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FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS, LONDON PROFESSOR OF MEDICINE, JOHNS HOPKINS UNIVERSITY, BALTIMORE AUTHOR OF A PRACTICE OF MEDICINE LECTURES ON THE DIAGNOSIS OF ABDOMINAL TUMORS, ETC. NEW YORK D. APPLETON AND COMPANY 1897 i Y^ rC 07 X X ■A Copyright, 1896, 1897, Br D. APPLETON AND COMPANY. I i • t ^ •if ^ ^ TO W. T. GAIPDNER, M.D., F.R.S., REGIUS PROFESSOR OF MEDICINE IN THE UNIVERSITY OF GLASGOW. Dear Dr. Oairdner : Please accept the dedication of this little volume in token of the appreciation which your cis-atlantic brethren feel of the value of yout life and work in our profession. Sincerely yours, William Osler, NOTE. These lectures were delivered to the graduate class in medicine at the Johns Hopkins Hospital, and appeared in The Neil) York Medical Journal, 1896, vol. Ixiv. They are here republished with slight additions and corrections. * I ■It CONTENTS. LECTURE I. History of the recognition of angina.-Heberden. Rougnon. Morgagni. -Literature.-Deflnition.-Form3 of heart pain.-Classification of the forms of angina.-Physiology and pathology of the coro- nary arteries LECTURE n. • ANGWA PECTOftIS VERA. AETIOLOGY. GENEBAL DESCRIPTION OF THE DISEASE. Incidence of the disease.-Station in life.-Ses.-Age.-Epidemic in- fluences.- Heredity. - Gout. - Diabetes. - Syphihs. - Specific fe- vers.— Heart disease.— Locomotor ataxia.— General picture of the disease LECTURE in. ANGINA PECTORIS VERA. PHENOMENA OF THE ATTACK. Exciting causes.— Symptoms.— State of heart and pulse.— Pericarditis. —Respiratory features.— Gastro - intestinal symptoms.— Nervous and psychical symptoma LECTURE IV. ALLIED AND ASSOCIATED CONDITIONS. I. Syncope anginosa.— II. The Adams-Stokes syndrome.— HI. Angina sine dolore.— IV. Cardiac asthma LECTURE V. PSEUDO-ANGINA PECTORIS. I. Neurotic group : (a) Hysterical and neurasthenic cases ; (b) Angina pectoria vaso-motoria; (c) Reflex angina.— 11. Toxic angina: forms of heart pain from tobacco PAQB 20 45 67 86 ^ CONTENTS. LECTURE VI. THEORIES OF ANGINA. p^^g The importance of coronary artery disease.— Intermittent claudication. —State of the heart muscle in an attack.— Seat and cause of the pain.— Vaso-motor changes in angina.— Relations of spurious and true angina HI LECTURE VII. DIAGNOSIS, PROGNOSIS, AND TREATMENT OF ANGINA. Anomalous cases of heart pain.— Elements in the diagnosis of true angina.— Differentiation of true and pseudo angina. — Prognosis. —Treatment of angina pectoris vera.— Treatment of false angina. — Conclusion 131 APPENDIX. Note A. — Rougnon's " 157 " B.— The case 0* 'atthew Arnold 158 " C— Retention < J consciousness after apparent cessation of heart's action 160 f OK ,11 31 [57 [58 L60 But wel I woot thou doost my herfe to erme That I almost have ^xnght a cardiacle. The wordes of the Host to the Phisicien and the Pardoner.— Chaucer. ^ LECTURES ON ANGINA PECTORIS AND ALLIED STATES. LECTURE I. History of the recognition of angina.— Eeberden, Rougnon, Morgagni.—Lit- eraturo. —Definition.— Forms of iieart pain.— Classification of the forma of angina. — Pliysiology and pathology of the coronary arteries. The history of the recognition of the disorder known as an- gina pectoris is connected with the names of three celebrated men — Ileberden, Jenner, and John Hunter. On July 21, 17G8, Ileberden read, at the Royal College of Physicians, a paper entitled Some Account of a Disorder of the Breast, which was published in vol. ii of the Medical TranS' actions of the College of Physicians, 1772. An extract from the original description must be quoted: " There is a dis- order of the breast, marked with strong and peculiar symp- toms, considerable for the kind of danger belonging to it. . . . The seat of it and sense of strangling and anxiety with which it is attended may make it not improperly be called angina pectoris. " Those who are afflicted with it are seized while they are walking, and more particularly when they walk soon after eat- ing, with a painful and most disagreeable sensation in the breast, which seems as if it would take their life away if it were to increase or to continue; the moment they stand still all this uneasiness vanishes. In all other respects the patiei/s are at the beginning of this disorder perfectly well^ and, in particu- ANGINA PECTORIS AND ALLIED STATES. ' II lar, have no shortness of breath, from which it is totally dif- ferent." Subsequently, in the celebrated Commentaries upon which our grandfathers in the profession were educated, lleberden gave a fuller account of his experience with the disease. The name which he adopted can not be regarded as altogether sat- isfactory, since it was already in use in designating aifectiong of the threat, with which its literal meaning — a strangling — is much more in harmony. In one sense, however, the term is fairly appropriate, since, as noted by Gairdner, the words anx- iety and anguish, expressive of two of the most prominent fea- tures of the disease, have a derivation from the same Greek word as angina. In 1773, John Hunter had his first attack, wliich was graphically described by his nephew, Everard Home: " While he was walking about the room he cast his eyes on the looking- glass, and observed his countenance to be pale, his lips white, giving the appearance of a dead man. This alarmed him and led him to feel for his pulse, but he found none in either arm; the pain continued, and he found himself at times not breath- ing. Being afraid of death soon taking place if he did not breathe, he produced the voluntary act of breathing by work- ing his lungs by the power of the will." In 1776 he had a second attack, and when convalescent he visited Bath. Here he was seen by his friend and pupil, Edward Jenner, of Berke- ley; and one of the most interesting and sagacious letters of that distinguished man was written to Heberden, giving his diagnosis of John Hunter's case, and suggesting, for the first time, the probable association of disease of the coronary arteries with angina pectoris. The letter is worth quoting in full: * " When you are acquainted with my motives, I • Baron's Life of Jenner, London, 1827. •■1 HISTORY OF THE RECOGNITION OP ANGINA. 3 presume you will pardon the liberty I take in addressing you. I am prompted to it from a knowledge of the mutual regard that subsists between you and my worthy friend Mr. Hunter. "When I had the pleasure of seeing him at Bath last autumn I thought he was affected with many symptoms of the angina pectoris. The dissections (as far as I have seen) of those who have died of it throw but little light upon the subject. Though, in the course of my practice, I have seen many fall victims to this dreadful disease, yet I have only had two op- portunities of an examination after death. In the first of these I found no material disease of the heart, except that the coronary artery appe. red thickened. " As no notice had been taken of such a circumstance by anybody who had written on the subject, I concluded that we must still seek for other causes as productive of the disease; but, about three weeks ago, Mr. Paytherus, a surgeon at Ross, in Herefordshire, desired me to examine with him. the heart of a person who had died of the angina pectoris a few days before. Here we found the same appearance of the coronary arteries as in the former case. But what I had taken to be an ossification of the vessel itself, Mr. P. discovered to be a kind of firm, fleshy tube, formed within the vessel, with a considerable quantity of ossific matter dispersed i^^-regularly through it. This tube did not appear to have any vascular connection with the coats of the artery, but seemed to lie merely in simple contact with it. " As the heart, 1 believe, in every subject that has died of the angina pectoris, has been found extremely loaded with fat, and as these vessels lie quite concealed in that substance, is it possible this appearance may have been overlooked? The importance of the coronaries, and how much the heart must suffer from their not being able duly to perform their func- tions (we can not be surprised at the painful spasms), is a AS 4 ANGINA PECTORIS AND ALLIED STATES. subject I need not enlarge upon, therefore shall just remark that it is possible that all the symptoms may arise from this one circumstance. " As I frequently write to Mr. H. I have been some time in hesitation respecting the propriety of communicating the matter to him, and should be exceedingly thankful to you, sir, for your advice upon the subject. Should it be admitted that this is the cause of the disease, I fear the medical world may seek in vain for a remedy, and I am fearful (if Mr. Hunter should admit this to be the cause of the disease) that it may deprive him of the hopes of a recovery." In another letter * Jenner gives as his reasons for not pub- lishing his views earlier an anxiety lest they should be a source of annoyance to his friend Hunter. " Soon after Mr. Paythe- rus met with a case. Previous to our examination of the body I offered him a wager that we should find the coronary arteries ossified. This, however, proved not to be exactly true; but the coats of the arteries were hard. ... At this time my valued friend, Mr. John Hunter, began to have the symptoms of angina pectoris too strongly marked upon him; and this circumstance prevented any publication of my ideas on the subject, as it must have brought on an unpleasant conference between Mr. Hunter and me." He says that Mr. Cline and Mr. Home did not tiiink much of his views. " AVhen, how- ever, Mr. Hunter died, Mr. Home very candidly wrote to me, immediately after the dissection, to tell me I was right." The further details of Hunter's remarkable case are always referred to. From 1785, when he had a severe illness, the at- tacks became increasingly frequent, and were brought on par- ticularly by exercise and by worry and anger; and, indeed, he was accustomed to say " that his life was in the hands of any * Parry. An Inquiry into the Symptoms and Causes of the Syncope Anginosa, commonly called Angina Pectoris, 1799. «*« HISTORY OF THE KEOOGNITION OP ANGINA. 6 rascal who chose to annoy and tease him." During the last few years of his life, though he did a large amount of work, the attacks seem to have been very frequent, and would come on aftcH* very slight exertion and while he was operating. As he had himself predicted, death came suddenly, in conse- quence of a fit of temper at a meeting of the governors of St. George's Hospital, October 16, 1793. "When contradicted flatly, he left the board room in silent rage, and in the next room gave a deep groan and fell down dead. The coronary arteries were found to be converted into open bony tubes, and the aorta was dilated. Attempts have been made by French writers to claim the priority in the description of the disease for Rougnon, pro- fessor of medicine in the University of Besangon. In a letter addressed to M. Lorry, dated February 23, 1768,* he describes the case and circumstances of the death of a Captain Charles. The patient had become asthmatic, and on walking fast had a sort of suffocation. Six weeks before his death he had com- plained to M. Rougnon of " une gene singuUere sur toute le partie anUrieure de lapoitrine en forme depladrcm?'^ The attacks evidently occurred with great suddenness, and disap- peared with equal abruptness. The chief stress is laid upon the feeling of suffocation, but it is evident that associated with it there was pain of great intensity; "seulement une douleur gravative dans la region du cosur, lorsquHl eprouvoit ses suf. focations^'' Captain Charles died very suddenly, shortly after dining with his friends. The pericardium was fatty; the heart was large ; there were no valvular defects; the coronary veins were enlarged " prodigiously " ; no mention was made of the condition of the coronary arteries. Rougnon lays stress upon the obstruction in the lungs and excessive ossification of • Ltttn d Jf. Lorry sur une maladie nouvelle. Besan9on, 1768. 6 ANGINA PECTORIS AND ALLIED STATES. the cartilages. He confesses, however, that the condition was very puzzling, and the autopsy not at all satisfactory to his friends: "Jf. Charles est mort, disoient-iUy parce quHl est mortP I can not agree with Professor Gairdner, who says that " there was no trace of anything like a clinical description of angina pectoris in M. Rougnon's letter." * The suddenness of the attacks, the pain in the region of the heart, the abrupt termination, and the mode of death — during exertion after a full meal — favor the view that the case was one of true an- gina. (Xote A.) To Morgagni, not Rougnon, is due the credit of the first description of a single case. Ir the splendid section on aneu- rysm of the aorta, he describes angina pectoris accurately in Case V, referring to the paroxysms, the pain, the difficulty of breathing, the numbness of the left arm, and the effect of exer- tion. I read you here extracts from the case. "A lady, forty-two years of age, who for a long time had been a valetudinarian, and within the same period, on using pretty quick exercise of body, she was subject to attacks of vio- lent anguish in the upper part of the chest on the left side, ac- companied with a difficulty of breathing and numbness of the left arm; but these paroxysms soon subsided when she ceased from exertion. In these circumstances, but with cheerfulness of mind, she undertook a journey fron; Venice, purposing to travel along the continent, when she was seized with a parox- ysm, and died on the spot. I examined the body on the follow- ing day. . . . The e'^rta was considerably dilated at its curva- ture; and, in places through its whole tract, the inner surface was unequal and ossified. These appearances were propagated into the arteria innominata. The aortic valves were indurated." He remarks: "The delay of blood in the aorta, in the heart, in the pulmonary vessels, and in the vena cava, would occasion * Lancd, 1891, i, p. 604. HISTORY OF THE RECOGNITION OP ANGINA. 7 the symptoms of which the woman complained during life; namely, the violent uneasiness, the difficulty of breathing, and the numbness of the arm." — (Cooke's Morgagni.) There are those, indeed, who regard Seneca as the first to describe the affection, in the remarkable account which he gives of his own disorder. "With this view Forbes and Gaird- ner agree, but Parry and Stokes do not. I quote from Parry the following translation of part of Seneca's graphic account: " The attack is very short and like a storm. It usually ends within an hour. I have undergone all bodily infirmities and dangers; but none appears to me more grievous. Why not? Because to have any other malady is only to be sick; to have this is to be dying." Seneca states, too, that his physicians called the disease a meditatio mortis. The literature of angina pectoris has become very volumi- nous. English writers have contributed most largely to the clinical description of the disease. Perhaps the two most valuable articles are lectures xxxvii and xxxviii in Latham's Clinical Medicine^ which you will find in vol. i of the New Sydenham Society edition of his works; and Professor Gaird- ner's essay in Reynolds' System of Medicine. The best recent expositions in French and German are to be found in IIu- chard's T '*'e clinique des maladies du cceiir, second edition, 1893, which gives a most exhaustive account of the various forms of angina, and O. Rosenbach's Die Kra/nhheiten des HerzenSy 1896. I pass about for your inspection a number of the monographs and journal articles which I have collected on the subject. Parry's essay has become very scarce, but it is in all the larger medical libraries. Rougnon's Lettre, pub- lished at Besangon, 1768, is still more rare. The copy in the Surgeon-General's Library is the only one I have ever seen. I would ask you to look at the first part at least of these fly leaves, which I picked up in an old book shop a few years ago. 8 ANGINA PECTORIS AND ALLIED STATES. It is a letter to Dr. Ileberden from a man who signs himself " Unknown," descriptive of his own ease. He had seen, in the Critical Review^ an extract from Ileberden's original paper, and, recognizing his malady, he wrote in this letter one of the very best accounts which exists in the literature. It is particularly noticeable for two things: He clearly dissociated the pain of the attack from the angor or mental feature, and he first made use of the now hackneyed phrase describing the latter aspect as " an universal pause within me of the opera- tions of K'ature." Expecting a sudden death, he left orders that Ileberden should examine his body. Within three weeks from the writing of the letter the dissection was made by Jolin Hunter. DsFixiTiox. — In the consideration of a disease it is well, if possible, to start with a clear understanding, or at least some concise statement, of its nature, and of the characters of the manifestations by which it is recognized. AVitli some disorders this is a very easy matter. For example, insufficiency of the aortic valves is a clearly defined affection, with, it is true, a diverse aetiology, a varied anatomical picture (from a trifling curl of the edges of a valve, to a clean shaving of a segment from the aortic ring) ; but with all its variations there are asso- ciated definite sequences and well-characterized signs. Angina pectoris is not a disease, but a syndrome or symp- tom group (without constant aetiological or anatomical founda- tions) associated with complex conditions, organic or func- tional, of the heart and aorta. Pain about the heart of an agonizing character, occurring in paroxysms, is the dominant feature of all varieties of the syndrome. Used to define paroxysmal attacks of pain in the chest — breast-pang — we em- ploy the term generically, qualifying the varieties by such names as true, false, hysterical, and voso-motor. '"\ HEART PAIN. 9 Before passing to the diacussion of the varieties of angina pectoris let me refer briefly to the subject of Heart Pain. — Disturbance of sensation is a most incon- stant symptom of heart disease; the gravest affections are often painless; the most trifling may present the features of an intense neuralgia; while a very limited lesion may have as its sole manifestation paroxysms of agonizing pain. The following abnormal cardiac sensations may be recog- nized : 1. Consciousness of the heart's action; a fluttering, a sense of goneness, the indefinable uneasiness associated with palpita- tion, a sense of tension in the chest with gasping, all or some of which are common phenomena in emotional states, in indi- gestion, neurasthenia, and hysteria. 2. Pain — darting, stabbing, tearing or boring, dull and heavy, or acute and piercing, steady or paroxysmal — varying in grades of intensity and in duration, often transient and trifling, as in dyspepsia and the tobacco habit, more enduring and severe in hysteria and neurasthenia, and occurring in paroxysms of an agonizing, intolerable character in the forms of angina. It often radiates over the area of distribution of certain of the cervical and dorsal nerves. 