hich can in an y w ay in fl uence these ; in other
w ords he must en d eavor to ascertain the s p ecies or v ariety
”
of an g ina a c cor d in g to the d istinction formerl y pointe d out
This clear statem e nt of S ir J ohn Forbe s forms a fi tti n g intro
duction to the d iscussion of this part of our su b j ect S uc
c e ssfu l treatment d epen d s often upon corre c t d ia gnos i s ; but
there are cases of angi na p ectoris brou g ht to the consult ant
in w hi c h d ia g nosis an d p ro gnosis in themselves const i tute the
treatment T o a man w ho has felt tha t j u dg ment has been
g iven a gainst him the d oom pronounced and w hose min d
i s haunte d w ith the d rea d of su dd en d eath the assurance that
the condition is functional and curable comes as a reprieve
and may be the one thin g necessary to effect the cure
—
u
A
n
r
e
n
i
e
ermine
in
the
fi
rst
place
i
f
possible
T
a
D
t
g
the existence of an y constitutional disease as s yp h i lis g out
or d iabetes and th e presence or absence of valvu lar lesions
—
m
en t
I
n
q
uire
carefull
y
a
b
out
the
e
n
e
a
M
e
m
a
e
r
a
G
l
( )
g
excitin g causes of the attac k s w hich di ffer in d ifferent cases
Usually the patient has learne d b y bitter experience h i s limita
tions in certain d irections an d k no w s much better than y ou
can tell him j ust w hat to avoi d ; but y ou can emphas iz e the
importance of mental w orry exercise an d d iet the three chief
factors " uiet of min d avoi d ance of w orries and cares the
—
cultivation of a calm e q uanimit y w ith th ese or suc h lik e
TR E A TM E N T
.
.
,
,
,
,
,
,
,
.
'
.
.
,
,
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,
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,
,
,
,
,
.
,
.
,
,
,
.
,
,
,
,
,
ANGINA P E C T O RIS AND ALL I ED S T AT ES
1 44
.
p hrases w e try to im press a p oor v ictim w ho to p re vious anx ie
ties has no w the ad d e d bur d en of a disease the terr ible char
acter of w hich he can ap preciate but can not understan d
Ou r w or d s Often seem a moc k ery and y et the y may be help
ful in persuad i n g a man to cast off all unnecessary business
and to live a l i fe in w h ic h t h e re shall be a mi ni mum of fri c
tion T ime too w ith its soothin g d ece p tion comes to allay
the access of earl y ap p rehension an d as succee din g attac ks
p ass there may be less an d less mental d istress A n im p ortant
q uestion ari ses h ere S hall a man w ith an g in a give u p his
business " In a maj or i ty of cases this sacri fi ce is unnecessary ;
t h e literature abounds w ith examples of men w ho l ik e J ohn
H unter hav e d one the best w or k of their lives after the onset
of an gina T here is so m u ch uncertainty that no rule c an be
lai d d o w n ; each in d ivi d ual case must be cons i d ere d separatel y
The patient s a g e occu p ation an d above all the con d ition
of the vas c ular sy stem must be tak en into account E v en
after a most severe attac k follo w e d by a car d iac breakd o wn
of several months d uration a man may be able to resum e
w ork an d as in C ase V refe rred to in L ecture III b e bene
fit e d b y the stea dy occu p at i on
E xe r c ise must be ta k en w ith in t h e limit s wh ic h each in
divi d ual soon learns to reco gn i z e
In severe recurrin g attac k s
induce d by Sli ght muscular efforts a p erio d of absolute rest
shoul d be enj oine d T h e su dd e n q uic k mo v ements w hi c h
ra p idl y increase t h e bloo d p ressure an d th ro w a strain u p on
t h e heart are th e most d an g erous ; an d m ost of all t h os e
w ith w hich are associate d stron g emotions
T he p atient
shoul d be urg e d to w al k on the le v el in t h e literal as w ell as
metaphorical meanin g of th e phrase H e shoul d learn to
live w ithin the income of his circulation w ith which w ise
sa w from the lip s of the lat e D r S ibson a frien d with org anic
h eart d isease has been comforte d an d sustaine d for a q uarte r
'
,
.
,
'
.
,
,
,
,
.
,
.
,
,
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.
’
,
,
,
,
,
.
,
’
,
,
,
,
,
.
.
,
.
,
.
,
.
’
,
.
P EC T O R IS A ND ALLIED S T A T ES
A N G IN A
1 46
of flat u le n c y Be y on d the g enerally acce p te d restrict i on
of the carbohy drates w e can not g o very far w i thout meetin g
in d ivi d ual peculiarities w hich have to be considere d T he
p atient himself has to be consulted carefully S ome of y o u
may call to min d w hat our d istin g uishe d collea g ue D r S mol
lett ma k es one of his c h aracters M att Bramble say in H u m
For
m
y
o
w
n
p
art
I
have
ha
d
a
hos
p
ital
these
h
r e y Ulin he r :
p
fourteen y ears with in m y self an d stu d ie d m y o w n case w ith
the most p ainful attention , conse quentl y may be supp ose d to
We are too a p t to for g et
k no w somethin g of the matter
this A n intell i g ent man shoul d be able to tell y ou j ust w hat
articles of foo d cause most d isturbance an d p ro d uce w in d in
the st o mach or bo w e ls T he fault ma y not lie in the foo d
but in the inability of the stomach an d bo w els to d i g est it p rop
—
erly T he obese fl abb y subj ects of an g ina not the most
—
an d those w ith w eak heart
n umerous class in m y ex p erience
—
an d arterio sclerosis are s p eciall y p rone to fl atulence A fe w
d oses o f blue mass an occasional saline p ur g e an d the use at
times of a g oo d bitter tonic k ee p this con d ition in chec k T he
use of hot w ater before meals p articularl y before break fast
has be e n foun d very serviceable
In el d erl y men accustome d to stimulants h o t gro g at be d
time allay s t h e ten d enc y to flat u le n c y w hich is sometimes
the cause of w ak efulness or w hich is apt to disturb the pa
tient in the earl y m ornin g hours P e pp ermint spirits of cam
phor H offmann s ano dy ne carbolic aci d iodine an d creosote
”
are useful for w in d on t h e stomac h
For the intestinal
flat u le n c y a saline p urg e is often a g oo d corrective ; the v ari
—
ous suppose d intestinal d isinfectants may be trie d salol beta
naphthol an d corrosive sublimate of which pilules of from
one sixtieth to one thirtieth of a grain may be g iven sometimes
w ith a d vanta g e
—
b
e
n
e
r
a
i
l
M
e
a
l
T
r
e
d c
a tm e n t
Of constitutional con
( ) G
ter
.
.
.
.
.