3. There is an element peculiar to certain conditions of the heart, often associated with, but which can not itself be prop- erly characterized as pain — indeed, the patient often expressly states that it is not of the nature of physical pain — a sense of imminent dissolution, a mental anguish, which has been vari- ously expressed by patients and writers as a pause in the opera- tions of ^Nature, the very hand of death, angor ammi, etc. This it is which constitutes the special feature in a majority of the cases of true angina. Classification of the Forms of Angina Pectoris. — ^It may seem a refinement to subdivide and sort cases of a disorder a r 10 ANGINA PECTORIS AND ALLIED STATES. which is acknowledged to be only a symptom, or, as it has been expressed, a ncurosal incident of cardio-vascular disease; but there are practical advantages which far outweigh any theo- retical objections — advantages of the very greatest moment in prognosis and in treatment. Following the work of Ileberden, Parry, and others, there were cases reported as angina which did not belong properly to that category, and the disorder was confounded with cardiac asthma, wiiich we now term cardiac dyspnoea. As early as 1812 J. Latham read a paper on certain symptoms usually but not always denoting angina pectoris {Medical Transactions, Royal College of Physicians). He remarks that when the ex- tremities are cold, tho countenance is bluish or purplish, the pulse is rapid, and respiration is performed with difficulty and in an upright position of the body, the practitioner has usually concluded that the disease is angina pectoris. The class of cases which he described were evidently orthopncea and car- diac dyspnoea, associated chiefly with affections of the abdo- men. He calls the state angina notha, spurious angina, the first time, so far as I am aware, that the term was used in literature. Laennec recognized different degrees of intensity in an- gina, stating that it was " far from possessing the degree of severity attributed to it by many authors," and was evidently aware that it occurred commonly enough without indicating any serious disease of the heart or large vessels. " Angina pectoris, in a slight or middling degree, is extremely common, and exists very frequently in persons who have no organic affection of the heart or large vessels." * By far the most important contribution to the recognition of varieties of angina pectoris was made by Walshe, who, in ■Is ■■"A: I I ♦ Forbes's edition of Laennec, fourth edition, p. 650. L I FORMS OF ANGINA PECTORIS. 11 his text-book on Diseases of the Hearty described a pseudo- angina pectoris, occurring particularly in women, and in the subjects of hysteria, spinal irritation, and various forms of neuralgia. The recognition by Beau, Graves, Stokes, and others of the relation between the abuse of tobacco and attacks of angina led to the separation of the important group of toxic cases. Other forms of pseudo-angina which are described are those depend- ent upon reflex causes, and the vaso-motor type of Xothnagel. In any long series, the cases of angina fall into two groups: those in which there are signs of lesion of the heart or arteries, or of both, and those in which all symptoms of organic disease are absent. This was the important division recognized by Forbes into organic and functional angina — the angina pec- toris vera and the angina pectoris notha — the true and the pseudo-angina. In looking over the cases which form the basis of these lec- tures, I find that they fall into the following groups: (1) An- gina pectoris vera, and (2) angina pectoris notha, under which are grouped hysterical, vasomotor, and toxic forms. The Coronary Arteries. — A few essential points in the anatomy and physiology of the heart may here engage our at- tention for a few minutes. The coronary arteries are the Abana and Pharpar of the vascular rivers, " lucid streams," which water the very citadel of life. By means of these in- jected specimens, which I pass around, you may refresh your memories on their distribution. The arteries are, as you see, large in proportion to the size of the organ to be nourished. From the position of their origin it is evident that they must be subject to blood pressure during both systole and diastole. The left coronary is usually the larger, and divides into two main branches: the circumflex or posterior, which runs in the groove between the left ventricle and auricle, and the anterior la ANGINA PECTORIS AND ALLIED STATES. or descending ramus. Note particularly the branches of the latter vessel, which runs in the anterior interventricular groove. You will see a very large branch, which is given off to the anterior wall of the left ventricle, and several branches which pass deeply into the septum. This anterior branch is the important one in the morbid anatomy of the coronary arteries, since it is by far the most frequently found the seat of extensive sclerosis or of embolism or thrombosis. It may be called the artery of sudden death. From the date of Sir John Eric Erichsen's observations on the subject (1842) to the present the effects of closure of the coronary arteries have been much discussed. A very good his- torical summary is given by W. T. Porter in the Journal of Physiology, vol xv, 1893. It is remarkable how discordant are the statements of different observers. As this author remarks, seldom have the results of physiological studies been more at variance; there is no statement which is not denied, no fact which is not disputed. More recently Porter has again gone over the whole question with a great deal of skill, and I will give you here some of his conclusions.* The frequency of the stoppage of the heart's action is in proportion to the size of the artery tied. Ligation of the small- est artery, the arteria scpti, does not cause arrest; of the next in size, the coronaria dextra, fourteen per cent, of the ligations were followed by arrest; then comes the larger descendens wiih twenty-eight per cent. ; and, finally, the circumflex, the largest artery of all, with sixty-four per cent. The effect of closure of the coronary arteries on the blood pressure within the heart is of great importance. After the tying of a single vessel there is a diastolic rise of pressure, which is not compensated for by any increase of pressure in ♦ Journal of Experimental Medicine, vol. i, No. 1, 1896. A THE CORONARY ARTERIES. 13 the coronary arteries; on the contrary, in them the pressure is falling, while that in the auricles is rising. It is known that the normal mean pressure in the auricles, and consequently in the coronary veins near their mouths, is very low. A rise of a few millimetres of auricular pressure might interrupt the entire coronary circulation. This is one of the most impor- tant points brought out by Porter's researches, and I quote here a paragraph on this point: " It must be acknowledged, then, that a rising auricular pressure after ligation may at length put a stop to the whole blood supply of the cardiac mus- cle, and, as this rise is often occasioned by the closure of a single vessel, it is plain that the entire coronary circulation can, in fact, be interrupted by the ligation of one coronary artery." It has been much debated whether the coronary arteries are really temiinal or end arteries. Anatomically, it may be shown that they are not, since an injection liquid can be made to pass from one artery through communicating branches into the other. All are agreed, however, that the anastomosis is not sufficient to permit collateral circulation to keep a vascular area alive after the distributing artery is blocked. The effect of plugging of the artery is the production of what is known as an anaemic infarct, a well-recognized pathological condition, the consideration of which need not detain us. A very impor- tant matter relates to the effect of plugging of the coronary arteries upon the heart-beat; the contractions become of the type known as fibrillary, and it is difficult or impossible to get the organ to resume the ordinary co-ordinated beats, though experimentally this has been done, even after fibrillary con- traction has been established. The relation of coronary-artery disease to angina pectoris, which was suggested by Jenner, has directed the very particu- lar attention of writers to the changes in these vessels. It does 14 ANGINA PECTORIS AND ALLIED STATES. one good to look over tlie older literature, and to note the ac- curacy with which sonic of the cases have been recorded, par- ticularly by Morgagni. Parry, too, gives an interesting series from the older writers. The subject is so extensive that I can not enter upon it here in great detail, but I may, perhaps, bring it before you with sutHcient emphai5is if I speak of the common sequences in connection with illustrative cases. The coroniuy arteries are very subject to degenerative changes, particularly in persons who have passed the middle period of life. They may l)e affected alone or as part of a wide- spread disease of the vessels. For practical purposes we need not consider any other change than arterio-sclerosis in its vari- ous grades, from a trifling thickening to atheroma and rigid calcification. We must, however, recognize an affection of the orifices of the ai'teries, apart from the common degeneration of the trunks. A gradual narrowing of the orifice of a vessel may be quite as serious as extensive disease of the branches. There is a form of aortitis met with not infrequently in men between the ages of thirty and forty, who have had syphilis and who have worked hard and drank deep {devotees of Venus, Bacchus, and Vulcan), in which the intima is swollen, almost corrugated, with fresh translucent areas of endarteritis. I skip all considerations of its anatomy. Three serious se- quences may follow: {a) Rupture of the aorta, sometimes only of the intima, as clean cut as with a razor, in half or a third of the circumference, sometimes with the formation of a dissecting aneurysm; {h) the slow development of the ordi- nary form of aneurysm of the arch ; and {c) narrowing of the orifices of the coronary arteries. Angina attacks, sudden death, and slowly developing myocarditis and its sequences are the possibilities in this third category. I pass around this fine plate of Corrigan's, taken from the Dnhlin Journal^ in which you see great swelling of the intima above the valves, due, as % V M '**t'(i THE CORONA IIY ARTERIES. 15 Corrigan expressed it, " to an eflfusion of organized lymph be- tween the lining niemlinnic and the fibrous coat." The pa- tient in this case, a man only thirty-nine years of age, suffered with severe attacks of angina. Let me illustrate by these specimens some of the more com- mon pathological conditions associated with disease of the branches of the artery. Here is an extraordinary heart, which illustrates how much of the coronary circulation can be cut off if the obstruction takes place gradually. The organ was taken from a man aged about thirty-six or thirty-seven, who had been an inmate for eighteen years of the lastitution for Feeble-minded Children at Elwyn, Pa. He was a large, powerful imbecile, dumb but not deaf. He was very good tempered, did a great deal of work about the farm, and fre- quently did very heavy lifting. He never had epilepsy; he was not known to be short of breath, nor had he complained or indicated in any way that he was out of health. One after^ioon he had a sort of fit, the face became very much con- gested, and he died in about half an hour. There was nothing special found in the brain. The heart, as you see, is large, and weighed twenty ounces. There was general hypertrophy with dilatation. There was quite extensive fibroid myocarditis, particularly in the anterior wall of the left ventricle, at the apex, and in the lower portion of the septum ventriculonim ; the valves were normal. But what I wish you to examine most particularly is the state of the coronary arteries, which are freely dissected out. The left vessel is almost obliterated, only a pin-point channel remaining, while of the right artery the main division passing between the auricle and ventricle is converted into a fibroid cord ! It is much more common to find one artery extensively dis- eased, or even completely obliterated. Take, lor example, this specimen, which was removed from a colored man, aged about fc i k I 4 IQ ANGINA PECTORIS AND ALLIED STATES. thirty-five, who had aortic insufficiency, with dyspnoea and oedema of the legs. He died suddenly, though he had for some weeks great dilatation of the heart and general anasarca. The aortic segments are curled and thickened; the ascending arch is greatly deformed, with a recent general endarteritis. There are a few calcareous plates. The right coronary artery is completely obliterated. There is no opening whatever on the aorta. The left vessel is dilated, and presents atheroma- tous, patches. There are areas of fibrous myocarditis in the left ventricle, but in other respects the muscular substance of the heart does not look abnormal, and it is not fatty. Here is a much more common condition. In this anterior coronary artery you see a firmly adherent thrombus, which completely occludes the descending branch, to the lumen of which it is firmly attached. It was taken from a man about fifty years of age, who had mitral-valve disease and had a good deal of cardiac dyspnoea. Early one morning he was seized with severe pain about the heart and shortness of breath, and died in a very few moments. Both coronary arteries were thickened and calcified, and presented atheromatous plates, but no doubt the sudden death was due to the blocking of the anterior branch of the left coronary artery by the thrombus. AVhen the occlusion has persisted for any length of time before death the condition of anaemic necrosis may be found. I am sorry not to have a fresh specimen to show you, but most of you have, no doubt, seen microscopic, if not macroscopic, examples. It is important in the dissection of the heart to slice carefully the septum and the wall, as these infarcts of the heart muscle are found in numbers directly proportionate to the care with which they are sought. We have not had any very large number of cases. They are much more common, I think, in hospitals with old chronic cases, or with which there are in connection large almshouses, as at the Blockley Hospi- THE CORONARY ARTERIES. 17 icea and had for inasarca. scending arteritis. y artery tever on ;heroma- i the left ;e of the anterior 3, which umen of in about d a good as seized 'ath, and ies were s plates, M ig of the 'onibus. of time e found. but most roscopic, heart to M •ts of the M lonate to had any mmon, I !ch there y Ilospi- tal. I was much impressed at that institution with the num- ber of cases of anaemic infarcts — many more than I saw at the Montreal General Hospital or have seen here. They occur most frequently in the walls of the left ventricle and in the septum, particularly toward the apex. When fresh they stand out beyond the level of the surrounding muscle, and are sometimes very firm, yellowish white, or even quite opaque white in color. With the fresh infarcts there may be old fibroid patches, into which ultimately these areas of anaemic necrosis are transformed. To complete the series, I show you here sections of the de- scending branch of the left coronary artery, which you see is almost completely obliterated by an old, much-altered throm- bus. This case illustrates another sequence of slowly develop- ing coronary artery disease — namely, fibroid myocarditis at the apex, with weakening of the wall, and the gradual forma- tion of aneurysm of the heart. The specimen was taken from the body of a large, powerfully built man whose heart symp- toms developed with great abruptness, and who presented for many months an obscure train of symptoms pointing to serious disease of the myocardium. Autopsies on cases of angina pectoris are not common. The man with a fresh thrombus in the anterior branch of the left coronary artery probably died in a paroxysm of angina, but he had not had previous typical attacks. As I will tell you lateT" '^n, the affection is rare in hospital practice so that we do not have opportunities of making the inspection of the bodies of persons who have died of the disease. And, lastly, a few words on the innervation of the hearty a cardinal point, inasmuch as the very essence of the angina par- oxysm must rest on some profound disturbance in the function of the nerves. The newer methods of investigation have added considerably to our knowledge of the distribution of the in- 18 ANGINA PECTORIS AND ALLIED STATES. trinsic nerves of the organ. Doubtless some of you have seen in the pathological laboratory Dr. Berkeley's wonderful speci- mens illustrating the ultimate terminations of the filaments between and on the fibres.* In looking at them one realizes the truth of the remark of a recent author, that it is difficult to say in which the myocardium is richer, nerve elements or muscle fibres. Everywhere throughout the organ — in the tis- sues beneath the endocardium and pericardium, throughout the muscle substance, and about the blood-vessels — the nerves are in extraordinary profusion. The double nen'e supply you know, from vagus and sympathetic, and the double function, the fonner controlling, checking, and inhibiting, the latter augmenting the force and hastening the fre(piency of the heart-beats. The researches of His junior and Romberg have shown that the ganglion cells of the heart, even those lying in the vagus branches, have the same origin as all other sympa- thetic cells. They differ in protoplasmic appearances and in other %vays from the cells of the spinal ganglia. The rhythmic action of the heart is probably automatic, due to a power in- herent in the muscular fibres, though this point is still in dis- pute. Of the functions of the nerves we know a good deal, of the functions of the ganglia nothing. His and Romberg sug- gest that from them are transmitted to the central nen^ous sys- tem infinitely delicately graded, unconscious imp'ilscs, which regulate the circulation reflexly through the vagus and accel- erator. Of Kronecker's co-ordination centre our knowledge is still very indefinite — indeed, its existence has been called in question. I have seen Kronecker perform the experiment, and certainly when the point in the dog's heart is pricked — it is situated about the lower limit of the upper third of the ven- tricular septum — the organ becomes paralyzed in a state of fibrillary tremor, from which it does not recover. This point * Described in Johna Hopkins Hospital Reports, vol. iv. ,-.# THE CORONARY ARTERIES. 