,
,
,
,
’
.
.
.
.
,
,
.
,
,
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,
,
.
,
,
,
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,
’
,
,
,
,
.
,
,
,
.
.
GENE RAL M EDICAL T R EA T M EN T
1 47
.
un d erly in g an g ina p e c toris and ca p able of treatment
sy philis an d g out are the most important G enuine ang ina
in a man under thirt y fiv e y ears of a g e should arouse a sus
i
and
vi
g
orous
m
e asures shoul d be a d opte d
c io n of s y ph i lis
p
In g outy cases free elimination b y the bo w els sk in and k id
ne y s should be secured a pro p er d iet or d ere d an d at inter v als
a course of colchicum may be prescribe d
On e p atient D r
emphasi z ed re p eatedly the bene fi t
he ha d d erive d from colchicum S timulants should b e avoi d e d
G ly cosuria is usually controlle d b y d iet an d rarely g ives much
t rouble
In a larg e p ro p ortion of all c a ses of an g ina pectoris the
treatment consists i n the administration of the iodides an d
nitrites remedies w hich are believe d to in fl uen c e arterial fun c
tion and arterial nutrition T he u se of the io did es of po t as
sium and sodium in this d isor d er has been advocated most
w armly by H uchar d w ho states that of ei ghty p atients w ith
org ani c an gina treate d thoroug hl y b y these d rug s t w enty
t w o recov ere d forty three w ere greatl y bene fi ted an d fi fteen
*
Th e iodi d es appear to have a bene fi cial e ffect in chec k
d ie d
—
in g or modify in g the p ro gress of arterio sclerosis an d in lo w er
in g the blood p ressure T he y ma y in fluence too arterial
p ain I have calle d y our attent i on repeate d l y to the infl uence
of io d ide of potassium in aneury sm of the aorta in w hich the
relief of the pain is one of its most strik in g effects While I
can not say th at m y experience is in every w ay so favora ble as
H u c h ard s I can testify to th e g reat relief w h i ch has f o l lo w e d
its use in man y cases an d in a fe w an apparent cure C ases
w hich w ere thorou g hl y treated nearl y ten y ears a g o rema i n
q uite w ell and I have ha d w ithin the past three y ears several
p atients w ho have been greatl y bene fi ted I usuall y or d er
dit io n s
,
.
-
,
.
,
,
,
,
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,
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-
,
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’
,
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,
,
.
L
e
T ra ite m en t d e l
’
angin e
de p o itrine ,
Paris
,
1 89 2
.
A NGI NA P E C T O RI S AND ALLIED S T ATE S
1 48
.
the io d i d e of p otassium in d oses of ten or fifteen grains th re e
times a d ay S houl d it d isag ree w hich is v ery seldom I g iv e
the sodium salt L arg er d oses are not often necessary I f
intolerance d evelo p s sto p the use for a w ee k an d be gin w ith
smaller d oses The success in treatment de p en d s upon the
p erse v erance w ith w hich the d ru g is use d On th is p oint let
me q uote from H u c h ard s p am p hlet : On e of the princip al
—
con d itions of success is p erseveranc e c onstanc y in the me d i
cation T he dru g must b e tak en for a p e ri o d of tw o to four
y ea rs in d a i ly d oses of one to th ree grammes until all sy m p
toms of an g ina have disapp eared for man y months an d I h ol d
that a permanent an d d e finitive recovery is not obtainable
”
R easonable caution
exc e pt after man y y ears of treatment
must be em p lo y e d an d y ou w oul d not give the io d i d es in pa
t ie n t s w ith a d vance d arterial d e g eneration a d ilate d heart
and si gns of interstitial nephritis T he p atients w ho stan d t h e
treatment w ell are the robust middle a g e d men in wh om t h e
an g in a is t h e sole sym p tom With aortic d isease , if fairl y
com p ensate d the d ru g ma y be use d
T h e nitrites in h yp ertension an d a n g ina p ectori s are of
v alue q uite e q ual to the io d i d es T he nitrite of amy l is em
plo y e d in the p aroxy sm Th e nitro g ly cerin or trinitrin is
in d icate d in all cases in w hich t h e tension is persistently h i gh
G iven pro p erl y it is a ver y v aluable reme dy but to g et an y
a d vanta g e from its use each cas e must be tak en by itself
In the fi rst place be sure that the nitro gl y cerin eith er in
solution or tablets is fresh T he tablets containin g one one
hun d re d th of a g rain are as a rule reliable I t is w ell to
be gin w ith onl y one of these three times a d a y T he d ose
ma y be increased g ra d uall y until the patient tak es four or five
thre e times a d ay , or e v en a lar g er d ose I f the p atient notices
a slight glo w or fl ush an d a little sensation of fullness in t h e
I feel sure
h ea d y o u m ay k no w that t h e re m e dy is actin g
.
,
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’
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.
ANGINA PEC T O RIS AND ALLIED S T A T ES
1 50
.
'
p are d either in li q ui d or tablet form as chloro dy ne is som e
times very advanta g eous In tablet form it is particularl y
convenient as it may be carried in the w aistcoat p oc k et
For the p aroxy sm itself there are three reme d ies :
N itrite of amy l t w o to fiv e minims inhale d from a han d
k erchief or from cotton w ool placed at the bottom of a w i ne
g lass g ives promp t relief in cert ain cases T he p atients are
in the habit of carry in g the reme dy in p e r le s containin g
three to five minims w hich can be rap i d l y bro k en in a han d
k erchief an d inhaled so soon as the very earliest sy m ptoms of
T he intro d uction of this dru g in the
t h e attac k are notice d
treatment of an g ina b y D r L au d er Bru
n ton has certainl y
been a great boon to man y su fferers but too much must not b e
I t is sin g ularl y uncertain While in one
e x p ecte d of it
case the attac k s are p rom p tly cut short an d almost imme d iate
relief obtained in others it seems q uite inert
C uriously
e nou g h consi d erin g that its p h y siolo gi cal effect is in d ilatin g
the p eriph eral vessels an d relie v in g t h e w i d es p rea d an ge io
s p asm in m y exp erience it has been less e ffi cacious in the
v aso motor typ e of the disease than in cases of org anic an g ina
I t ma y pro d uce its effect with great ra pi d ity as sh o w n b y t h e
fl ushe d face of the p atient an d the increase d volume an d soft
w ithout relie v in g the pain I t sometime s
n ess of the p ulse
acts better g iven by the mouth , combin e d w ith the tincture
of capsicum in peppermint w ater
M orp hine h y po d ermicall y is the most useful d ru g in the
attac k an d if the pain is not relieve d q uic k l y by the nitrite
of am y l an inj ection of a q uarter of a grain shoul d be g iven
and repeate d in a half or three q uarters of an h our if the
patient is not relieve d I n one case the nitrite of amyl faile d
re p eate dl y to give the sli gh test relief but from a q uart er to a
thir d of a grain of morp hine h y po d ermicall y never faile d
to allay t h e terrible d istress , an d seeme d also to stea dy an d im
.
.
,
,
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,
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,
T RE A T M EN T OF T H E C O M PLIC A T I O NS
1 51
.
p ro v e t h e heart s action A p oint about the use of morphine
in an gina w hich I have never seen mentioned except in the
paper by D r Burne y Y e o in the P r a c tit ion e r alread y re
ferre d to is the remark able tolerance of m orph i ne in certa i n
cases In reportin g C ase X XXII I mentione d that this pa
tient receive d bet w een ten o cloc k on S aturday n i ght and 1
M on S un d a y fi ve g rains of mor p hine h y poderm i call y and
P
by t h e mouth w hich relieve d the p ain but did not g i ve him
slee p T here are cases in w hich a h ypo d ermic inj ection of a
q uarter of a grain of morp hine g iven at the first ind i cation of
the attac k as a numbness in the han d or tinglin g in the
fi n g ers chec k s it at once
A n d thir d in an y paroxy sm of g reat intensit y w hile
w aitin g for th e nitrite of amy l or morphine to tak e effect
chloroform may be dro pp e d u p on a hand k erchief an d inhaled
Balfour recommen d s th at it be p oure d on a sp on g e in a smell
in g bottle an d the p atient tol d to breathe it throu gh the nose
as d ee p l y as p ossible In a minute or tw o rel i ef is obtaine d
an d as t h e patient comes un d er the in fl uence of t h e dru g
the bottle d ro p s from his han d an d there is i n this w ay no
d an g er of an over d ose
T he c h loroform acts much more
promptly an d is m uch pleasanter to ta k e than ether an d I
have ne v er seen an y d an g erous effects from its use even in
p erson s w ith very w ea k heart s action
—
For
the
s
y
ncope
h
e
omp lic a t ion s
t
C
r
m
e
n
o
T
e
a
t
t
d
( )
f
of serious attac k s the aromatic sp irits of ammonia w ith H o ff
mann s ano dyne an d bran dy may be g iven or h ypo d ermic
inj ections of ether or camphor For the d ilatat i on of the
heart and cardiac w ea k ness w hich sometimes follo w the at
tac k the nitro gl y cerin w i th stron g frictions to the l i mbs may
favor the circulation at the periphery w hile d igitalis or di g i
talin may be g i ven freel y t o stimulate the heart s action
X
X
V
X
C
i
g
italin
somet
i
mes
acts
w
ell
as
in
ase
III, an d ma y
D
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ANGINA PEC T O RIS AND ALLIED S T AT ES
1 52
.
be g iven h ypodermicall y N o liar d an d fast rule can be lai d
I t sometimes acts badly
d o w n re g ard i n g the use of d i g ital i s
as i n a case very careful ly studied by W T S harpless of
W est C hester C affe i ne an d camphor ma y also be emp lo y ed
I f all these measures seem futile I w ould not hesitate to em
—
—
p lo y puncture Of the hea rt cardiocentesis w h i ch may
arouse to q uite vi g orous action a d i late d and paretic org an
I do not k no w that this has been e m p lo y e d in the cardiac
asy stole follo w in g a se v ere p aroxy s m of angina but there are
instances on recor d notabl y th e case of S loane (E din bu rgh
M e dic a l Jo u r n a l vol xl ) in w hich p un c ture of the heart w ith
a nee d le d riven firml y into t h e ventricle has arouse d the flag
g in g action a pp arently w ithout d oin g the sli g htest injury
For the con d ition of chronic e ta t d e m a l a n gin e u w in
w hich for a p erio d of man y day s or e v en w ee k s th e p atient
has recurri n g attac k s w ith car d iac a sthma an d feeblene ss of
the circulation y our resources w ill be taxe d to the uttermost
For the dy s p n oe a an d the C he y ne S to k es breathin g full d oses
of stry chnine h yp o d ermicall y may be em p lo y e d from a for
t ie t h to a t w entieth of a grain three or four times a d a y
S pecial care shoul d be ta k en that the bo w els are k e p t freel y
opened T he c ardiac measures alrea dy spo k en of may be em
p lo y ed an d fly in g blisters to the p rae cor dia and to the base s
of the lun g s may sometimes g ive relief
T r e a tm e n t of P se u d o a n gi n a P e c tor is — T h e measures
must usuall y be directe d to combatin g t h e un d erlyin g con
dit i on o f neurasthenia or h y steria Oc c c asion ally it happens
particularl y in me d ical men that the mental relief affor d e d
by a p ositive d ia gnosis of p seudo an g ina is in itself su ffi cient to
e ffect a cure C ases II an d III given in L ecture V are g oo d
illustrations of the im provement an d permanent cure up to
the pres e nt d ate of attac k s of maximum severity I t is not
easy to say to w hat the rapid relief c oul d be attribute d as the
’
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,
ANGINA PEC T O R IS AND ALL I ED S T A T ES
1 54
.
tion is not onl y very common but d evelo p s o f ten at a rela
For th i s I b el i eve that the h i g h pressure at
t iv e ly earl y a g e
w h i ch men live and the habit of w or k i n g the machine to its
max i mum capacity are resp onsible rathe r than excesses in
eatin g an d d rink in g or than an y special prevalence of syphi
lis A n ge io s c leros i s creepin g on slo w ly but surely w ith no
”
p ace p erceived is the N emesis throu gh w hich N ature ex
acts retri b utive j ustice for the tr ans g ression of her la w s
comi n g to one as an a p oplexy to another as an earl y Bri g ht s
di sease to a thir d as an aneury sm and to a fourth as an g ina
p ectoris too often slittin g the thin s pu n life in the fi fth
d eca d e at the very time w hen success seems assure d
No
w here do w e se e such an element o f tra gic sadness as in man y
of these cases A man w ho has earl y risen arid late tak en rest
w ho has eaten the brea d of carefulness strivin g for success
in comm ercial professional or political l i fe after t w enty
fiv e or thirty v e ars of incessant to i l reaches th e point w here
he c an sa y perhaps w ith j ust satisfaction
S oul thou hast
”
much g oods lai d u p for many y ears : tak e thine ease all u n
conscious that the fell ser g eant has alrea dy issue d the w arrant
H o w true to life is H a w thorne in the H o u se of the S e ve n
T 0 J u d g e P y n c h e o n w ho ha d experience d a mere
G a ble s
—
dimness of si g ht an d a throbbin g at t h e heart nothin g more
— an d in w hose g rasp w as the mee d for w hich he ha d fou g ht
”
and toiled an d climbed an d crept ; to h im as he sat in t h e
thin k i n g of the cro w n
Ol d oa k en c h a ir of his g randfathers
in g su ccess of his life so n ear at han d the aven g er came
throu gh t h e arteries
With w hat strife an d pain s w e come into the w orl d w e
”
k no w not but it is commonl y no easy matter to g et out of it
S ir T homas Bro w ne say s ; an d h avin g re g ar d to the u n c e r
t ain t ie s of the last sta g e of all th e avera g e man w ill be of
C aesar s Op inio n w ho w hen q uestione d at his last d inner p arty
,
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C O NCLUSI O N
as
1 55
.