19 is within the area of distribution of the anterior coronary artery, the vessel oftenest found plugged by thrombus or em- bolus in cases of sudden death. Do these cardiac nerves possess other properties? Have they also, with the special function, the endowment of receiv- ing tactile and painful impressions? Certainly the heart is not an organ of very acute sensibility. The most extensive lesions, inflammatory, degenerative, and neoplastic, may not excite a single painful sensation. Pericarditis of the most intense grade, with deep involvement of the myocardium, may give not the slightest indication of its existence. In experimental work, pinching of the heart muscle may excite reflex movements of the muscles of the body. There are a few interesting cases in the human subject in which the heart has been exposed by accident sufficiently to enable it to be grasped or touched. In the well-known, case which Harvey gives * of the young Viscount de Montgomery, in whom Charles I was so much interested, in consequence of a fracture of the ribs on the left side, with excessive suppuration, the heart was exposed, and from Harvey's account was quite insen- sitive: " Nempe, in homine vivente et vegeto, citra ullam offensam, cor sese vibrans, ventriculosque ejus pulsantes vi- deret, as manu tangeret. Factumque est, ut serenissimus Rex, una mecum, cor sensu tactus privatum esse agnoscerejt. Quippe adolescens, nos ipsum tangere (nisi visu, aut cutis ex- terioris sensatione) neutiquam intelligebat." There is one other point of great importance. Sensory- nerve endings have been demonstrated in the arteries by Thoma, and recently Smimow f professes to have demon- strated similar structures in the connective tissues of the heart, he thinks the sensory-nerve beginnings of the depressor nerve. * Exercitatioties de generatione animalium, 1651, p. 311, f Anatomischer Anzeiger, 1895. LECTUKE n. I I I I ANGINA PECTORIS VERA. ETIOLOGY. GENERAL DESCRIPTION OP THE DISEASE. Incidence of the disease.— Station in life.— Sex.— Age.— Epidemic influences. -Heredity.— Gout.— Diabetes.— Syphilis.— Specific fevers.— Heart dis- ease. — Locomotor ataxia. — General picture of the disease. Incidence of the Disease. — As noted long ago by Sir Gilbert Blaine, angina pectoris is a rare affection in hospital practice. Gairdner criticises this statement rather sharply, and yet I think that a majority of hospital physicians would be found to support it. During the ten years in which I lived in Montreal, I did not see a case of the disease either in private practice or at the Montreal General Hospital. At Blockley (Philadelphia Hospital), too, it was an exceedingly rare affec- tion. I do not remember to have had a case under my per- sonal care. There were two cases in my service at the Univer- sity Hospital. During the seven years in which the Johns Hopkins Hospital has been opened, with an unusually large " material " in diseases of the heart and arteries, and with many cases of heart pain of various sorts, there have been only four instances of angina pectoris. You will find the statement in Fagge's Practice (third edition, vol. ii, p. 26) that " the writer has never seen classical angina in hospital practice." On the other hand, an individual consultant may see within a year more cases than occur in all the hospitals of his town 80 % ANGINA PECTORIS VERA. 21 within the same period. In corroboration of this striking con- trast between the incidence of angina pectoris in hospital and consulting work I may refer to the statistics of the Edinburgh Royal Infirmary, in which for the two years covered by the JlospitalJieportSjlSOS and 1894, there were five cases among a total of 8,8G8 medical cases. Compare with this the personal experience of the distinguished Edinburgh consultant. Dr. Balfour, who, in his recently issued work on The Senile Heart, gives an analysis of ninety-eight cases of angina pectoris seen within ten years. My individual experience embraces a series of sixty cases, forty of which may be regarded as true an- gina. The predisposing causes of angina pectoris vera are those of arterio-sclerosis; that is to say, so intimately associated is the true paroxysm with sclerotic conditions of the coronary ar- teries that it is extremely rare apart from them. Men of mus- cular, even athletic build, who have been devotees of Bacchus and of Venus, form perhaps the largest contingent. Gout, syphilis, and hereditary influence the causation only so far as they tend to cause sclerotic changes in the arteries; but it would be altogether too narrow a view to suppose that the {Etiology of the disease is identical with that of arterio-sclero- sis. The one is so common and the other comparatively rare even among the individuals most prone to sclerosis, that there must be a third element, an indefinite something, which yet escapes our knowledge, but which is the essential factor in the production of this terrible affliction. Station in Life. — As Sir John Forbes remarks, it is an at- tendant rather of ease and luxury than of temperance and labor; on which account, though occurring among the poor, it is more frequently met with among the rich, or in persons of easy circumstances. It is remarkable how many prominent individuals have succumbed to the disease. "We may say of it 22 ANGINA PECTORIS AND ALLIED STATES. l! as Sydenham did of the gout, that more wise men than fools are its victims. I do not know that any special occupation or profession predisposes to it, but the frequency with which physicians are attacked has been commented upon by several writers. In my list of sixty cases of all forms, there were thirteen medical men, eight of whom had true angina. This percentage is doubtless exceptional, and due, in part at least, to my nomadic habits, and wide acquaintance in the profession. Sex. — From the earliest description of the disease, the re- markable preponderance of males who are attacked has been noted. Heberden says: " I have seen neai'ly one hundred people under this disorder, of which number there have been three women " {Commentaries). The statistics collected by Huchard give in two hundred and thirty-seven cases of true angina only forty-two in women. In my own series of forty cases of true angina there was only one woman. Age. — The age at which it is most common is that of ar- terio-sclerosis — after the fiftieth year of life. Of the forty cases on my list there were only four under the fortieth year. One of these, a man, aged thirty years, had had syphilis five years before; the other case, a woman, aged thirty-two years, had mitral-valve disease; the third case had terrible attacks of angina following chronic pleurisy. In the fifth decade there were thirteen; in the sixth, thirteen; in the seventh, rme; and of one case I did not get the exact age. The aver- ■ r^Q of the thirty-nine cases was about fifty-three years. Cases ;uc' reported in quite young individuals, even in children, but such are almost invariably the subject of chronic valvular dis- ease or of adherent pericardium. Epidemic, Ijiitative, and Emotional Influences. — La( nee was " of the opinion that the prevalent type of disease influences its development," and adds, " I have some years met ANGINA PECTORIS VERA. 23 i with it frequently, and hardly at all in others." You will find reference in the literature to so-called outbreaks of angina which have been reported by Kleefeld * and by Gelineau.f I can not see that the cases recorded by Kleefeld have anything to do with angina pectoris. He describes the epidemic as a re- mittent fever with gastric complications, and much pain about the heart. Some of the cases were fatal, but tic autopsies were made. Young persons, chiefly women and children, were attacked. Gelineau, surgeon to the French corvette L'Embuscade, reports a remarkable outbreak among the sailors during a pro- longed cruise in the Pacific. Scurvy had broken out and the men were much debilitated and anaemic. They became sub- ject also to a severe dry colic. Following this there were many cases of angina. The first case was that of an old sailor, scor- butic and anaemic, who while climbing the mast was seized with intense pain about the heart. Five days after, five other men were attacked in the same sudden way, and three days later, three more. Gelineau lays a good deal of stress upon tobacco as a factor in the causation of the pain, and also upon the debility following the scurvy, dysentery, and dry colic. The effect of imitation, that extraordinary occult influence so potent in many forms of hysteria, must, no doubt, be taken into account. Perhaps the most notable instance is given by Dr. Taber Johnson in his report of Mr. Sumner's case.* " I have observed a curious fact, which it may be interesting to refer to here. I mean the unusual number of patients suffer- ing from this disease, who, previous to Mr. Sumner's severe illness, had never supposed that they had any disease of the heart. This fact has been referred to by newspaper corre- * Journal d. praet. Heilkunde, 1823, Ivii. f Gazette den ffopitaux, 1862, xxxv. X Boston Medical and Surgical Journal, 1874. i u ANGINA PECTORIS AND ALLIED STATES. spondents — viz., that during the illness of Mr. Sumner, and especially since his death, instances of its occurrence have considerably increased, and especially among those who strongly sympathized with the late senator. This seemingly sympathetic cause of disease has been noticed in other cases. I have been consulted by as many as thirty individuals, since Mr. Sumner's death, who imagined they were afflicted with his complaint. In some of these cases there was organic dis- ease of the heart, but in a majority of them there was no cardiac trouble at all. Two weeks after the autopsy in Mr. Sumner's case, one of the physicians who assisted, a devot- edly attached friend of the deceased, died of angina pectoris. I am informed that Dr. Hitchcock had but a few attacks, and that, prior to Mr. Sumner's death, he had never been a suf- ferer from angina pectoris." Dr. Johnson says that he himself suffered from two attacks very closely resembling, if they were not really, angina. One of these occurred immediately after Mr. Sumner's death, and Brown-Sequard, who was present, said the phenomena were undoubtedly those of a paroxysm of angina. Twenty-two years have passed, and, happily for himself, as well as for our brethren of the District of Columbia, Dr. Taber Johnson has now less mobile nerves. In Case X of my series of pseudo-angina the patient's hus- band died suddenly in a paroxysm of true angina. Mental worry, severe grief, or a sudden shock may precede directly the onset of the attacks. In Case XXXVI, the parox- ysms came on after the shock of the announcement that a son had committed suicide. Heredity. — True angina pectoris is an arterial incident, and since the members of certain families show a special tend- ency to arterial degeneration, it -is not surprising to find cases in father and son, or in brothers, or even in representatives of ANGINA PECTORIS VERA. 26 three generations. Tliere are remarkable instances on record. The first, and one of the most remarkable, is that reported by Dr. Robert Hamilton,* in which the father of the patient, a young man aged twenty-four, two brothers, and one sister were affected. In all, the disease developed in early life; in Hamilton's own patient, at the twelfth year. It is quite pos- sible from his description that the disease may not have been angina pectoris, but spasmodic asthma associated with heart pain. The best-known instance is that of the Arnold family. Wil- liam Arnold, collector of customs of Cowes, died suddenly of spasm of the heart in 1801. His son, the celebrated Thomas Arnold, of Rugby, whose case I will narrate to you shortly, died in his first attack. Matthew Arnold, his distinguished son, was a victim of the disease for several years, and died suddenly in an attack on Sunday, April 15, 1888, having been spared, as he hopes in his little poem called A Wish — " the whispering, crowded room, The friends who come, and gape, and go; The ceremonious air of gloom — All, which makes death a hideous show! " At the time of his death, the accounts which appeared in the Lancet and British Medical Journal were not clear as to the existence of attacks of angina. The various stages in the progress of his illness can be traced very well in his Letter s,\ in which you will find an account of numerous attacks from May, 1885, until the time of his death. (:N'ote B.) In looking over the literature one finds occasional refer- ences to cases occurring in several members of one family. * Medical Commentaries, 1785, ix. f Letters of Matthew Arnold, Macmillan & Co., 1896. 8 26 ANGINA PECTORIS AND ALLIED STATES. Cazanave de la Roclie * records three cases in one family — a sister, who was affected at the time of the report, and two brothers who had died of the disease. In Case XXIII on my list the patient's father died of angina pectoris. Gout. — The relation of certain constitutional disorders to angina pectoris has been much discussed. The importance of gout as a factor was early suggested, and in this interesting little monograph of Butter's, which I show you here — the first separate treatise on the disease — the author places the scat of the disorder in the diaphragm, and calls it diaphragmatic gout. The affection has also been termed asthma arthriticum. Nathaniel Chapman advocated strongly the arthritic na- tui of angina pectoris, and there can be no question, I think, that in a certain number of the victims gout plays an impor- tant role in inducing the arterio-sclerosis. I have been particularly interested in examining into this point in the cases which have come under my observation within the past four or five years. There are four cases at least of my series in which gout seemed to play a part. Dr. , of Virginia, seen April 3, 1894, a very robust, vigorous man of forty-eight, temperate, a hard worker, who had not had syphilis, and in whom the attacks were fairly characteristic, thinks that gout (which is in his family) is directly responsible for the attacks. Certainly, after using without benefit for many months the iodides and the nitrites, he obtained the greatest relief from a prolonged course of colchicum. It is now more than two years since I saw him, and he remains well. In another case, a patient with attacks of angina pectoris sine dolore, there had been attacks of acute articular gout. In a third case, a man aged sixty-four, the upper half of the pinna of the lobe of the right ear was firm and calcified, La Tribune midicah, 1895, p. 832. {•V, ANGINA PECTORIS VERA. 27 and the same process was beginning in the left ear. Thero were no tophi, but the calcification was, to say the least, sug- gestive. A fourth case was that of a physician from North Carolina, aged forty-six, who had for many years attacks of gouty arthritis, chiefly in the big toe, less frequently in the ankles. There was a well-marked tophus in the right ear. Diabetes. — The association of angina pectoris with dia- betes has been frequently noted. No instance has fallen under my personal observation. You will find the whole sub- ject very thoroughly discussed by Ebstein in a recent paper in the Berliner klinische Wochenschrift of last year (1895). Syphilis is one of the potent factors in inducing arterio- sclerosis, and thus indirectly plays a role in angina pectoris. Of the cases in my series, only four gave a history of syphilis. The instances of aortitis to which I have already referred, oc- curring in the third and fourth decades in men who have had syphilis, have worked hard, and have been heavy drinkers, are sometimes associated with severe attacks of angina. In Case I, Lieutenant X., aged thirty years, a robust, powerful man, had had syphilis six years before his visit to me. The secondary symptoms were slight, and he had not had very thorough treat- ment. A year before I saw him he began to have severe pains in the heart, recurring in paroxysms, and associated with pain down the left arm, and dyspnoea on exertion. There was no perceptible enlargement of the heart; there was a systolic murmur at the apex and a soft bruit at the aortic area, with- out special accentuation of the aortic second sound. The at- tacks had been of such severity that he had been off duty for many months. He improved very much upon the iodide of potassium, but siill had attacks six months after I saw him, since which time I have not heard of him. Corrigan's case, you remember, the illustrative plate of which I showed you at the last lecture, was in a young man, and belonged to this 28 ANGINA PECTORIS AND ALLIED STATES. group. The frontiHpicce in Balfour's work on the heart (sec- ond edition) ilhistrates another case of the same kind in a still younger man, aged twenty-four yeai-s. The angina attacks were associated with an aortitis which narrowed greatly the orifices of the coronary arteries. Si'KCiKic Fkvkks. — In connection with the specific fevers several writers have described angina-like attacks. Fraentzel, iti his Vodesunyen iiher die Krankheiten des Jlersens (Berlin, 1889), describes attacks of angina pectoris In the weakened and dilated heart following the infections, particularly ery- sipelas, typhoid fever, and pneumonia. J. VV. Moore * has re- ported two instances of angina symptoms in connection with heart weakness during and after the specific fevers. In the epidemic of a remittent fever reported by Kleefeld (and al- ready referred to) the attacks of heart pain may have been of this cliaracter. I do not remember to have seen a case in which the attack developed during convalescence from one of the ordinary fevers. Among the many nervous sequels of influenza, {c\v are more distressing than the attacks of severe cardiac pain. In some cases, indeed, the disease seems to have boon the starting point of attacks of true angina. The frequency of the compli- cation in the practices of some physicians is remarkable. In a paper on The Action of Influenza Poison on the Heart, Cur- tin and Watson state that within two years they met with fully seventy cases of painful attacks about the heart. The il- lustrative cases in their paper f show that some of the attacks must have been of very great severity, but, in most instances, the duration of the disease was short and the cases evidently belonged to the category of pseudo-angina. I have seen but * Dublin Medical Journal, 1890, vol. Ixxxix. f International Medical Magazine, January, 1893. ANGINA PECTORIS VERA. S9 two inatnnpcs in whioh the attack seemed to follow directly upon the influenza. One is certainly pseudo-angina; the other proved to be the genuine disease. I saw on several occasions in Toronto a medical friend who, after a tolerably severe attack of influenza about three years ago, began to have attacks of agonizing pain about the heart. They came on without warning, the pain appearing in various parts of the chest, commonly under both shoulder blades, and espe- cially severe in both wrists. There was at first no irregularity of the pulse or difficulty in breathing; but in some attacks there wcic piping rales during expiration. At first these attacks were almost nightly; several times they ended in vomiting (preceded by profuse salivation), the passage of more or less flatus, and copious sweating. There was no mental anxiety whatever, ex- cept, as he expressed it, " the pain was so intense that I was afraid I would recover, in order to endure it again." The pain in the arms was chiefly in the front of the wrists. The patient had not had any serious illness previously, had never had syphi- lis, had not been a heavy drinker, but had been a pretty heavy smoker. The attacks recurred with intensity throughout the early part of January. When I saw him there were no signs of cardiac disease. He had had a good deal of digestive disturb- ance. During the following summer and autumn he progres- sively improved, and I heard from him recently to the effect that now only in any extra strain, an in the attendance upon a difficult case of labor, does he feel any pain. He used the iodide steadily for some time without any special benefit. He at- tributes more benefit to lavage of the stomach with hot water night and morning. How far the influenza in this case was responsible for the attack is, of course, difficult to say, but when I saw him first he was very insistent that it was the cause of his whole trouble. From the rapid way in which the attacks have ameliorated and his present general condition there is, to say the least, a strong probability that it is functional and not associated with organic disease. The other case was that of the late chief justice of this State, who had, in the early winter of 1893, a very severe attack of J I X\! I ' i^ 30 ANGINA PECTORIS AND ALLIED STATES. i I influenza with much fever and prostration. In the latter part of December he began to have pain about the heart in walking briskly up a hill. Then he had more severe attacks, but in the summer of 189i he was better, and was able to take long walks. Tin attacks recurred about Christmas, 1894. I saw him on January 20, 1895. There was no enlargement of the heart, tbe sounds were clear, the second aortic a little accentuated. The only striking anomaly was a condition of trigeminal heart- beats — groups of three beats, with an interval, followed in regu- lar sequence. He improved very much through the summer of 1895. In October he had a severe shock on hearing of the sudden death fror.i angina of his brother-in-law (Case XXXV on my list). He did not, however, have any recurrence until December. I saw him on January 5, 189G. The paroxysms had become more frequent and very severe. In the following week he died in an unusually prolonged attack. The onset of the angina corresponded with the period of convalescence from the influenza, which he always insisted had caused the attacks. Heart Disease. — Paroxysms of agonizing substernal pain, with radiation to the neck and ann, are rare in the ordi- nary forms of heart disease which we meet with in hospital work. II'?art pain is connnon enough, and if we counted all such cases as angina we would not have to lay stress on the in- frequence of this syndrome in the wards. You remember the small boy in Ward F during the early part of this session, with greatly enlarged heart, probably from pericardial adhesions. Pran was the most distressing symptom of the case, but it had neither the intensity, the paroxysmal character, nor the ac- companiments which warrant the diagnosis of true angina. So, too, in the case of the old colored woman, at present in Ward O, with mitral-valve disease and extreme artcrio-sclcro- p's. I have pointed out to you that the attacks of sudden breathlessness and distress with transient pain, are of the na- ture of cardiac asthma, with which, as I will tell you later, angina pectoris is often confounded. Then, again, you have I ANGINA PECTORIS VEEA. 31 to bear in mind the common complaint of pain beneath the left breast in patients with chlorosis and various forms of anaimia. Of valvular affections, aortic insufficiency is that with which angina pectoris is most frequently associated. Of the forty cases in my list three presented signs of this lesion. The subjects of the degenerative type of the disease, which de- velops in men after the fortieth year, are much more prone to angina than those in whom the insufficiency has followed en- docarditis. The younger the subject, the greater the proba- bility that the incompetency results from an acute aortitis, as in Corrigan's case, to which I have referred on several occa- sions. Angina pectoris is excessively rare in mitral-valve disease. This is well illustrated by Nothnagel's experience.* Of fifteen hundred cases of valvular disease of the heart seen in hospital and private practice, very many of which had symptoms of an- gina, there was but a single case in which the syndrome oc- curred in connection with mitral stenosis. Only one of my cases, a woman, had a mitral lesion. By far the most common heart disease with which angina is associated is chronic myo- carditis, the signs of which are often dubious. Cases of adherent pericardium and of aneurysm of the aortic arch may present the features of typical angina, more often, in my experience, of constant substernal pain or of cervico-brachial neuralgia. A mr jority of the subjects of angina present the signs of arterio-fclerosis, with accentuation of the aortic second sound and slight increase in the area of transverse heart dullness. Some of the most rapidly fatal cases are those in which the physical signs are very sligltt, or even absent. Of the cases on ■■■■ y Sl i % Verhandlungen dea Congresses f. innere Jledicin, Bd. x. 32 ANGINA PECTORIS AND ALLIED STATES. i 'i my list, in four only was the physical examination negative; three presented apical or basic murmurs; of the remainder, all of whom showed signs of sclerosis of the arteries, nine had indications of myocardial changes. Locomotor Ataxia. — Considering the close relationship of syphilis to this disease, in which also arterio-sclerosis is so common, it is not surprising that attacks of angina pectoris should occur. No instance has fallen under my personal ob- servation. You know that aortic insufficiency is not rare in tabes. At Blockley the association was a matter of every-day comment, and in the physical-diagnosis class we would send to the out wards for the old tabetics to demonstrate the lesions of arterio-sclerosis, and if not of aortic incompetency, of the ring- ing metallic aortic second sound, which so often accompanied the dilated and rigid aortic arch. You will find the subject fully discussed by Leyden in the Zeitschrift f. klin. Iledicin for 1887, and since his paper there have been several less im- portant communications. General Picture of the Disease. — In any long series of cases of angina we can recognize four groups: T, Sudden Death, without other Manifestations of Angina Pectoris. — Much more true of angina pectoris is what Andral said of the fulminant form of cholera: it begins where other diseases end— "n death. The affection has indeed been called by Sir Walter Foster a mode of death, which reminds one of the expression of the physicians who spoke of Seneca's malady as a meditatio mortis. Xo inconsiderable proportion of sudden deaths in men of middle age and robust habits rosult from coronary-artery disease, from the rapid culmination, so to speak, of a condition which, in another (or on previous occa- sions in the individual himself), would have caused an ordi- nary attack of angina. Before all is over there may be a mo- mentary conscious agony expressed by a cry, but in other in- i ANGINA PECTORIS VERA. 83 stances (and this is most frequently the ease in the subjects of angina) the death is literally instantaneous; more rapid, per- haps, than that which occurs by any other mode. Of the fifteen deaths in my series, eight took place sudden- ly; in five, gradually by cardiac asystole; in one, I did not learn the exact mode of death ; in another, the patient died of obstruction of the bowels. Of the eight cases, in five death was sudden, almost without warning, and not in a paroxysm p+' angina. >ir. S. (Case XXVI) died on his doorstep; Mr. W. (Case XXVII) died as he was leaving a friend's house; Dr. X. (Case VIII) died as he was walking from one room to another. He had had cardiac arrhythmia, Cheyne-Stokes breathing, and marked mental disturbance; Mr. E. (Case XXXV) died in- stantly on the edge of the bed as he was recovering from his first attack of angina, not having had pains for nearly twenty- four hours; Mr. R. (Case XI) fell over dead on attempting to get out of bed. The literature abounds in cases of this sort, and the proportion of the victims of angina who die abniptly is muc' !a!jj,'^r than my figures indicate. Forbes mentions that ' f • ;. '-.four cases sudden death occurred in forty-nine. Anatomicti 1; n has been shown that lesion of the coronary arteries is almost invariably present — either extensive arterio- sch iosis, embolism, thrombosis, or in rare instances the burst- ing of a small athertjinatous abscess in one vessel, such as killed the celebrated sculptor Thorwaldsen.* An explanation of the awful suddenness — " Life struck sharp on Death " — is prob- ably 1 > be found in the arrest of the heart in fibrillary con- tract r R uli as takes ])lace experimentally in animals after ligation of a coronary vessel. II. Death in the First ^^^eU-mar'Tced Paroxysm., — A man I III :- s m * Virchow's Archiv, Bd. xxv. 11^ j f 3i ANGINA PECTORIS AND ALLIED STATES. in full health, in the prime of life, may be seized with a parox- ysm of angina, and die within a few hours. The cases in this category are not numerous. Perhaps the most remarkable one on record, which has become quite historic, is that of the cele- brated Dr. Arnold, of Rugby, who in the words of his distin- guished son (also a victim of the disease), arose "... :> ■^TP'^d In the summer mor^ 'he road Of death, at a call unfui^seen, Sudden." II ■ The following is Latham's account: * "T. A. was within a day of completing his forty-seventh year. Up to a few hours before his death, both body and mind seemed equally to give proof and promise of health, lie still took his accustomed pleasure and refreshment in strenuous exercise. His thoughts were still busily employed upon the highest subjects, conceiving and composing with wonderful ease, rapidity, and power. He retired to rest at midnight on the 11th of June, 1842, feeling and believing himself to be in per- fect health. At a quarter before seven the next morning his medical attendant was called. What had previously occurred and what followed I will give in the words of Dr. Bucknill, who was with him during the short remaining period of his exist- ence. * On my entering his room he said that he was sorry to disturb me so soon; and that ho had not sent for me before, thinking that it would go off. He added, "I have had very severe pain in the chest since five o'clock, at intervals, and it gets worse, I think." This pain was seated at the u])per part of the chest, toward the left side, and extended down tlie left arm. He had been rather sick. He then asked mo what the pain was. " What is it? " He was now almost free from pain. His pulse I coiild scarcely feel. The tongue was clean. There The feet and legs were was cold perspiration over his face. * Latham's Works, vol. i, p. 453 ; Now Sydenham Society, 1876. also Stanley's Life of Thomas Arnold. See ANGINA PECTORIS VERA. 35 cool. The breathing at this time not troubled. I gave him immediately some hot, strong brandy and water, and having ordered a mustard plaster for his chest, till this was ready I applied hot flannels, and had his legs and arms rubbed and the feet wrapped up in flannels wrung out of hot water and mus- tard. The pulse became natural, the extremities more warm, and he was free from pain. The mustard plaster was brought and put on. It was not large enough and I ordered another. The pain then returning, I gave him more brandy and water, and it soon left him. And now he asked me again what the pain was. I told him I believed it was spasm of the heart. He exclaimed, "Ah!" I asked him whether he had ever fainted in his life. " No, never." If he had at any time difficulty of breathing. " No, never." If any pain in his chest before. " No, never." I then asked him if any of his family had ever had any disease of the chest. " Yes, my father had; he died of it." He in- quired if disease of the heart was suddenly fatal. I answered that it was. " Was it a common disease ? " I said not very com- mon. "Where do you find it most?" "In large towns, I think." " Why? " " Perhaps from anxiety and eager com- petition among the higher, and intemperance among the lower classes." He was then quiet and free from pain, and I proposed to leave him for a minute or two. He had no pain whatever in my absence. On my return the perspiration was still in drops upon his forehead. The pulse was again feeble, and I gave him more brandy and water and had the flannels with mustard renewed. An attack of pain was coming on. He said, " I must stretch myself." I took one of his hands and held it until the pain was gone off. It was of short duration. I said, " Is it gone?" He answered, "Yes, entirely," adding that he "could scarcely bear it if it were as severe as it had been." ITc then asked me " what was the general cause of this kind of disease." He then said, " Is this likely to return? " I answered that I was afraid it was, but that, as the attacks had been less severe and less frequent, I hoped they would pass off. He next asked me if the disease was generally suddenly fatal. I said generally (for those who knew him were aware that it was impossible not to tell him the exact truth). I then asked him if he had any i'1.1 3G ANGINA PECTORIS AND ALLIED STATES. pain. He said, " None but from the blister; one can bear out- ward pain, but it is not so easy to bear inward pain." I was now dropping some laudanum into a wineglass, when he in- quired what I was going to give him. I told him laudanum, Hoffman's anodyne, and camphor; and, while I was preparing the mixture, and before I had finished, 1 heard a rattling in the throat and a convulsive struggle. I called out, and on turning to him I sup[)orted his head, which was thrown back on my shoulder. His eyes were fixed and his teeth set, and he was insensible. His breathing was very laborious, his chest heaved, and there was a severe struggle over the upper part of the body. His pulse was imperceptible, and after deep breathings at a few prolonged intervals all was over. He died in little more than half an hour after I first saw him.' " The examination showed a soft, flaccid heart muscle. There was but one coronary artery, and that, considering the size of the heart, of small dimensions. It presented also a slight athe- romatous deposit an inch from its orifice. In no case in my series did death occur in the first parox- ysm. The most rapid case was 'Mr. E. (Case XXXV), who had an agonizing paroxysm at 2.30 r. m. on October 14th, and several lesser recurrences throughout the night. There was no attack on the ISth, and he passed a comfortable night. On the IGth, at 9.10 a. m., he sat up on the edge of the bed to be helped to the commode, and fell over dead, about forty- two hours from the onset of the first attack. III. Hecurring Attacks extending over a Period of Months or Years. — Much more commonly a victim of angina pectoris has many paroxysms over a period of many months, or from three or four to twenty or even twenty-five years. The re- currences may be at long intervals, as in John Hunter's case, or they may render the patient's life unbearable, since he feels that the slightest transgression, muscular or emotional, may precipitate a paroxysm. Many a poor sufferer has felt what Senator Sumner expressed: " This treacherous disease pro- ANGINA PECTORIS VERA. 37 duces in my mind a positive uncertainty, when I go out of my house, whether I sliall ever enter it again a hving man, and, with the pain I have to suffer, makes my life such a bur- den that the sooner it does its work the better I shall be pleased. Life, at the price I have to pay, is not worth the hav- ing." Let me read you the history of a typical case of this sort: Case XXVL — Mr, S., an editor by occupation, aged fifty- five, consulted me January 10, 1894, complaining of attacks of agonizing pain in the region of the heart. The patient was of a nervous temperament, but had been a very healthy man. He had never done hard physical work and had been moderate in the use of alcohol and tobacco. lie did not think that he had ever had sypliilis. Three years ago, following upon the shock of the announcement of the suicide of a son, he. had his first attack of severe pain about the heart. Ever since, the at- tacks have recurred at irregular intervals, at first of a few weeks or a month, but within the past year they have been very fre- quent, so that he now rarely passes a day without paroxysms. They vary a great deal in intensity. If he walks fast or makes any unusual exertion he is stopped by an intense pain in the heart, and he has to pant for breath. After lasting for half a minute or so the pain passes off, and he is able to resume his walk. Any unusual emotion or excitement will bring on an attack at once. lie not uncommonly now has as many as a dozen or more attacks in the day. In the severer paroxysms he feels as if the throat was greatly swollen, and says that both his throat and his temples throb, and tnat he gets very red in the face. As the attacks pass off he usually sweats quite pro- fusely. From what I can gather, he did not appear to have had paroxysms of terrible agony, in which the sense of impending death was present. He says, however, that the feeling is as though the heart was grasped in a vice, and the pains shoot up the neck and down the left arm. Two weeks ago, in Philadel- phia, while walking to the station, he felt an excessively severe pain in the chest, became short of breath, and fell unconscious. When he recovered he found himself in a neighboring chemist's i, 11 i^^ i 1 ■v 1 1 38 ANGINA PECTORIS AxVD ALLIED STATES. shop. He was able, however, to proceed on his journey. While in my waiting room this patient had two attacks, and while I was examining him he had a third, the phenomena of which I will describe to you later. Three days after his visit to me, while walking up the steps of his house, he dropped dead. The great majority of all cases of angina pectoris come in this group. lY. Rapidly Repeated Attacks over a PeHod of Days or Weeks, with the Development of a State of Cardiac Asystole — Vetat de mat anginenx. — An individual in apparently good health, who may not have had any indications of heart trouble, or who may have had at some previous date an attack of an- gina, is seized with a severe paroxysm. This passes away, but there is shortly a recurrence, and for several days in rapid suc- cession there are subintrant attacks, with increasing weakness of the heart. Huchard describes the condition as Vetat de mat angineux. In a way, it is a counterpart of the status epi- lepticus. The condition is one of terrible distress. I have seen but two cases, and as this feature of the disease has not been specially dwelt upon by writers, except Huchard, I will read you an account of them both. Case XXXII.