to the
most p referable mo d e of d eath , re p lie d
T ha t
”
is the most su dd en
A g ainst th i s one i n a str i n g of
grie v o us calamities w e p ray in the L itany thou g h D e " uinc y
”
insists th at the meanin g here is unp re p ared
In this sense
sudden d e ath is rare in an g ina p ectoris since t h e end comes
but sel d om in the fi rst p ar oxy sm T errible as are som e of
these inci d ental con d itions accomp any in g coronary artery
lesions there is a sort of k in d ly com p ensation as in no other
—
local d isease d o w e so often se e t h e i d eal d eath d eath li k e
”
birth a slee p an d a forg ettin g
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ANGINA PEC T O RIS A ND A LL I ED S T A T E S
1 58
.
have b een more f ortunate i n fi nd i ng what I can n ot he l p
suppos i ng to b e a qui te d i fferent document i n your marve l ous
li b rary at Wash i ngton I can on l y p l ead that my remark s app li ed
q u i te correct l y to the extract sent to me and I shoul d b e gl ad
i f th i s w ere made c l ear though I can not no w f ull y exp l a i n i t
Have you any i dea i n Ameri ca as to the proper pronunc i a
t i on o f angi na " F or years I a lway s pronounced i t wi th the i
l ong and never once heard i t otherwi se t ill D r Houghton o f
D ub li n pu ll ed me up I then made an e l a b orate i n qu i ry i nto
the c l ass i ca l authori t i es and f ound that i t comes out apparent ly
c l early that the i i s short as i n the test passage i n Pl autus s
T rin u m m u s wh i ch has b een annotated so my co ll eague P ro
fe ssor R amsey te ll s me
I s i t w orth wh il e to mak e the change "
In haste
Y ours very truly
W T GA IR D N E R
Yo u
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’
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—
B
TH E
N OT E
CA S E
.
OF M R
.
M AT T H
.
EW
O
ARN
.
.
LD
(
GE
PA
M at t he w A rno l d ,
the d i st i ngui shed son o f D r Thomas
A rno l d d i ed sudden l y on S unday af ternoon A pr il 1 5 1 8 88
i n h i s S i xty s ixth year The vari ous stages i n the progress o f
The fi rst i nt i mat i on
hi s d i sease are w e ll gi ven i n h i s l etters
we have o f any troub l e i s i n a l etter to h i s son dated M ay 1 8 8 5 :
I have b een h avi n g a horr i d pa i n across my chest and on
F ri day mamm a carri ed me to A ndre w C l ar k who has put me
—
on the str i ctest o f diets f or one w ee k no medi c i ne b ut soup
sweet th i ngs f rui t and worst o f a ll all green vegetab l es
ent i re l y f orb i dden and m y li quors con fi ned to one sma ll hal f
gl ass o f b rand y wi th co l d water at d i nner I am to see how th i s
sui t s me He th i nk s the pa i n i s not heart b ut i nd igest i on
A t present I f ee l ver y un li k e l awn tenn i s as g o i ng f ast or g o i ng
uph ill gives me the sense o f havi ng a mountai n on my chest ;
”
l uc k il y i n fi sh i n g one goes sl o w and stands st ill a great de al
To h i s daughter a b out the s ame t ime he wri tes : I can not
r
i
d
o
f
the
ache
across
m
y
chest
w
hen
I
w
a
l
k
i
ma
g
i
ne
m
y
e
t
;
g
havi ng to st e p ha l f a do zen t imes i n g o i ng up to P ai ns H ill "
”
What a mort i fy i ng chang e " B ut so one draws to one s end
O n A ugust 2 6t h he wr i tes to h i s wi f e f rom Wa l es :
O n the
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APPENDIX
1 59
.
who l e I d i d more y esterday and d i d i t easi er than I have done
”
s ince I was fi rst vi s i ted by th i s pai n
O n January 1 1 1 8 8 6 i n a l etter to h i s dau ghter he wri te s :
I g ot on very we ll and the s k at i ng d i d not b r i n g on the chest
pai n ; smooth mot i on does not b ut l ab or i ous mot i on— mak i ng
”
my wa y uph ill or through snow
D urin g h i s second vi s i t to Ameri c a i n 1 8 8 6 he had a ve ry
narro w escape f rom dro wn i ng The acc i dent was nothing ; a
wave carri ed m e heavil y agai nst a taut rope under water put
there f or the sa f et y o f b athers ; b ut the shoc k exhausted me
rather and was f o ll o w ed by a wee k or so o f troub l esome attac k s
”
o f pai n across the chest
On N ovemb er 2 7t h o f the same y ear he wri tes to h i s
—
daug hter : I am qui te m y o l d se l f a gai n wa l k ed ab out L on
”
don all y esterda y i n the f o g wi thout cho k e and pa i n
O n D ecemb er 2 2 d i n a l etter to P ro f essor N orton he wri tes :
I f I g o too qu i c k I am stopped by a warn i ng i n m y chest ;
b ut I can go a b out as much as I li k e i f I g o l e i sure l y and I have
no attac k s o f sharp pai n There w ere some ni ghts i n Ameri c a
when I thou ght that my grand c limacteri c —
an epoch i n li f e
wh i ch I used to hear a great dea l o f from my dear mother
woul d see the end o f me ; and I th i nk b y the way you l oo k ed
”
at me once or twi ce at A sh fie ld y ou thought so too
I n a l etter to M rs C oates January 2 9 1 8 8 7 he wrote :
O ne
shoul d tr y to b ri n g one s se l f to regard death as a qu i te natura l
event and surel y i n the case o f the o l d i t i s not d iffi cul t to do
th i s F or m y part si nce I was s ixt y I have regarded e ach y e ar
as i t ended as someth i n g to the good b e y ond what I coul d natu
ra ll y have expected Th i s summer i n A meri ca I b e gan to th i n k
that my t ime was rea ll y com ing to an end I had so much pai n
i n m y chest the si gn o f a mal ad y wh i ch had sudden l y struc k
down i n mi dd l e li f e l ong b e f ore they came to my present a g e
”
b oth my f ather and grandf ather
In a l etter to P ro f essor N orto n he aga i n re f ers to the
b ad
attac k s o f pa i n wh il e I was wi th y ou the w orst I had i n Ameri ca
”
the w orst I have ever had
There are no further re f ere n ces and w e know that he went
down to L iverpoo l to meet the steamer A urani a and on S un
,
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ANGINA PEC T O RI S AND ALLIED S T AT ES
1 60
.
day a fternoon A pril 1 5 1 8 8 8 d i ed sudden l y i n h i s s ixtysixth
year a b out three ye ars a fter the fi rs t man i f estat i ons o f an gi na
-
,
,
,
.
,
N
OT
C
E
.
—R E T E N T I O N
CE S S A
T
IO
N
OF
0F H
C
O
N SC
EAR T
’
I OU
A CT
S
A FT E R
SN E SS
IO
(
N
PA
AP P AR E N T
GE
very remark ab l e f act i n certa i n cases o f angi na i s the p er
si stence o f consc i ousness wi th the a b ili ty to engag e i n con
versat i on and even to wa l k af ter pu l sat i ons have ceased at the
wri st or even a fter the heart b eats c an no l onger b e f el t D r
M acrae o f C ounc il Bl u ffs has sent me note s o f the f o ll owi n g
remark a b l e i nstance o f the k i nd A p hys i c i an who had b een
the sub j ect o f angi na wh il e wa i t i ng for D r M acrae i n h isre
c e pt io n room was se i z ed w i th an attac k
When I came i nto
the room he was unconsc i ous wi th h i s head dropped over the
b ac k o f the cha i r He was pu l se l ess ; no card i ac sound coul d b e
heard He rega i ned consc i ousness and wi th m y assi stance
wa l k ed i nto the other room and l ay upon the l ounge C aref u l
exam i nat i on aga i n f a il ed to revea l any car diac movements He
was not i n pa i n was sens i b l e b ut seemi ngly da z ed He ask ed
me w hether h i s heart had ceased act i on I to l d h i m i t h ad He
gave a short l ovi ng messag e to h i s wi f e e j acul ated L ord have
merc y on me " b ecame unconsc i ous and d i ed then i n a f ew sec
He must have lived at l east five m i nutes af ter I f ound
o n ds
h i m W hen la i d on the l oung e he b urst i nto a most pro fuse
persp i rat i on and b reath i ng was somewh at l ab ored The po i nt
I wi sh to ma k e i s that he lived was rat i ona l cou l d a l most wal k
by h imse l f and ta l k ed f or several minutes af ter his he art so
”
f ar as coul d b e determi ned had ceased to b eat
I n C ase XXIII
I w as ver y much i mpres sed by th i s retent i on o f comp l ete con
sc io u sn e ss and capa b ili t y o f en ga gi n g i n conv ersat i on w hen the
p ul se at the wri st cou l d not b e f e l t
A
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TH E
EN D
.
A S Y S T E M OF
G E N IT O U R IN A R Y D IS E A S E S
-
S Y P H IL OL OG Y ,
A N D D E R M A T OL OG Y
C ON S I S T I N G OF T
HR E E
E
V OL UM S ,
A S F OL L OW S
VOL
:
VOL II SYPHILO
LOGY;
I GENITOURINARY DISEASES ;
-
.
.
,
.
,
AND VOL III, DERMATOLOGY
.
.
B Y VA R I O US A UTH OB S
I
E D TE D
P R IN C E
BY
ON L Y
S OL D
A
BY
.
M OR R OW , M D
.
.
S U B S C R IP T I O N
w i ll
i
i
i
wi l
i
i
v
h vl
p
i l
ii
k i
h l y h
h
v l
y
.
.
i v l
v y
o um e ,
b e an n a u a b l e aid t o e e r
T is s st e m , j ud ge d b y t h e fi rst
b e m o re t an
m an w h o t re at s ge n t o ur n ar d se ase s —an d w h o d o e s n o t " It s
M ore o e r , it is n o t o ut o f ac e t o say t at
l b e a gu de an m o n t o r
an aid : it
l e asure in t se f o n acc o un t o f t h e go o d a e r, c l e ar
re ad n g su c
a
o u m e is a
’
o
k
n
a
ma
t a wa s c arac t e r ze A
m r n t , a n d e x qu s t e b o
e t on s
u b ca
g t
”
t on s
D e nver M edical Tim es
"
i ll
-
pl
h
pp
pp l
p li
.
.
i pi
—
i
h
i
.
.
i n ti
bl
uni f m it y
h
w
k
f t
ut t h
th
t m nt t h t i
g
ut h
l d m t t d in w k b y v i
Ow i g n d b t t t h
ful n d
d it
h
t i b ut
h
v i d t ly t t i d full
ffi i n t up v i i n f t h
f hi t k b f
mm
p
i
i
ng it
A
ti n f t h n tu
th w k i d
p
n
n
f
h
t
t
l
p
i
i
l
h
p i li t t h i f t u i f
d
f
h
t
t
t
g
g
w ul d t h w i
m
i
y h pt
p v d i pp i ting t n n t
t v lu
p b l f pp i t i g t h i m i g N p i w t d i t h
it t i n f
g
ull y
hi t i l d t
in p ul t i v di
i
E y h p t i m in t l y
l
t
lin
in b l k l t t
d in
t m k it
d
u b di v i d d b y l
y f
"
se
T
h
o
e
ro u
c e
a
ai ne
a
o
re c a
ne
si
a
e o
ca a
so
an
s
n
o
sc uss
or
ac e
c
s
s
as e
e
a
s
ea
o
n
s
a
or
s
,
s o
e
o
a
en
e
re
o
e re c
s e
o
o
rac ic a
e
e as
re c re n c e
o
.
”
'
a
o
c are
o n
sa
a
e n e r a ne
ec a s
er
e
e
s
e
a
e rs as
i
o
,
.
ro
ver
re a
en
e
e
se
0 s
ac
ou
o
e nc
a
.
o
.
as
co
n s.
o
es
g
or
er
e an n
e
a
n
e ss
o
e r
ea
—Ohio M edical Jour nal
e rs
or
.
e o re
no
er
o
a
ec
e
s
c
re c a
a
a a or
s o r ca
an
s nce
rac
a
c on r
as
s
o
e
o rs
or, e ac
e
re
a
e n e ra
e
e
e
o
e
o
or
re a
s o
ce a
o
s
ar o u s a
s
or
er
s
e re
or
e
o
.