— On January 3, 1894, I saw with Dr. Pole, Mr. L., aged fifty-five years, merchant, who for a week had had attacks of severe pain in the region of the heart. The patient was a stout, large-framed man, who had lived for many years a life of great activity. He had always enjoyed very excollont health; never had had rheumatism. He has seven healthy children. He had been a moderate smoker and moderate drinker, chiefly of beer. He had not had syphilis. Seven years ago, after a slight exertion, he had a very severe attack of pain about the heart, which lasted, however, only a day and then passed off. He had no recurrence and had been very well, though, occasionally, he has been a little short of ANGINA PECTORIS VERA. 39 breath on walking rapidly. A week ago, December S7th, a fire occurred in his place of business, and he was naturally very much excited, and helped to save the papers and books. That night he had a severe attack of angina pectoris, accompanied with vomiting and sweating. He was better the next day and able to go out. Since then he has had three attacks, all of tliera of a good deal of severity. He feels very weak and feeble and the pains are severe enough to require morphine. Last night they were very much worse. He was a well-nourished, healthy-looking man. The pulse was about 90, and there was no increase in tension; the radials were not sclerotic, and though the temporals stood out promi- nently, they were not firm. During the examination, the pa- tient had an attack of very severe pain, and clasping his hands over the heart rolled about upon the bed. He was flushed in the face, and then broke out into a profuse perspiration. During the attack the pulse did not change materially in character, but remained regular. The pain was described as very intense, a feeling as if tlie heart was grasped in something. It extended also dov/u the left arm and in very severe paroxysms down the right arm. The apex-beat was difficult to feel on account of the fat mamma. The cardiac dullness was not increased. The sounds were clear at apex and base; the aortic second was not accentuated. The lungs were clear on percussion and the breath sounds were normal. The abdomen was distended and the stomach tympany was high. As nitroglycerin and nitrite of amyl had no influence whatever on his attacks, morphine was used. On the 4th he was better. On the 5tli and 6th he had very severe attacks, requiring much morphine. On the 7th and 8th he was still worse, and displayed a remarkable resistance to the morphine. Thus, in the hours between ten o'clock Saturday night and 1 P. m. on Sunday, he had received by mouth and by hypodermic injection five grains of morphine, in spite of which he scarcely slept at all, and at the time of the visit, the pupils, though small, were not extremely contracted. So resistant had he appeared to be to the morphine that we discarded the tablets which had been employed and obtained a fresh solution. ■Tiyn 40 ANGINA PECTOllIS AND ALLIED STATES. Tlic attacks of pain were of great intensity and recurred fro- qiicntly. They were of the sharp, agonizing form, and in the intervals tliere was a dull, heavy weight. Only the fullest doses of morphine on Sunday and Monday kept him free from pain. On Tuesday he was somewhat better, and on Wednesday he was almost free. During these protracted attacks he was frequently almost beside himself with the pain, and sweated very profusely, and on Sunday and Monday and Tuesday he had severe attacks of vomiting. There was no fever. On Wednesday, the 10th, ho was better. I saw him early on the morning of the 11th. lie had had a bad night with the shortness of breatli. I found him with a pulse of 115, small in volume; the heart sounds feeble and distant. The change, sc far as his hcf rt was con- cerned, was very striking, as the heart sounds had previously been quite clear. To-day they were extremely feeble and the action somew.at irregular. Over the left lung there were numerous bronchial rales, particularly in the axillary region. In the evening his condition seemed really critical. The respirations were 40, labored; expiration prolonged, and there were medium-sized rales heard over the whole chest. He was given whisky freely, Hoffman's anodyne, and ammonia, and in spite of the threatening condition in his lungs he was given during the night two or three hypodermic injections of morphine. On the 12th and 13th the cardiac condition was better. He had had no attacks of pain since Wednesday. The bronchial symptoms and cough continued. On the 14th he was not nearly so well. The respirations were hurried, the cough troublesome, and over the whole chest piping rhonchi were heard. The pulse was at about 120 and feeble. He took his nourishment better, and the feeling of weight about the heart had gradually diminished. All along, the color of his face had kept pretty good, though that of the finger tips was sometimes a little cyanotic. On the 15th and IGth he was decidedly better, though the wheezing rhonchi were still present everywhere. His expectora- tion throughout these attacks had been muco-purulent, and m ANGINA PECTORIS VERA. 41 then piinilont, hut the cough was never paroxysmal. On sev- eral occasions the urine presented slight traces of albumin. January 21st. For the past few days the condition had been better, little or no pain, less wheezing, and he has been sleep- ing better and taking more food. Last evening, however, he had hallucinations, and did not know where he was, thinking he was in some hospital, and that his wife was his mother-in- law. He seemed, however, so well that they thought i)artly that he was joking. His wife stated, too, that on several occa- sions during liis illness he had made odd remarks, as if he did not realize fully his surroundings. He spoke of it himself this morning and joked about it, seeming quite clear and bright mentally. The pulse was soft, 90, regular, and without in- crease in tension; the heart sounds were a little feeble, but clear. The bronchial rales were still to be heard everywhere over the chest. I left him, saying that as he was so much better I probably would not see him again. 22d. Dr. Pole sent word that the patient died suddenly at 2.45 this afternoon. He wrote: "I saw him about one o'clock, after he had had a severe heart pang, which he de- scribed as of a very sharp, cutting character, and he felt as though his heart had stopped. The color changed as usual. He had been cold all day at the extremities, though not more so than he had frequently been before. He rested fairly well last night and took no morphine, but throughout the day he has had cutting pains in his left hypochondriac region." Case XXXVIII.— On the 24th of February, 1896, I saw, at 10.30 A. M., with Dr. Mary Sherwood, Mr. L., aged fifty-nine years, who had been attacked at seven o'clock in the morning with agonizing substernal pain. He was a healthy man of good stock; his mother, still living, was aged nearly ninety; his father died about the age of sixty, of, so it is said, fatty heart. The patient had been an abstemious man, of good habits, not a heavy smoker. During the past thirty years he had scarcely had a day's illness. For a year or more he had been using the bicycle, and had noticed that he was a good deal distressed and short of breath on going up hill. For several weeks he has had occasional attacks of pain of a 42 ANGINA PECTORIS AND ALLIED STATES. singular character about the wrists, chiolly the left, which, ho said, felt as if encircled by a band, lie has occasionally felt pain about the elbow and the left shoulder. They did not seem to be rheumatic. Yesterday he had a very comfortable day, took a light evening meal, and went to bed feeling in his usual health. He was aroused this morning at seven o'clock with a very severe pain beneath the breast-bone. It extended to the region of the apex, and was felt very severely down the left arm and about both wrists. He became pale, but Dr. Sher- wood, who saw him about half-past seven, said that the pulse was not much affected. He obtained temjwrary relief by in- halations of the nitrite of amyl, but between eiglit and nine it became so severe that he had to be given whill's of chloroform. I saw him at 10.30. He was a healthy-looking man, with grayish hair and mustaches; tliere was no arcus senilis. He was not sweating, and he did not look very greatly distressed. The pulse was 90, of fair volume, without increase of tension, and the coats of the vessel were not specially thickened. The apex-beat was not easily to be felt. The heart sounds were dull and muffled at apex; there was no murmur at the base. The aortic second sound was not accentuated. There was no dull- ness over thfi manubrium. He had no respiratory distress, and there were no piping rales. The al)domen was not distended. The intensity of the pain had passed, but he was still suffer- ing a great deal from a very severe constant pain beneath the breast-bone. He had not had any sweating or s})ecial coldness of the hands or feet. He was ordered a quarter of a grain of mor- phine, and to have it repeated at intervals if necessary. He improved somewhat through the day, though tlie pain did not entirely disappear. He had a pretty comfortable night. On Tuesday, the 25th, he seemed better. He had five or six free movements from the bowels, and, as he insisted upon walk- ing to the water-closet, they exhausted him a good deal. On Wednesday, the 2Gth, without any active paroxysm, he had a great deal of substernal pain, and his pulse became feebler. He dreaded very much a return of the severe pain, and had small doses of morphine at intervals. I did not see him again until Thursday at 2 p. M. He had not had a good night, and ANGINA PECTORIS VEIIA. 43 had become much worse throii<,'h tlie morninfj, signs of great cardiac weaicness having apj)eared. lie had had no sweating. When I saw him he was greatly changed. I'he i)all()r was marked, and tiie general depression extreme. There was no sweating; tiie face was pale, rather than ashy gray. Thv tongue was thickly furred. His mind was (^uite clear, and he com- plained only of feelings of great exhaustion and an uneasy pain beneath the sternum. The head was low; the respirations were not hurried. The pulse was scarcely to be counted, only a few feeble beats reaching the wrist. There was no heaving over the pnecordia; the sounds at tiic apex were only just audible in gallop rhythm. At the base the gallo}) rhythm could just be perceived. There seemed to be a slight increase in the area f cardiac dullness. He had been having hypodermics of strych- ne one sixtieth, but one thirtieth was ordered every two hours, and a hundredth of a grain of digitalin. He had passed very small qmintities of urine. At ten o'clock tliat evening he was decidedly better; the pulse was stronger and the beats were regular. There was still slight gallop rhythm at the apex. The sounds were very much nu)re distinct. He complained a good deal of an un})leasant gasping in his breathing at intervals, which distressed him very much. February 28th. Patient had had a rather restless night, sleeping only at intervals, and being much distressed by gasp- ings for breath. He had taken small qiuintitics of nourishment, and had had no vomiting. The pulse was regular, snuill, and about the same as last evening. He had had digitalin and strychnine regularly through the night. He had a very com- fortable day, and seemed altogether better, though ho had had some slight delirium and wandering, particularly after waking. He had slept with his head high, and had not been quite so much troubled with the cardiac asthma. He had had no attacks of pain. 29th. This morning he was not so well. He had had a quarter of a grain of morphine at ten last night, which quieted him, but he was aroused at intervals with a distressing sense of the need of air. The delirium was marked and he looked distressed; there was no coldness of the hands and feet, and 44 ANGINA PECTORIS AND ALLIED STATES. ., no sweating. The pulse was feeble, irregular, and intermittent; sometimes three and four beats were dropped in succession. The apex-beat was not palpable. The heart sounds were only just audible at the apex. There was a gallop rhythm. At the base the second sound could onV just be heard. There was no murmur. Throughout the day he was quiet, except for at- tacks of gasping for breath, which were very distressing. At 5.30 the pulse could not be felt at the wrist. He was con- scious; the respirations were not hurried, though every five or ten minutes he would become a little restless and gasp. The heart sounds could be heard both at apex and base; a very dis- tinct embryo cardia, but no murmur. The feet and hands were cold, but he had had no sweating. It was rather remarkable to see a man in such a desperate condition entirely conscious and perfectly alive to his surroundings. He was at times very nervous and restless. Throughout the evening he grew worse; the heart sounds became feebler, and after a period of terrible distress for an hour or more, death occurred, about six days after the onset of the first paroxysm. jlii t; If' LECTUKE III. ANGINA PECTORIS VERA. PHENOMENA OF THE ATTACK. Exciting causes.-Symptoms.-State of heart and pulse.-Pericarditis.- Respiratory features.-Gastro-intestinal syraptoms.-Nervous and psy- chical symptoms. Exciting C vuses.— There arc three important elements- muscular exertion, mental emotion, and digestive disturbances. Any muscular effort which calls for increased action of the heart is liable to bring on a paroxysm. Ileberden refers par- ticularly to this: " They who are afflicted with it are seized while they are walking, more especially if it be up hill." Some patients who can not walk except on the level without bringing on a paroxysm can, however, take active horseback exercise. In extreme cases even an attempt to move in bed or assuming the sitting posture will cause an attack, or such slight exertion as stooping to lace the shoes. Hurrying to catch a t ain has been often the exciting cause of a fatal attack in the Aibjects of angina. The muscular and mental excite- ment jf coitus is particularly dangerous, and has in many in- stances caused death. Two of my patients laid great stress on the terrible character of the attacks which had followed the act. The well-known effect of mental emotion has never been better expressed than by John Hunter, who used to say that « his life was in the hands of any rascal who chose to noy 45 II ) I 40 ANGINA PECTORIS AND ALLIED STATES. I and tease him." And yet some of the victims of angina have not found mental excitement to be the most serious exciting cause. Thus, in Mr. Sumner's case, '' a sudden turn in his easy-chair, while quietly reading at night, would start up the most tearing agony, while at other times an exciting speech in the Senate, accompanied with the most forcible and mus- cular gesticulations, would not create even the suggestion of a pain." — (Taber Johnson.) For some of the woi"st attacks, however, neither Tmiscular action nor mental emotion is responsible, since they come on when the patient is quiet and at rest, or may wake iiim from sleep. Cold is another exciting cause, particularly in the vaso- motor form, but in the organic variety a cold wind, ^ven the opening of a window in wintei*, or the cold sheets at night have been known to bring on an attack. In almost every case in which the paroxysms recur with frequency the patient lays stress upon the condition of tlie stomach. Exertion immediately after ;i full meal, the eating of certain articles of food, and especially of late suppers, are very apt to cause attacks; and, as I will mention later, there are in- stances in which the dvspepsia is so marked a feature that the character of the disease is entirely overlooked. In some pa- tients flatulency is one of the most common exciting causes. SYMrioMS. — In the report of the two cases wdiich I read to you at the end of the last lecture I described the phenomena associated with severe attacks. The physician has not often an opportunity of watching the onset and coui*so of a j)arox- ysm. Only once that I remember did a patient have an attack in my consulting room, Mr. S., to whose case I have already referred (XXVI). As he sat quietly in the chair, just after the completion of my examination, his eyes became fixed and he suddenly grasped both hands over the heart. For a moment the face did not change; then it flushed, and the neck became ANGINA PECTORIS VERA. 47 swollen, and the cervical veins full. The face became very much congested, and tears filled the eyes. The respirations, which had been 18, increased to 30 in the minute. The pulse, which had been 80, increased to 90, and became smaller and harder. Considering the increase in the respirations, and the congested state of the face and neck, I was surprised that the pulse changed so little. He remained immobile during the entire attack, which lasted just a minute and a half, passing off abruptly, and he at once began to put on his clothes. There are two chief elements in the paroxysm: first, the pain — dolor jpectoris y and second, the indescribable feeling of anguish and sense of imminent dissolution — angor animi. The resources of the language have been taxed to describe the pain of angina pectoris. Patients speak of a hand of iron grasping the heart, or a band of metal encircling it and being gradually tightened; or as though an enormous weight was com} essing the breastbone against the spine, or ns though the whole chest were compressed in an iron case, i n other in- stances the pain is associated less with pressure than with the sensation of stabbing, as though a dagger had transfixed the heart. While the maximum intensity of the pain is substernal (whence the name of sternalgia is derived), it may be in the Tipper or lower part of the breastbone, or over the body and apex of the heart. There are cases in which the chief agony is opposite the point of the xiphoid cartilage in the scrobiculus cordis. During an attack there may be marked tenderness over the region of the heart, or the left breast or the nipple may be tender to the touch. The pain may cease as abruptly as it began. One of Parry's patients said the transitions from acute pain to a state of ease were so sudden that at times he felt both extremes at the same moment. A feature noted by Ileberden and all the early writers was the radiation of the pain to other parts. Ileberden says: I.' \ ^ 48 ANGINA PECTORIS AND ALLIED STATES. 