.
h i p in b k p du t i n — p i lly i w k f u h
p t i n — m t b i m p ly n ut m f t h n w d m h f i
d i
hi v m
N
m n
p y h i li w i t h i n y
t
uld h v w i tt n t hi t
ti
d f tim
i
nt y t
t ll p p t i
n um d b y t h
t
t i l uf
t t th t
p
m k i g it
d y f th
i t
h n d N n ut h
ul d h v t
t d ll t h
ll
h
l
h
w
ll
i
n
l
p
p
h
p
i
l
i
d
u bj
t
i
m
m
n
t
t
t
t
t
t
y
;
q
y
it i m pl i t
w i t u p n y p il i
l g t u t h t f th
th
n u
th
y ti
h p v il i g
n
v u y t m t h rt h p di u g u
y p h il i f t h b
t n d n y t m p d up n v y h p t
i tp v id n
nd
i m t t d t il
f
th
v id t i t t i t h t h ub t h ll b t h
p
th
vi w
th
t
d p
l p i
f d m f m b ib l i g p h i l
h
u t e d in a
t iki
f
w it gi v t h im p i n f
T h u gh ut t h i di v i d l w k f
full y d n
f th
h vi g b n
p nd
t m k it w t h
d w it l t h d i
f th
a m
y t m t wh i h t h i v l um [1 1 ] b l g —M d i l t d
Th e
sc
h
re e n s o
ac
e
er o
In
s
r
er
e
se e
en s
e
o
s
o
a
ua
e
s
o
o
s s
e
c
art n e rs
e
ro
or
re a
ec s e
p
s
0 one
.
e a
n
a
e m e of co
e
e o
,
s a
e
a
co
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r n er s
an
se e
a
a
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e
c
a
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e o
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co
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er
er
ssu e s ,
e
e
on s
s
e
ro o
e
s o
o
a
e
S
ec a
or an
un
e
an
en
n en
e rs on a
re e re n c e s
ex
on
a
n
ee
c are
i
o
e s
s e
D
.
e ac
e r e nce ,
ro
.
a
o
o
c
s
ee
a
as re s
e
,
o
s
e
,
n
ua
an
s
A PPLE T O N
e
.
o
or
e
AND
e
e
s r
n
o
e s re
r
o
s
a
”
.
C O MPA N Y
,
e
o
o
ro
er
es
re e
e ac
e on
one n
ex
e
e
e
o
ca
e cor
N E W YO R K
.
n
a
e
s
ra
ca
re s s o
o
e sc o
.
e
a
or s
o
u
o
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au
or
<
s
a
'
e
S
re
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e
a
a
e
.
s
e rs
r
s
on
is
on e s
e
ce o
a
e
t
an
re a e
e
c
n a
re e c or
a
e
a
s
s o
s
-
or co
e a
ro
on s
a e
e
or
sc e n c e
o
ar c
se u
e
n
ec a
ar
re a
s
o o
.
es
o
c
e
r e on
c s
er
s
e
ca e s
ae
e
o
’
ro
co
a
o na e
or
o
o
o
a
s as
s e
oo
e
a
P R A C T IC A L
WI TH
S P E CIA L
W
BY
P
ro es or
f
of
s
D IE T E T IC S
R E F E R E N CE
T O D IE T IN
D IS E A S E
GILM A N TH OMP S ON , M D
.
.
.
,
M ater a M e ica T erapeutics d Clinical M ed icine i t h U
t h C ity
York ; Visiting P h y si cian to t h P resb yt erian
ell evue H ospitals N w York
i
d
h
,
of N e w
and B
e
L A R GE
an
.
n
n w e m l t y at
e
'
e
e
,
.
0 0 TA V0, E I G H T H UN D R E D
C L OT H ,
P A 0E 8 , IL L U8 TBA TE D
SH E E P
.
,
S O L D ON L Y B Y S U BS CR I P T I ON
.
c m m e nd t o t h cri ti cal att e n ti on f t h m e di cal pr fess i n t h i s n w and
v al ua b l e wo rk W h e si tate not t e x press th c n vi ct ion th at w ith in t h p ges f
t his v l um e w i ll b fo und m o e f expli ci t reli ab l e and practi cal i n structi on w i t h
e feren c e t t h sel e cti on pre pa ati on and admi n i strat i n f food s pp p t to
eve ry g d c ondi ti n b o th i n si ck n e ss and i n h ealth t h an h h i th e t o b ee n
—
f
m
h
f
e
se
n
t
e
d
i
n
a
n
y
o
r
e
d
i
ca
l
r
o
e
s
i
on
t
t
m
N th A m i
t it i
P
p
p
T h arra nge m e n t f t h i s treat i s e i s s u ch t h at a b us y practi ti n e r ca n turn i n
m m e n t t a d i etar y w h i c h i
d apte d t o any d i sease h m y h a ve u nder treat m n t
a nd the re fi nd specific di recti n s W c om m e nd t h b oo k t o eve ry ph y s ici an b
l ievi ng th at i ts frequ en t use w i ll rel i e ve h im fro m a part f h i p t i l w o rk
w h i ch h i t h past b ee n m st unsat is fact ry b t h t h i m se lf a nd t h i patie n t
"
We
o
e
o
e
.
o
o
e
r
o
e
o
r
e
o
o
o
o
e
,
o
o
a
or
s
er can
o
e
r
r ac
o n er .
e
.
e
e
o
e
M e dical Jo ur nal
a
a
o
o
e
,
o
T his
na c
o
s a
—B rookly n
rO
as
,
o
n
o
'
o
as
a
,
,
e
e
o
,
o
"
e
r
,
an
e
a
r
e
ro e ss o n a
s
o
o
”
s
.
.
o k strikes us
ve y i m po rtant con trib uti on t m e di cal li t e rature
W are g re at ly m i stak e n if i t do e s no t m eet w i th a v ery l arge sal e A l l c l asses f
”
practi t i on ers w i ll fi d i t f t h great e st practi ca l v a l ue to t h em i n th eir d ai y wo rk
b
as a
o
r
o
.
e
o
.
—P aci/ic
n
o
e
M e clical Jo ur n al
Th i s
l
.