1 i " It likewise very frequently extends from the breast to the middle of the left arm. . . . The pain sometimes reaches to the right arm as well as to the left, and even down to the hands, but this is uncommon. In a very few instances the arm has at the same time been numbed and swelled." In an instance reported by Ileberden the patient had attacks of pain in the left arm without any affection of the chest for fif- teen years prior to his sudden death. The pain most common- ly extends to the shoulder, to the left upper arm, and to the neck of the same side. Wher it extends to the arm and hand it is along the inner surface of the upper arm, and in the lower arm on the ulnar side in the distribution of the ulnar nerve. The feeling is one of numbness and tingling, or of pins and needles. There may be hypera^sthesia of the skin. Very often the chief pain is in the region of the elbow, or there may be, as in a case I have already narrated to you, a band- like sensation around the wrist. Sometimes the radiation of the pain is more marked in the right arm and in the right side of the chest. Quain states that Dr. Morison has reported a case in which disease of the right side of the heart was ac- companied by symptoms of angina affecting the correspond- ing side of the chest and arm. Curiously enough, as noted by Ileberden, the pain in the arm may precede the angina attacks for years. Blackall, in the interesting appendix upon Angina to his work on Dropsies^ refers to the account which Lord Clarendon gives of his father's sudden death, evidently from angina, " without one minute's warninge or feare," though the pain is said to have been only in the arm. As this case is often referred to, I will give you the extract from the Life. Mr. Hyde was in church, and " found himself a little pressed as he used to be." Going to his home, " the pain in the arm seizing upon him, he fell down dead, without the least motion of any limb." In some cases there is sen- ANGINA PECTORIS VERA. 49 sory disturbance throughout the entire left side, a feeling of numbness or tingling in the neck, arm, and leg. There are instances on record of extension of the pain to the left testis, with swelling; or the attack may begin with furious pain in this organ. There are very interesting areas of cutaneous hyper- sesthesia in the attacks, chiefly in the praecordia, about the pectoral fold, and sometimes along the side of the neck. They have been studied particularly by Mackenzie, and are rarely absent. I do not know of any clearer view in explanation of the radiation of the pain in angina than that which was afforded by the late Dr. James Ross, of Manchester. I will quote a brief summary. I do not know whether it was ever elaborated. " When a viscus was diseased there was local pain which might be regarded as of splanchnic origin (praecordial pain in the case of the heart). In addition, the irritation was conducted to the portion of the spinal cord from which the viscus de- rived its splanchnic nerve, and thence spread in the gray matter of the posterior horns, whence by the law of eccentric projection it was referred to the termination of the somatic nerves derived from the segment of the cord — the second and first dorsal in the case of the heart. This explained the pain, shooting between the shoulders and down the inner side of the arm (second dorsal) to the elbow and the ulnar border of the forearm and hand and ulnar fingers (first dorsal)." * The subsequent studies of Mackenzie and of Head have fully corroborated this view. Head f concludes that • " 1. In diseases of the heart, and more especially in aortic disease, the pain is referred along the first, second, third, and fourth dorsal areas. (■ * Lancet, 1891, i. f Brain, xvi. 60 ANGINA PECTORIS AND ALLIED STATES. i "2. In angina pectoris the pain may be referred in addi- tion along the fifth, sixth, seventh, and even the eighth and ninth dorsal ai-eas, and is always accompanied by pain in cer- tain cervical areas." A very remarkable feature is the motor disability which may follow a severe attack. The left arm may not only be numb, but for a time almost powerless. Blackall says that he has seen instances in which the muscles of the arm and chest were not only painful, but were affected with a twitching noticeable by the patient, and visible to the observer. B. W. Richardson * says ^' the voluntary muscles seem to be affected and rigid." Still more extraordinary is the fact, noted by Eichhorst, f of atrophy of the muscles of the hand supplied by the ulnar nerve. Von Dusch, in his admirable Lelirhuch der Ilerzkranh- heiten (which remains one of the best works of its kind in the literature), refers the hiccough, the occasional difficulty in swallowing, the globus and uneasy feelings in the throat, and the gastric symptoms to sympathetic involvement of the phrenic and vagus nerves. Yaso-motor disturbances are almost constant in the attack. A sudden pallor of the face may be the first indication, and, as a rule, vaso-constrictor influences prevail in the severe paroxysms. A cold sweat breaks out upon the forehead and upon the arms and legs. In recurring attacks I have seen the skin of the hands like that of a washerwoman from constant soaking in perspiration. As in Case XXXV, there may be great pallor and coldness without sweating. Though rarely absent in the organic form of the disease, these vaso-constrictor disturbances are often more pronounced in the hysterical an- gina. The countenance is expressive of the deepest anguish, * Asclepiad, vol. xi. f Handhuch der speciellen Pathologic, 5te Auflage. ANGINA PECTORIS VERA. 51 and may assume a deathlike, aslien hue. In other instances, as in Case XXVI, the face is suffused, or even deeply con- gested at the outset, and the veins of the neck may stand out prominently. More commonly in a fatal paroxysm there is })allor at first, which is followed by great lividity, as noted by Powell * in a man who died in his consulting room. Complaints of coldness and of swelling of the extremities are more frequent in the hysterical form. In many cases of true angina the pain alone is experienced, but in severe paroxysms the other factor — the mental element, the angor anlmi — is also present. Latham was the first to dis- tinguish clearly these two features of the attack : " The sub- jects of angina pectoris report that it is a suffering as sharp as an}' that can be conceived in the nature of pain, and that it includes, moreover, something which is beyond the nature of pain — a sense of dying." And he adds, " the dying sensa- tion I have more fretjucntly found to surpass the pain than the pain the dying sensation." The one is in reality a physi- cal, the other a mental phenomenon, and was described by Ileberden's unknown correspondent as the sensation of a universal pause in the operations of I^ature, or a sense of im- minent and immediate dissolution. This feature of the attack was certainly referred to by Seneca (quoted by Gairdner) when he says, " As compared with any other disease, it is like the difference between being sick merely and giving up the ghost." Associated with this sensation there may be a feel- ing of air-hunger, or, as one patient expressed it to me, the same sensation that one has after holding the breath for as long as possible; yet the attack is not necessarily associated with any special respiratory disturbance. The attitufle during an attack is best described by the * Practitioner, vol. xlvi, p. S54. 62 ANGINA PECTORIS AND ALLIED STATES. Ni ! ' I: word immobile. If seized on the street, the patient grasps a lamp-post or leans against a wall, unable to stir until the agony has passed oif. The attack usually comes on during some slight exertion, while the patient is in an erect posture. lie may be quite unable to sit down. In other cases, when the attack comes on at night, the patient usually assumes the sit- ting posture, or he finds slight relief by pressing a firm pillow to the chest, or by pressing firmly against the back of a chair. Immobility, however, is not a constant feature of a parox- ysm of true angina. In Charles Sumner's case. Dr. Taber Johnson notes that he would at times get ease by walking the floor, quite unconscious of any increase in the agony by the exertion. In others the erect posture is assumed with the head and shoulders thrown back. One patient assured me that in moderate attacks on the street, by a strong effort of the will, he could continue to walk and the pain gradually subsided. This is like the gigantic farmer, of whom Forbes tells, who thought he could rule the disease as he did his horses. State of the Heart and Pulse. — ITeberden states that " the pulse is at least sometimes not disturbed by this pain, consequently the heart is not affected by it." Parry is more positive as to the occurrence of change, holding that " what- ever may be the state of the pulse as to regularity, I believe we shall always find it become more or less feeble according to the violence of the paroxysm." The question is one about which very diverse opinions are held, and you will find in vol. i of the Lancet, 1891, several interesting letters which passed between Professor Gairdner and Dr. Ilarringtoii Sainsbury. It is quite evident that there are good authorities who accept the statement that in some cases at least the paroxysm is not associated with special change in the pulse, and consequently not in the action of the heart. ANGINA PECTORIS VERA. 53 The opportunities for observing the paroxysm do not come very often, and when they do the condition of the patient is such that our efforts are directed rather toward his relief than to the study of special points in the case. In an attack of moderate severity, such as Mr. S. (Case XXVI) had in my consulting room, the pulse, which had been 80, increased to 90 in the minute, and became smaller and harder. The ten- sion certainly became increased, but I had not time to do more than count the radial beats for half a minute and to listen hurriedly to the heart sounds before the attack was over. In Case XXXII, in the first paroxysm in which I saw him, Janu- ary 3d, the state of the pulse threw me a little off my guard; it was full and regular, and did not change much, if at all. I am not certain that it was an intense attack, as he threw him- self about on the bed, the face was flushed, and there was a good deal of commotion. Subsequently the pulse became feeble and irregular, 115 a minute. Then, on the day before his sudden death, the pulse was soft, regular, without special ten- sion, and 00 a minute. In Case XXIII the pulse fell in the paroxysm to 42 in the minute and became small and soft. For days the range had been about 96. For several hours after the paroxysm the beats at wrist and at heart ranged from 40 to 50 a minute. Subsequently the heart beats be- came more numerous than the pulsations at the wrist, rang- ing from GO to 70 a minute. In Case XXXVI I did not see the patient in his first paroxysm, but three hours later the pulse was 90, of fair volume, regular, and without increase of tension. On succeeding days, as the attacks increased in frequency, the pulse became small, feeble, and at times could not be felt. Following a series of severe attacks, the pulse may be persistently small and irregular, as in Case XXXV. In Case IV, that of a man, aged forty-five, admitted to the University Hospital, Philadelphia, February 24, 1887, I had fi 64 ANGINA PECTORIS AND ALLIED STATES. several opportunities of feeling the pulse during the parox- ysm. On the 25tli the pulse was 80, regular, and small, and the respirations 134. During an intense paroxysm the pulse became more and more feeble and at last could not he counted. This sentence 1 find underlined in my notes. Osgood has chilled attention * to a remarkable difference in the radial pulse of the two sides. The case was one of hys- terical angina in a young girl, lluchard (p. 524) refei*s to its occurrence in true angina, both in the attacks and in the in- tervals. The heart's action in severe spells is probably always disturbed, the force of the impulse weakened, and the rhythm altered. There are two changes which have been most com- mon in my experience — namely, the shortening of the long pause and the occurrence of gallop rhythm. AVHiatever may be the mechanism of the production of these changes, they both, I think, mean the same thing, weakening of the ven- tricular systole from dilatation, and debility of the muscular wall. The case which called my attention to the foetal heart rhythm following angina I saw with Dr. Underwood, at Pitts- ton, Pa., in February, 1889. The patient. Case VI, aged sixty, had well-marked signs of myocarditis, with cardiac asthma and severe pains about the heart and down the ann, so that he had to take morphine freely. I saw him shortly after an attack; the pulse was 104, weak, and irregular. At apex and base the sounds were clear, rather ringing in quality, and all distinction between the two seemed lost. " There was a shortening of the pause between the second and the first sounds, so that they followed each other in a unifonn scries, as in the foetal heart beat." This, so-called, embryocardia was a most persistent featin-e in Case V, and was present also in Cases XIX, XXIX, XXXV, and XXXVI. The gallop American Journal of the Medical /Sciences, October, 1875. ANGINA PECTORIS VERA. 55 rliytlim is, I think, met with quite as often, and was present after attacks in Cases XI, XlII, XIX, XXXII. It does not fall to the lot of many physicians to witness a sudden death in angina, but there are observations to show that the pulse beats (and tlie heart) stop abruptly. Potain mentioned a case to Iluchard (p. 525), and in the case of our good friend, Mr. E., Case XXXV, Dr. Thayer, who was pres- ent, tells me that the death seemed instantaneous — the pulse ceased at once, and there were no further heart beats. (Xote C.) As I before remarked, the mode of death resem- bles that produced by Kronecker's heart puncture. As the subje(!ts of angina pectoris present very frequently the signs of arterio-sclerosis and increased tension, you will often find a ringing, accentuated, aortic second sound. An aortic diastolic nmrmur is much more common than my fig- ures would indicate. As I have already mentioned, mitral- valve disease is rarely present. There is a very interesting feature in certain cases of angina with recurring attacks — viz., that with the development of a mitral systolic murmur the attacks have ceased as though a relief of the intraven- tricular pressure had been effected by the establishment of a relative mitral insufficiency. My attention was called to this point by Musser,* who has had several illustrative cases, and Broadbent has dwelt particularly upon this point, f Pericarditis. — During a severe attack pericarditis may develop from the involvement of the epicardium in a soften- ing infarct (Kernig). :}: Dock * has described the onset of pericarditis in a case of thrombosis of the coronary artery, due to the same cause. ITood || records a case in which the fric- * Transactions of the Association of American Physicians, x, p. 85. f British Medical Journal, 1891, i, p. 747. If. Quoted in Lancet, August 20, 1892. * Medical and Surgical Reporter, 1896. O Lancet, 1884, i, p. 205. 66 ANGINA PECTORIS AND ALLIED STATES. tion (lovclopcd twenty-four hours after tlie attack, and aub- 8e(iucntly there were signs of effusion. In the discussion which followed, De 11. Hall mentioned a similar case. llKsriRAToitY Featubes. — We have here to consider sev- eral important points — the symptoms in the attack, the rela- tion of cardiac asthma to angina, and the interesting group of cases of chronic pleuro-pulmonic affections in which angina- hke attacks of great intensity occur. (rt) In the attack, except slight acceleration in the move- ments, there may be no special changes. You will remember, in reading John Hunter's case, that, as he expressed it, he felt as though he had forgotten to breathe; and a patient may feel some sort of relief from the pain by voluntarily fixing the chest at the full inspiration, or by nuiking a very forced expiration and holding the breath. In a lethal attack the respiration may become slowed and sighing, and a few gasps follow the abrupt cessation of the heart's action. One of the most remarkable features of the attack to which the attention was early called is the development of a bronchial asthma. Erasmus Darwin * called the disease painful asthma — asthma dolorificum — without, so far as I can see from his account, any justification. On auscultation one hears over the chest numerous sibilant rules, and the breathing may become labored and expiration much prolonged, lluchard likens it to a condition of acute emphysema. In Case XXXII, which I gave you in full at the last lecture, the attacks of shortness of breath with piping nllcs formed a very distressing feature in the case. The expectoration was muco-purulent ; Cursch- mann's spirals were never found. Throughout the illness, which persisted for several weeks, this condition continued, and was the cause of much annoyance. Though Ileberden • Zoonomia, third ed., 1801, p. 41, ANGINA PECTORIS VERA. 57 (Iocs not refer specially to the asthma, he speaks of two pa- tients who had spat np blood and matter. Many patients have referred particularly to the " wheezing " which haa accom- j)anied the attacks. (Joodhart,* who describes the condition as an aci't;' bronchitis, thinks it of very grave prognosis. The same bronchial wheezing is present in some cases of cardiac asthmr ;ind doubtless gave the name to this symptom. (h) Cardiac asthma may develop during an attack or al- ternate with the paroxysms of pain. In another lecture I shall speak more at length on the relations of this feature to angina, particularly to the angina pectoris sine dolore. Here I wish only to call your attention to the distressing spells of dyspncTii. chiefly nocturnal, which may come on in the sub- ject of flTi'ina, either independently of or following an attack. In the ciises with advanced arterio-sclerosis the cardiac asthma may be the most pronounced and distressing feature, dis- turbing the patient at night, making him dread to fall asleep, owing to the horrible sensations which accompany the awaken- ing in a paroxysm of dyspnoea. The subject may die in an attack of angina after a long series of asthmatic seizures. Case XXIII, Dr. , aged forty-seven years, from Santa Fe, X. M., had advanced arterio-sclerosis. Fifteen months before his death he had an attack of angina; then for a year he had many attacks of cardiac dyspnoea, chiefly nocturnal, and once had transient hemiplegia with aphasia. He died after several paroxysms of terrible angina, recurring in the course of twelve hours. Cardiac asthma is an everyday symptom in the course of chronic valve disease and cardio-sclerosis. In hospital prac- tice it is as common as angina pectoris is rare. It may recur in paroxysms very like angina pectoris, in one of which the * Oxiy's ITospital Reports, vol. xliv. 68 ANGINA PECTORIS AND ALLIED STATES. Ill patient may die. Dresclifeld reports * the ease of a woman, aged forty-nine years, who, when younger, had been hys- terical, and later very neurasthenic. Suddenly, one night she was seized with severe dyspna?a, without any cardiac pair. A week later she had a second attack, again without pain, and in a third attack, the following night, £'art in the sym- pathetic system. The two diseases may co-exist. We have to distinguish between the attacks of nervous palpitation with * Clinical Medicine. New Sydenham Society edition, vol. i, p. 663. f Asclepiad, vol. xl. ANGINA PECTORIS VERA. C5 cardialgia in opiloptics, not infrequent symptoms, and attacks of true angina. 'J'he only instance of combination of the two disorders which I have met is the following: Case 111. — An engraver, aged forty-eight years, was ad- mitted under my care to the University Hospital, Philadelphia. He had served in the army during the war of secession, and en- tered the navy as a marine in 18V 1. After a blow on the side of the head, in the latter part of 18T3, he was insane for several months and required constant watching, lie recovered, but has had ever since, at intervals, ci)ileptic attacks, and he has frequently been picked up unconscious on the street. For the past four years he has had also violent pains in the chest with choking sensation, dilHculty in swallowing, and shooting pains down the left arm. He does not lose consciousness during these attacks, but they are evidently of terrible severity, and he feels in each one as if he were about to die. He has a well-marked aura preceding the epileptic fit, which starts in the lower part of the chest, but he is not aware of any close association be- tween the epilepsy and the attacks of angina. The patient was in a very bad condition on admission, almost pulseless at the wrist, but after the administration of whisky and digitalis he revived, and in a f<;w days seemed quite himself again. He had hypertrophy of the heart, with aortic insufficiency. There was in the wards last June (1895) a colored man, aged thirty-four yoai*s, who had remarkable attacks of ])ain about the lieart vith unconsciousness. He was a healthy- looking fellow; the pulse was not slow, the tension was in- creased, and the radials felt a little hard. The heart was not enlarged; the aortic second sound was a little accentuated. The urine was normal. Ho had probably had syphilis. Eight years ago he began to have pains about the heart, and from July to September the attacks wore so severe that he was un- able to work. In December they returned, and ever since, at intervals, he has been subject to them. Any extra exertion, 66 ANGINA PECTORIS AND ALLIED STATES. w if such as walking fast up hill, or mental excitement will cause severe pain, xactly under the left nijiple, often of great severity. In March of this year, while working in a stable, he felt a sudden agonizing pain in the heart, became giddy, and fell to the floor unconscious. He did not bite his tongaie, and, so far as we know, he did not " work " the muscles or foam at the mouth. On June 17th he had a second attack, with very much more pain about the heart, which lasted for five or ten minutes before he became unconscious. On the 24tli he was walking on the street, felt a severe pain and great oppression about the heart, and then fell unconscious and was brought to the hospital by the police patrol. The loss of con- sciousness lasted several hours. He had no attacks while in the ward, and it seemed impossible to determine precisely the nature of the case — whether the so-called cardiac epilepsy, or an anomalous type of angina pectoris. Newton * has re- ported an interesting case in which very probably both the epilepsy and the angina were associated with syphilis. * Medical Record, 1893, i. I LECTURE IV. ALLIED AND ASSOCIATED CONDITIONS. I. Syncope anginosa.— II. The Adams-Stokes syndrome.— III. Angina sine dolore.— IV. Cardiac asthma. I WISH to call your attention in this lecture to several in- teresting conditions closely allied to true angina which may cither develop in the course of an attack or which occur spon- taneously in the subjects of heart disease or artorio-sclerosis. I. Syncope anginosa.— Yow remember that Parry called angina syncope anginosa, and this feature of faintness may detain us for a few moments. The distinguished old Bath physician, from whose monograph I have so often quoted, says: " The angina pectoris is a mere case of syncope or faint- ing, differing from the common syncope only in being pre- ceded by an unusual degi-ce of pain in the region of the heart." This is too strong a statement, as in a majority of the parox- ysms, though the pallor and other vaso-motor phenomena of 2i faint may be present, consciousness, unhappily for the poor victim, is not lost. In looking over the histories of my cases I do not ^w(\ fainting, as wc usually understand the term, to have been a common symptom. There is, of course, the syn- cope of a fatal paroxysm— aS'. letalis, as Quain tenns it. Dur- ing a severe attack the patient may lose consciousness, ^fr. S., Case XXVI, was once picked up on the street. In Case XXV, mentioned in connection with angina and epilepsy, we could not determine the nature of the attacks of loss 67 68 ANGINA PECTORIS AND ALLIED STATES. ii of consciousness. Another feature of which I have no ilhis- trativc example is thus referred to by Broadbent: * A pa- tient who has ceased to suffer witli attacks of angina " may have attacks of what he calls faintness, in one of which he ultimately dies. These which have lost the title to the name angina have an ccpially serious signilicance." And, lastly, an individual subject all his life to fainting spells may present remarkable attacks of the nature of Gairdner's angina pec- toris sine dolore, about which I shall speak shortly. Case XXXIV. — T. J. J., aged sixty-one years, seen win Dr. King, ^fay 11, 1895, complaining of curious attacks which occur on the street while walking. The patient has been a very vigorous, healthy man, has never had syphilis, and has been abstemious. He has had two attacks of sciatica in the past ten years, the last, a severe one, two years ago; he has had no joint airections. lie has had an exceptionally healthy life. From boyhood, however, he has been liable to faint on very trifling provocation, such as a vomit- ing attack, a slight shock, the sight of blood, or the extraction of a tooth. From any of these causes he would drop instantly in a faint. He has not had a spell of this kind for more than two years. His present attacks date from eighteen months ago. The first one occurred when walking from the Union Station to North Avenue. He had a tingling feeling in the hands, and then a sudden fainting sensation, as though he was going to die. He had no pain. The attack passed olT in a few moments. lie took the street car and then walked to his home, having a sec- ond attack on the way. Subsequently he had these attacks at intervals, always when walking on the street. On Xovember 22, 1804, he had two very severe attacks, i;nd he then consulted Dr. King. In every instance they have con.o on while he is walking. He does not think that going up hill or walking against the wind makes any difference. He has never had an attack at his place of business or in his home, and ho * British Medical Journal, 1891, i, 747. SYNCOPE ANGIXOSA. C9 is able to go up three or four fliglifs of stairs quickly and readily witlidiit the sliglitest ciiibarrassinent. They come on with abruptness, begin now every time with a fcoliiig of numbness and tingling in lingers and hands, wliieli sometimes extends up the arms, and wliieh is not more on one side than the other, lie iuis never vomited in an atlacic; tliere is no cough, and there is no dyspna'a. lie turns of an ashen-gray color, sweats pro- fusely, and feels in each one as though he would sink away and die. It is this sensation of impending dissolution which has alarmed him so much. He has never had the slightest sen- sation of pain. During an attack he is not immobile, but he has to move slowly. Tiie day before yesterday, for example, he had an attack before he reached his house, and was able to get up the steps into the porch and close the door; but he had then to sit down, and he was found there by his son in a con- dition of exhaustion and sweating profusely. He was a healthy-looking man, with iron-gray hair and moustache; no arcus; the })ui)ils were normal. JFe was not stout, but well nourished. The pulse was 72 and regular, the vessel wall not specially sclerotic, and the pulse could be com- pressed readily. There was a slight throbbing in the vessels of the neck. The venules were marked along the course of the diaphragm. On auscultation there was a short, sharp, somewhat rough mur- mur heard only in the apex region and as far as the mid-axilla. The apex beat was not visible, but was palpable in the normal situation, in the lifth space just below the nipple. The heart impulse was felt also below the ensiform car ti age; there was no thrill. The dullness began on the fourth costal cartilage and did not extend beyond the nipple line. The percussion on the manubrium was clear. The aortic second sound was not accentuated. Both sounds were clear in the vessels of the neck; the second was a little loud at the sternal notch. The lungs were clear. Posture made no difference in the heart sounds or in the apex murmur. The liver was not enlarged; spleen not enlarged. After dressing, and in the erect posture, the pulse was 88 a minute. TO ANGINA PECTORIS AND ALLIED STATES. June 14, 1895. I heard of this patient to-day. He has had no attacks for a month. May 5^9, 1890. The patient was seen to-day. lie had a severe attack in April of this year, one of the worst he has ever had. After a hearty dinner he was attacked in the street. Tliero was no shortness of hreath, but an " all-gone " feeling, as though he were going to expire, but there was no pain with it; sweat "rolled off" him. He was well that evening. He has had in the year about eight mild attacks. He had an attack yesterdny. They occur nearly always after meals. II. — The Adams-Stokes Syndrome. — There is a most in- teresting group of symptoms associated with myocardial changes, and sometimes with angina, to which llobert Adams, of Dublin, first called attention, and which Stokes subse- quently described more fully. Most of the text-books refer to a pseudo-apoplexy in connection with fatty or fibrous myo- carditis, a condition in which with a permanently slow pulse the patient has transient vertigo, or falls into a deep coma, with or without convulsive movements. Iluchard lias given it the name maladie d"* Adams or Stol'es-Adams. As it is al- ways pleasant and profitable to have the author's first-hand description of any symptom or disease, I will give you an abstract of the case recorded in the Dublin Hospital liejwrts, vol. iv. Adams, I may remind you, was one of that distin- guished band of men, including Cheyne, Colics, R W. Smith, Graves, Stokes, and Corrigan, who gave sucli renown to the Dublin school in the first half of this century. He is best known through his superb work on rheumatoid arthritis. Adams's patient was a man, aged sixty-eight years, who liad had in seven years not less than twenty apopleptic attacks, each of which was preceded for a few days by hebetude and loss of memory. The pulse was permanently slow, and at the time of the attacks became slower. There was never any ADAMS-STOKES SYNDROME. 71 paralysis. Death followed an attack. Post mortem, the heart was found to be excessively fatty. There was no note about the coronary arteries. II. W. Smith * also noted the condition of very slow pulse with fatty heart, and Stokes de- scribed ii more f ully,f and suggested the name false or pseudo- apoplexy, lie laid stress on the syncopal character of the at- tacks, their fre<|uency, the absence of paralysis, and the good effect of a stimulant rather than a depleting plan of treat- ment. The first case which he gives is very remarkable, and is worthy of a brief abstract, as recent Anglo-American au- thors have not dwelt specially upon bis symptom-group: A man, aged sixty-eight years, was suddenly seized with a faint- ing fit, which recurred several times in the day. For the three years before he was admitted to the Meatli Hospital he had never been free from the attacks for any length of time, and had had at least fifty such seizures. A sudden exer- tion or a distended stomach was most apt to cause an attack. He had no convulsions, nor was there ever anything like pa- ralysis. He was perfectly insensible for four or five minutes. The pulse was 28 per minute, and the arteries were " in a state of permanent distention, the temporal arteries ramify- ing under the scalp, just as they are seen in a well-injected subject." There was a soft hruit with the first sound. The threatenings of attacks he could recognize, and he had often warded off a seizure by turning on his hands and knees and keeping the head low. In passing I may remark that you will find in this paper Stokes's original description of the Cheyne-Stokcs breathing, which, though fuller, is not a whit better than Cheyne's ac- count published thirty years before. * Dublin Journal, ix. f Observations on some Cases of Permanently Slow Pulse. Dublin Quarterly Journal, 1846, p. 73. 79 ANGINA PECTORIS AND ALLIED STATES. 1^' PerinnncMt slowness of tlie heart action and vertigo or syncope are tlie two distinguishing features of tliis syndrome. Do not forget that slowness of heart's action is tlie special fea- ture, not simply a diminished number of pulse beats at the wrist. In myocarditis, in mitral-valve disease, and as an effect of digitalis the raain in tlic chest, and broiu hitis. Tliroughout the summer he had iiad at times very evere ])ain in the region of the heart and down the left arm. When ih-st ^oen he was anaMuic, witli a dilated heart and * Reynolds's System of Medicine, art., Angina Pectoris. w V i 16 ANGINA PECTORIS AND ALLIED STATES. I.: an enlarged liver. With rest and iron he did very well. I saw him at intervals through the winter; the attaeks of pain ceased, but ho had severe cardiac asthma at night, which troubled him very much. I subsecjueutly saw him in several attacks which followed the exertion of walking from tiie street car to my house, in which the feature of dyspmea was subsidiary, and that of great oppression in the chest the most important. In these at- tacks the color changed, )ie became pale, looked very distressed and haggard, remained motionless, the forehead covered with sweat, the hands cold, the pulse feeble and irregular. After the attack he exj)ressed himself as having had a feeling of in- definable distress without actual pain. There was no dyspncea. The attacks at night were sometimes very severe, and he dreaded to go to sleep lest he sliould be roused in one. Though in the snmmer of 1 89'^ he had had repeated attacks of what seemed to be true angina, yet he subsequently had only attacks of the kind just described. In the spring of 1893 he became much worse; there were sigi;s of dilatation of the heart, with the gallop rhythm, and a soft apex systolic murmur, lie had cardiac dyspmea, as well as atiacks of severe oppression, and in one of these he turned on his side and died suddenly. An attack of an angina sine dolore may be the very first indication of cardiac trouble. An intimate friend, a man of about fifty-six years of age (Case V), of excellent iiabits and great energy, while on a visit to England, walking one Sunday afternoon with the late Dr. Hack Tuke up a slight acclivity, felt, as he expressed it, a sense of intolerable distress about tlie heart, turned ])ale, vomited, aiul for a few minutes could not move from the phue at which he was attacked. He recogni/ced the serious character of the })aroxysm, and said that had there been the severe pain he would have called it angina. The attack was the starting ]H)int of a series of very distressing seizures, culminating in a protracted condition of cardiac dilatation, which kept him in his bed in Paris for several months. On his return he was i:s. AXGINA PECTORIS SINE DOLORE. 77 well. I saw pain ceased, roubled him tacks which to my house, and that of In these at- ry distressed L'overed with uUir. After eeling of in- no dyspntra. d he dreaded lough in the lat seemed to s of the kind there were lythm, and a niea, as well e he turned he very first years of a^o ile on a visit the late Dr. ed it, a sense ale, vomited, lace at which racter of the ioro pain he the start in;? linatintj in a h k('|)t him L'turn he was wonderfully better, took up his work, but soon had anoLher breakdown, bejiinnin^ with attacks of luujina sine dohre. In one of these which I saw the pallor was extreme, the extremi- ties were cold, a clammy perspiration bathed the forehead and face, the pulse was extremely feeble, and 1 thouj^ht any moment that he would die. After a protracted attack of cardiac dilata- tion, persistently feeble, irreguhi!' pulse, without any dropsy, but with the most remarkable psychical manifestations, he re- covered, and was able for more than three years to attend to his duties. Then he had a sudden, more rapid breakdown, with cardiac dilatation, and he died between three and four years from the date of his first attack. I have already shown you sections from the conmary arteries in his case, which were sclerotic, and the myocardium was fibroid in places. Cask XXX. — E. IL, aged fifty-four years, seen July 11, 1895, complaining of attacks of oppression in the chest, to which he had been subject for five years. The patient was a remarkably healthy-looking man, of good color, of medium size, with iron-grav hair. Thirty years ago he had syphilis, but was thoroughly treated at Kreuznach, and he has had no troublesome symjUoms. lie married eight or ten years ago, and has healthy children. ITe has been a very heavy smoker froju his eighteenth year; ctherwise temperate; he has never done heavy work. Five years ago he noticed that when making any extra exer- tion he had a sensation in the chest which compelled him to stop. After resting for a moment or two he could then go on. riuM-e was no ])ain with it. lie was smoking excessive- ly nt the time, and after sto))ping the tobacco the attacks be- < u.ie . ; frecpient; but for two years they troubled him a good deal. I'hrce years ago he retired from business and speiit a year in F .rojie. When there he had his first severe attack. While going home after a hearty dinner with a friend, he was seized with a sensation in the chest, had to stop in the street, and was taken to his hotel. The feeling in the chest was as if everything in it was being drawn together and tightened, but without any sharp pain. lie was very pale, he perspired, and the attack i i X' IS ANGINA PECTORIS AND ALLIED STATES 'it I II lasted until the night. After the attack he had great depression of spirits. The only other severe attack he has ever liad was six weeks ago. Jle had been feeling very well, but before sitting down to dinner an annoying circumstance developed, and while still under the inthience of the irritation he sat down and ate heartily. Inini'diately after dinner he had an attack of terrible opi>ression in the chest, feeling, as he expressed it, as though the life was being squeezed out of him. The slightest nu)vement would increase the oppression. In the attack absolute quiet is what he desires, lie does not even wish to be spoken to, but feels that the mind must be at rest. The immobility is evidently a very characteristic feature. When the sense of constriction and drawing is upon him, he says he could not f(u-ce himself to budge an inch. In these severe attacks the pulse becomes very slow. The sensation is in the breast-bone in the mid- dle. In describing his sensations during a conversation of at least 'throe (puirters of an hour he did not use the word pain once, and states exj)ressly that it isn't anything like i)ain, but an in- describle sensation of constriction and oppression. As he says, "he feels as if the end of everything had come" ; at the same time " he feels so healthy that behind it, as it were, there is a feeling tliat lie still has a long time to live." In the. two severe attacks a feeling extended into the mus- cles of the arms, not into the skin, he says, but there was a sense of strain and soreness in them. i'he small attacks, as he calls th^^m, recur with great fre- quen -y, and ahuost any day he has what he calls a hindrance; and if he makes any exertion of more than usual effort he has to stop sliort and wait a few moments until the sen>ation passes away. This may recur two or three tinu's, and then, if ^e takes it slowly, he can subse(piently walk two or three miles witiiout any distress. Two other circumstfinceH wiiich will bring on an attack are an unusually full meal and any mental worry. He never has the attacks at night. The pulse was I'i when he was ot rest; after his running ANGINA PECTORIS SINE DOLORE. 