.
i s at n ce t h b est and m st ex haustive book u pon th i s su bject wi th wh i ch
w e are fam i li ar T h b est b ecause in t h fi rst place i t i s w i tte n b y a t e h er f
the rapeuti cs w h k now s t h n e e d f t h practicing ph s i ci an and yet w h h
tau gh t i n p e vio us y e ars as a profess o r f ph y s i ol gy l th at
n ee d s t o k n w in
egard t t he pri nci pl es f digesti on and ssi m il ati on F t hi s reas on t h auth o r
i s u n suall y w e ll q lifi d t o prepare useful m an ual b t i t is not u nt il on e h
f
h
h
m
d
t
h
er
s
e
d
v
ol
u
e
t
at
t
r
o
u
l
y
ras
s
sc
o
e
d
e
t
ann e r
h
h
m
h
h
h
t
t
p
p
p
g
g
p
in w hi c h D T h o m ps on h t e ate d hi subj e ct —T7 p m G tt
f t h b est if no t t h
W i t h ut an y e xce pti on w e b e l i e ve th i s wo rk t o b
h
b
th
ract
i
ca
l
us
e
u
ln
ess
t
at
i
ssue
d
r
o
m
ress
a
n
y
aut
o
r
i
n
f
h
b st f
f
h
y
y
p
p
l st t y e ars It i s parti cul arly useful b ecaus e i t su ppl i es a v acan cy i n t h l i b rary
w h i c h e ery ph y si ci a n fi nd s w h e n ev er h h a c se t o treat and w h ere d iet o ccupies
It i s c o m pl ete i n
a part i n t h tr e at m e n t and t h r e cuperati on f t h pati e n t
ev ery d epartm e n t e ach ch apt e r b e ing a m od e l f c on ci se n e ss d perfectn ess W i th
b oo k l ike th i s at h a nd m n y a d ay s s i ck n ess wi ll b pr ev e n te d b y t h att nd i g
—
nt
d
i
l
C
M
h
y
s
i
c
i
n
ei
n
a
l
e
t
o
rescr
i
b
e
a
r
o
er
d
ie
t
b
b
p p
p
p
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o
o
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e
.
e
,
,
s
e
o
o
r
r
o
u
ua
u
y
e
a
a
s
e
e
,
as
o
e
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as
e
o
an
e
o
on e
or
.
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o
,
a l
o
o
o
ac
r
,
'
r
"
e
a
as
.
r
1 er a
s
aze
e
e on e o
o
,
eu
or
e.
e
e
,
e
an
as
e
en
e
v
,
a
a
APPLE T
ON
AND C
.
e
e
.
.
an
’
”
D
.
o
,
a
,
e
o
e
e
a
as
e
O MPA N Y
ca
,
u rr e
NEW
.
YOR K
.
e
n
ON T H E
A TR E A TIS E
W OM E N
D IS E A S E S OF
BY A L E XA N D E R
J o S KE N E , M D ,
P R O F E SSO R OF GY N E C O L O G Y I N T H E L ON G I S L A N D C O LL E G E H O S P I TA L B R OO K LYN
F O RM E RLY P R O F E SSO R OF G Y N E C O L O G Y I N T H E N E W Y O RK P OS T G RAD U A T E
M E D I C AL S CH OO L A N D H OSP IT A L E T C
.
.
.
.
.
,
N
,
.
Y
;
.
-
,
t
8 v o , 9 9 1 pa g e s
W it h 2 9 0 F in e
o o d E n g r a v in g s , a n d N in e Oh r o m o lit h o g r a ph s ,
p r e p ar e d e s p e c ia l l y fo r t h is w o r k
r e v is e d a n d e n l a r g e d .
Th ird E d i io n ,
W
.
.
.
ON L Y
S OL D
c e
i
c e
e i
i
e
ie e
e e
cii
ee he
B Y
S UB S CR IP TI ON
uc
ee
.
T H IS attra t iv w o rk s t h e o t o m e an d re pr s n t s t h e e x e rie nc e o f a
h as
lo n g an d a tiv pro f ss o n al l f , t h e gr at r part o f w
e n s p n t in
It 1 8 s p ally ad apt d t o m t t h e
t h e t r at m n t o f t h e d s as s o f w o m n
w an ts o f t h e g n ral pra t t o n r, b y n ab l ng h im t o r ogn z t s lass o f
d s as s as h e m t s t m in v ry d ay pra t e an d t o tr at t m s
ss
full y
t at t y are d s ss d in t ir
Th e arran g m n t o f s b j t s s s
s are m o re asily o m pr n d d an d r m m b r d b y
n at ral o rd r, an d t
e
ie e
.
e e
e
e
e
e
e e
u ec
i
e
e e
e
e
ee
ec i e hi c
e he ucce
e eci
.
i
hich
c ic
uch h
he
c
ehe e
i cu e
he
e e ee
u
e
hu
t he s t u d e n t
M e t h d s o f o pe rat i o n h a e b ee n m uch s i m pl i fi e d b y t h e au th o r in hi s
h
nde
b
c
t
ice
n
i
t
as
b
ee
n
hi
s
e
t
o
so
d
e
s
c
i
e
t
he
o
e
a
t
i
e
ro
ce
d
u
r
e
s
d
a
p
p
p
a d o pt e d b y h im e e n t o t hei m i n u t e s t d e t ai ls as t o m ak e hi s t re at i s e a prac
t ic l gui d e t t h e gyn ec olo gi s t
W hi l e att e n t i o n h as b ee n gi v e n t o t h e s u rgic l t e t m e n t o f t h e d i s e as e s
o f w o m e n an d m n y o f t h e o pe at i o n s so s i m pl i fi e d as t o b ri n g t he m w i t hi n
t h e c apab i l i t ie s o f t h e ge n e l s u g e n d u e re gard h as als o be e n pai d t o t h e
m e d ic al m an ag e m e n t f t hi s c lass o f d i s e as e s
A lt h o u gh all t h e s u b j ec t s w hich a e d i s cu ss e d in t h e v ari o u s t e t b o o k s
e b ee n t e at e d b y t h e au t h o r it h s b ee n
o m in e n t
o n gy n ec o l gy h
e b u t in c id e n t a 1y o r n o t
fe at u e in hi s plan t o c o n s i d e r als o t h o s e w hich
b
u
at all m e n t i o n e d in t h e t e t b o k s hi t he rt
p li s he d an d ye t w hich a e
c o nstant ly pre s e nt i ng t h e m s elve s to t h e prac t i t i o n e r fo r d i agno sis and t re at
m ent
Th i s work w as writ
I t h preface f t h first e d iti on f th is work t h auth o r st tes
ten f t h purpose f b inging to eth er t h fully m atured d essential facts in t h science
requirem ents f t h stud ent f m ed icine
d art f gynec olo gy s o arrange as t o m e t t h
reference T h d em and f a second ed iti on h
d b c onveni e nt to t h practi ti oner f
b een acc om pl i sh e d
T h read er can no t fail to
d em onstrate d h w f ll y t h i s pur po se h
c om m end t h conservatism d h onesty f t h auth or s opini ons d th care w ith w h ich
b een c ollecte d
t h m ateri al h
d arra ged
Th sec on d e d iti on c ont in s n ew ch apters on
d In j uri es f t h Ureters
d V e i cal H ern ia
T h first f
E cto pi c G estati on D i seases
t h ese sub j ects receives in th i s ed ition a careful expositi on t h w ant f wh ich w as am ong
f th
T h auth o r s work i n t h po s i ti on al d i s ord er
t h f w d efects f t h fo rm er ed i ti on
uterus d l aceration f t h perin eum sta d s p em inent am ong t h c ontrib uti ons to th i s
sub j ect H i d isc ssi on f t h use f pessaries th rows m uch ligh t upon a sub eet wh ich h
suffered from t h want f caref l t eatm ent b th p
b i h
d eserv e
d
Th
—
f
h
l
d
reat
cre
i
t
t
i
l
strat
i
on
s
d
e
n
era
l
st
y
l
e
h
wo
r
k
f
t
M di
N w
g
g
W h ave very l ittl e t o d d to wh at w e said f i t on its first appearan ce
d w e sti ll
Th
gard i t as on e f t h f w fo re m o st b oo k s i t h i s d epa tm en t in t h E ngli sh l anguage
ad d iti on f ch apters on D i seases d Inj ries f t h Ureters d on E t p G estati on
m ak e i t m o re c o m pl ete
T oo m uch i can not b given to t h illustrati ons w h i ch are
m o d el s f cl earn ess
d as i s no t p
w ay s t h case s h ow w h at i s m eant —B t n M d i l
.
o
ra
v
,
av o r
,
v
,
r
r
v
,
o
a
r
.
a
a
,
r a
r
ra
r
o
,
o
.
r
av
o
x
r
a
,
a
r
ar
r
x
,
o
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-
,
o
r
,
.
n
o
e
or
an
e
o
e
e
e
o
’
an
n
an
,
,
o
o
e
e
e
,
an
s
an
o
o
e
or
e
re
u
e
r
,
e
an
S urgical Journal
D
.
n
e
.
e
.
c
as
r
u
o
a
s.
an
A ND
e
,
e
.
,
O
Y
,
NEW
e
c O ie
an
”
C M PA N
re
.
,
,
os 0
.
A P P L E TON
e rs
e
e
e
s
e
,
ra se
,
con
”
e
n
.
,
ro an
o
an
e
e
-
o
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o
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an
u
a
o
o
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and
n
a
o
‘
u
s
.
e
e
.
e
’
e
.
e
a
,
e
as
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e
.
,
e
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or
.
o
an
as
e
e
.
as
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e
or
u
o
:
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e
,
e
a
e
r
o
an
o
Y OR K
.
e
ca
ON
T R E A T IS E
A
D IS E A S E S OF T H E
TH E
SY S TE M
N E R V OU S
W IL L IA M
BY
S
urgeon
A
H A M M ON D , M D
.
.
Ge ne ral U S
.
W ITH
TH E
GR A E ME
M
A rm y ( re tire d list )
.
COL L A B OR A TION
,
.
OF
MM ON D M
HA
.
.
.
,
.
D
,
.
P rofessor of D iseases of th e M ind and N e rvous S yste m in the N ew York
P ost Grad uate M e d ical S chool an d H ospital , e tc
.
W I TH
1 1 8 IL L U S TR A T
IO
N S
.
N I N T H E D IT IO N , W IT H C O R R E C T IO N S A N D A D D IT IO N S
8 v o , 9 3 2 pa g e s
Cl o t h .
.
.
sh e e p .
a ond s reatise n the D i seases f t h N e rv ou s S ys tem is w rk
w hi
ee
a ili ar t o t h p fess i on and h ttai n e d great r eputati n
am ong t h stand ard b ook s f re fe re n ce I t h preparati on f t h pres en t e di tion
l i s m ad e us e
A v st m o u n t f c li n i cal m t
t h auth o r h
b ee n ai de d b y hi s on
f a nd t h
results f p im t l i n ve stigation eco r ded T h b ook i s w i tte n i n
a cl ear and l as i ng styl e d ob scu re c ndi ti on s d eal t w i th i n a m ann e r w h i ch
w i ll pro ve Opgreat ass i tan ce in t h study f th i s m st in te re sti ng cl ss f di s e as e s
T
Dr H mm
n l on g f m
c h h as b
"
’
‘
o
.
e
e
o
eX
e
r act it io n e r
a
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a en a
o
r
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o
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o
a
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a
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s
Can adia n P
n
.
az
,
as
en a
er
e
,
.
s
as
e
,
ro
or
e
o
o
’
r
e
.
are
o
o
a
”
o
.
.
a ond pub li s h e d t h fi rst e d i t i on f h i T reat i s e n the D isease f t h
N er v o us y st e
i n 1 871 It h t he refo re b e e n b e fore t h professi on f tw e nt y
y ears
d uri n t h e s y e ars i t h c on ti n ue d t o gr w i n bli fav o r t h i s b e i ng
n i nt e d i i n t h at h b ee n issue d A ppreci ati on f t i s wo rk h n t onl y
th
b ee n s
wn i n t i s co u nt b ut ab ro a d as t h b een tran sl ate d int t h Fren c h
t h I tal i a n a nd t h S p i
l an gu age s T h prese n t e diti on h b ee n t h o ro ughl y
r evi se d and se v eral n e w ch apt e rs a dd e d T h is a b oo k f such great v al ue and
i s re ferre d t o s o frequ e ntly by” t h m e di cal ress n d t h er m ed i cal w rk s t h at n
—
li
m
h
l
i
s
c
o
l
e
t
e
w
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S ec ond e d i ti n th o ro u gh ly r evi se d a nd s o m e w h at e nl arge d
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m att e s as w e l re nd ere d n ecessary a t h o r o u gh re vi s i on f t h wo rk pu b l i s h e d s o m e
y ears g as t h j o i n t prod uct ion f D V n B e n a nd Key es M uc h f t h wo rk
h b e e n re w r i tte n e n ti re l y T h ere i s a l arge am o u n t f e n ti rely n e w m atter p
s en te d in t h i v ol u m e to m ake r oom f w h i c h t h reports f cases giv e n in t h
Th
w o rk i n i ts pr ese n t fo rm sta d s f i l
fo r m er wo rk are a ll o m i tte d in t h i s
a b reast f t h l atest a d v an ces i n ge nito uri n ary sur ery D Key es says f th b
t h at i t i s a n h on e st ex hi b i t f h vi e w s u pon l t h subj ects c on si d e red and i n
d s k ill w e c o m m e nd h i b o k t o t h
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n ece s ary by t h v st progress wh i ch h m ark e d t h h i sto ry f surgery d u i g t h
l ast te n y ears espe i ally i n t h fie ld f t h e rapeutics n d Oper tiv e pro c d ures T o
f lit h l r y
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f t h tu ni ca v agi n a l i s a nd t h m an y m i so r c h ges w h i c h fi nd x pres i on
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b l n w m atter a nd lar ge l y t m d i fy m uc h f t h rem i nd er
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