79 upstairs and down, 10-i; tlie tension was not increased; the Bupcrfieial vessels were not sclerosed. The apex-heat was only just visihle in fifth interspace with- in the nipple line. The shock of the first sound was felt, not of the second. Area of superficial dullness was reduced by emphy- sema. Both sounds of the heart were clear; first a little flapping and valvular; no accentuation of aortic second sound. The ex- amination of the heart was entirely negative. The liver was not enlarged. July 12th. The patient stayed in town until I could see his condition in an attack. He had had two to-day, one quite light in the morning. He walked into the room somewhat deliberately, talked clearly and well, and had not changed in color. He said he had a sense of great distress just beneath the breast-bone. The pulse was small and hard, 103 a minute, with distinctly increased tension. After sitting down for a few moments his skin became moist, but he did not become pale. In the course of a few minutes the attack passed off with a feeling of glow. Afterward there was a very decided change noticeable in his pulse, which was softer and fuller, and of decidedly low'er tension. He was advised to stop smoking, and ordered a course of nitroglycerin. I heard from him in September and of him in May (189G). He still has the "smaller attacks," as he calk them. The attacks may alternate with those in which agonizing pain is present, or they may entirely supplant the severer type. Some of the milder paroxysms, indicating the begin- ning, as it were, of the trouble, appear to be of this kind. An iron-gra}', healthy-looking man, aged sixty-four years, of good habits and excellent history, consulted me, May 25, 1805, about curious sensations in the chest. In October he noticed that when walking fast there was a peculiar sensation about the heart, as ho said, " an aureole, which spread up his neck and head and went out to the hands." If lie sto])pcd for a moment, the sensation would " recede like a glow " ; if he 80 ANGINA PECTORIS AND ALLIED STATES. I wont on, it would eiilniinate in a pain which wouhl conipol him to st()|). There was no sense of i'aintness, no dyspncea, and he did not sweat. Tiiey liave always followed exertion, and he lias had as many as four or live attacks in a day. His arteries were a little stiff, hut the aortic second sound was not accentu- ated. The top of the pinna of the left ear was calcified. Jle had never had gout. 1 heard from this patient on February Gth of this year. The attacks continue, though less frequent — only two or three a week. They are characterized by the same spreading glow, beginning at the heart, and lately the curious sensation has passed down the right arm alone. IV. Cardiac Asthma. — Ilohenhui insisted that in the paroxysm of true angina there was no ahortnesx of breathy and yet we find a few years after liis description tiie tenii asthma applied to the condition: Asthma dolorijicum (Dar- win), A. arthriticmn (Schmidt), A. cmivuhivitin (Fllsner). In reading the rejiorts of the cases published within tlie first half century after Ileberden's pai)er, it is very evident that much confusion existed, and nearly all forma of cardiac distress were termed angina. Desportes emphasized this on the title-page of his monograph (ISll) on angina, which he said was a malady " prescpie toujcmrs confondue avec asth- ma." The earliest and the latest, as it is the most urgent, symptom in heart disease is dj/sj>7ia'a, which the older writers characterized as asthma; and as it forms a common feature in eases of angina pectoris it is not surprising that more or less confusi(m prevailed. Even Stokes docs not seem to have had a very clear conception of the distinctions between these states, since he says that the disease which " most often gets the name of angina pectoris might be more properly desig- nated as cardiac asthma." "What, then, is this condition? Oo into the wards and ask the patients with valvular disease of the heart as to the very £,r8t s^nnptom of tlicir trouble. With scarcely an exception CARDIAC ASTHMA. 81 they will answer, " Shortness of breath." Take a long series of histories of cases of arterio-selerosis; you meet with the same eomi)laint at tlie very outset. To the hurly, obese dray- men, to the lieavy workers and the hard drinkers, and particu- larly if in addition they have been victims of the pox, Xemesis pays her first visit in an attack of shortness of breath — the first indication of broken comj)ensation in an enlarged heart. Clinically, we meet with various grades of intensity in this cardiac asthma. An exertion, the ascent of a pair of stairs, which may call forth only a fraction of the reserve force of a nonnal heart, may be too much for a right ventricle (in a case of mitral stenosis), or for a left ventricle (in a case of aortic insufficiency), and at the head of the stairs the pa- tient pants, and is perhaps a little cyanosed. In chronic val- vular disease such symptoms may recur on extra exertion for yeai-s without much significance; when the cardiac dysp- na^a develops spontaneously, loithout extra exertion, the breakdown is not far off; and in the slow, too often watery progress to the grave no other symptom is so distressing to the patient. In cases of advanced arterio-selerosis there are often attacks of dyspnoea of great intensity recurring in paroxysms, often nocturnal. The patient goes to bed feeling quite well, and in the early morning houre wakes in an attack which, in its abruptness of onset and general features, resembles asthma. There is usually a sensation of proBcordial distress, a feeling of constriction and oppression, what the Germans call Beliemmnng. Two other features about this form of attack will attract your attention — the evident effort in the breathing and the presence of a wheezing in the bronchial tubes and of moist rales at the bases of the lungs. The pa- tient may spring from the bed and throw open the window in his terrible air-hunger, and he assumes an attitude most favor- [ Mr p I 1 82 ANGINA PECTORIS AND ALLIED STATES. able to tljo working of all the accesriory nmsflos of nspinition. Slight fyano!*is is usually [JivfCMit, and in severe panjxy.snia a cold sweat breaks out iu the face and lind)s. The pulse is feeble, often irregular, and very suuiU, and on auscultation one hears either gallop rhythm or the f-T m 94 ANGINA PECTOiaS AND ALLIED STATES. tion of the heart wns negative, the aortic second sound was rinp;- in<,' and accentuated. The i)Ui)ils were equal; she had no arcus ticuilis. There seemed very little doubt that this wna a pseudo- angina, and I reassured her upon the (piestion of sudden death. I heard of this patient on July l.'5th and on Decem- ber 30th. She has not had a severe attack since February; for a few months she had '' threatcnings," as she calls them; since July she has been quite well. The followinj;; case is of interest from the intensity of the paroxysms and the hypenesthesia of the left arm. She had been alarmed, too, by the serious view which had been taken of her condition : Case IV. — ^^fiss C, aged twenty-two years, referred to mo September 29, 181)1, by J)r. Clark, of Skancat<'les, conii)lain- ing of remarkahlo attacks in the re<,non of the heart. The family history is good, and she has herself always en- joyed very good licalth. She is evidently a high-strung, nervous girl, who has studied hard. When quite young, about the twelfth year, she had for a time pain in the left side about the heart and sensations of coldness. The present complaint has persisted for between two and three years. She describes a pain, more or less constant in the left front of the chest, which sometimes goes down the arm, which becomes numb. She says she is never without this pain, and that it sometimes keeps her from sleeping. Then she had sudden spells, in which she has a terrible sensation of spasm in the region of the heart, as though something had grasped her. It differs altogether from the other pain. In severe attacks it has lasted all night, and she has had to gasp for breath. She does not perspire. The left arm becomes nimib, often tingles, and in severe attacks the numbness extends to the left leg. The left arm feels almost paralyzed and is tender, and she can not use it in the attacks. There may be headaches, but she is never sick at the stomach. She never has any special coldness of rSEUDO-ANGlXA PECTORIS. 05 •(•US -'111 ; the oxtroinitioH. Slio lias only had four -if these very sovore paroxysms witliiu the year. Durin;; tlieni she takes elilorol'oriii and nitrite of ainyl. Tiiey have never l)een broui^'ht on l)y exer- tion, and she has been able to play tennis (piito aetively. Kx- fitenient and emotion most fre(|ueiitly cause them. The jtatient was evick'nlly very neurotic. She had no heart disease, no increased tension, and no sclerosis of the vessels. An interestini,^ feature was the ^'reat sensitiveness of the left hand and arm. She junii)ed at once when 1 touched the wrist in order to feel the pulse. The various forms of sensation in it were p' rf'-ctly normal. Thoufih sensitive to the touch, she feels it nunil) and heavy. The sensitiveness did not extend to the skin o" the chest. The condition lind hccn tlio cniiso of a good deal of nlann to her friends, and a diagnosis had been made by one of lior ])liysicians of a tumor pressing in the region of tlie lieart. She was given a very favorable prognosis. I saw tliis patient for a few moments abont a year ago. She had entirely recovered from her attacks and, thongh nervons, seemed very well. Hysterical angina in the male is usually a very well- characterized affection. The following cases arc the most typical which I have seen: tn ^^ Case Y. — "W. IT., seen with Dr. Purvis, of Alexandria, aged thirty-two years, complaining of severe attacks of pain about the heart. The patient comes of excellent German stock. His mother is alive and his brothers and sisters are well and strong; there are no special nervous troubles in the family. Though an liotel- kcejier he has been very abstemious in the use of alcohol. He has never had syphilis. He has been nervous from boyhood. When about fifteen he had a fright, after Avhich he had nervous spells, called fits, for several years. From his description, they were evidently severe hysterical attacks. At the age of twenty- three he had scarlet fever and diphtheria, and nearly lost his li m ' !l r; 96 ANGINA PECTORIS AND ALLIED STATES. life. For the past six years he has had a great deal of mental worry, and for nearly two years a good deal of extra financial strain. During this time he has had at intervals what he calls nervous attacks. He would get numb in his feet and then in his legs, and a sensation would rise in his body like a wave, mak- ing him cold and faint. Dr. Purvis, who has seen him in the spells, says they are evi- dently hysterical. He does not lose consciousness. For the past three months he has had different attacks, con- sisting of very agonizing pain about the heart, extending to the shoulders and down the arm even to the fingers, very frequently only to tlie index finger and thumb of the left hand. They have come on most frequently while walking, lie catches his breath and has frequently had to sit down on a doorstep. He describes the pain as very agonizing, but he makes no mention of any sensation like that of impending death. Ilis hands get cold; sometimes the feet are cold, and he has at times broken out into a profuse perspiration. The attacks have recurred with great frequency. He has had as many as four in the twenty- four hours. Worry, overexertion, and on several occasions a full meal, have caused attacks. They have increased rather than diminished during the past month. The patient was a healthy-looking, well-nourished man, of good color, of fair physinue, with black hair and eyes. The pulse was quiet (80 a minute), tension not increased. He flushed easily, and there was the most marked factitious urticaria and dermatographia. The apex-beat was not visible and not palpa- ble. The superficial cardiac d illness was not increased. The sounds at the apex were clear. There was no accentuation of the aortic secoiiu, and there were no murmurs. There were no painful spots about the pra^cordia. The patient subsequently entered the private ward of the hospital, where he had several attacks of the character above described. Case VI. — On May 23d I saw at the Rennert Hotel, Dr. R., aged thirty-three years, a physician from one of the North- ern cities, who had had a series of most severe attacks dating from May 15th. The patient, a man of very high-strung, nervous organiza- PSEUDO-ANGINA PECTORIS. 97 tion, had had a very hard battle in life, overcoming almost in- superable physical difticulties. His general health had been very good. He had been a very hard student, and had done much work outside his ordinary professional duties. Three years ago, while engaged in instructing a class, he felt suddenly a terrible pain in the heart, and a numbness extended down the left arm and leg. He was unable to stand, but did not lose consciousness. He recovered from this attack in the course of an hour or so, and had no recurrence until the 15th of the present month. At 5.30 p. m., while in a cab, he was suddenly seized with an agonizing pain just below the left nipple. There were numbness and tingling in the left arm and leg. That night the pains recurred, and from his wife's account he evidently had a series of hysterical attacks; he became very emotional, wept, and had remarkable delusions. The pain was of such severity that he had to have morphine. The pulse was veiy variable, and at one time became extremely rapid, above IGO. His face was flushed, not pale. On Sunday, the 17th, he was better, and on Monday he was all right and attended to his practice. On Tuesday, while per- forming a minor operation, he had a recurrence of the agoniz- ing pain. He said: "Words can not describe my torture, but I went on and completed the operation." On Tuesday evening he had another severe seizure, and had to have morphine hypodermically, and took chloral and bromide through the night. Ox. Wednesday he was in very bad condition, was nervous, emotional, and quite delirious. On Thursday he was annoyed by a cabman, and had an attack in the street, which upset him very much, but which was not, however, followed by delirium. Altogether, in the past eight days, he has had five or six paroxysms of great intensity. In the attacks his wife says he is very restless, gets quite beside himself with the pain, and de- mands morphine at once. He has had all sorts of delusions, and has been in a most unnatural mental condition. Patient was very healthy-looking, evidently very high-strung and nervous, a man who had for years lived far too intensely, and had worked very carelessly and with too much friction. "I Jl !■! fi nil I i. ( 98 ANGINA PECTORIS AND ALLIED STATES. I I ^lll The physical examination was entirely negative. The pulse was quiet, without increase in tension. The heart sounds were clear, without accentuation of the aortic second. The vaso- motor system was extremely labile, and the slightest scratch was followed by an active reaction. The persistence of pseudo-angina is sometimes very re- markable. In 1888 I was consulted, in Philadelphia, by an old friend, a iDliysician from the Province of (Quebec, who had very severe heart disease. While I was visiting him late one evening at the Lafayette Hotel, lie asked me to step into the next room and see his wife, a woman sixty years of age, Avhom I found prostrate on the bed with her hands clasped over her heart, rocking herself from side to side, in an agony of pain. Her hands and feet were cold, the face somewhat flushed, the pulse small and rapid. I could not get an answer from her, but when I returned to the room the doctor said not to worry (I seemed anxious about her), that she would recover in a little while. He assured me that for more than thirty years she had been subject to these at- tacks, particularly when overanxious or worried. She was a very nervous woman, had been hysterical when young, and though at first lier husband and other physicians thought the attacks very serious, they passed off so quickly, particu- larly under the influence of a hot whisky punch, that he had ceased to regard them as in any way dangerous. (h) Yaso-motor Angina. — Yaso-motor phenomena are rarely absent in attacks of true angina, but they are even more pronounced in the nervous and hysterical subjects. Xothnagel has described a special type, angina pectoris vaso- motoria.^ In the four cases (all men) the symptoms con- sisted of peculiar sensations in the extremities or on one side * Deutsches Archiv. f. klin, Medicin, Bd. iii, 1867. L^. AXGINA PECTORIS VASO-MOTORIA. 99 of the body, with coklness and sometimes lividity of the hands and feet and sweating. AVith this there were palpita- tion of the lieart, terrible precordial anxiety or pain, and sometimes feelings of faintness. A striking feature in these eases was the tendency of the attacks to occur in the cold, or on washing the hands in cold water. Xothnagel regarded these vaso-motor phenomena as the primary features, and the cardiac embarrassment and distress as secondary to a widespread vaso-constrictor influence throughout the arterial system. A good deal of discussion has taken place upon the pro- l^riety of recognizing this as a special type, and considering the frequency of vaso-motoi* changes in both organic and functional forms it does siem doubtful; and yet the cases are wonderfully well characterized and in the most pro- nounced degree always, I think, of the functional variety. In a large proportion the vaso-constrictor influences dominate, and there is pallor with coldness. I remember but one in- stance in which the vaso-dilator phenomena alone were marked. In 1887 I saw (Case YII), in Toronto, a lady, aged thirty- five years, stout, well nourished, the mother of five or six chil- dren, who had been the subject, at intervals, of very puzzling and distressing attacks. Without any special reference to the menstrual period, and following particulnrly worry or excite- ment, she would experience a feeling of distress about the heart amounting to actual pain, and the vessels of the face and of tlie extremities would become congested, and she felt cold and nimib. But much more distressing than these were the sensa- tions of great pain in the back of the head and neck. The at- tacks would last for twenty-four hours or more, and were some- times very alarming. I could not gather from her that the pains about the lieart were ever of a very agonizing character, but they were always severe. I was asked to see her to determine ■ t '• I'i M I I; I I I I ! : ii i^l fi ii ':!| i| .ii; 100 ANGINA PECTORIS AND ALLIET> STATES. the presence or absence of a heart lesion. Both sounds seemed perfectly clear, and there were no signs of organic disease. I was much impressed with the neurotic condition of the patient, and suggested hysteria. I saw the patient in an attack, evident- ly hysterical; she was greatly prostrated, lay with the eyes closed, quite livid in the face, and the hands and feet were pur- plish in color and cold. She complained of great distress about the heart and agonizing pain in the back of the head and neck. The subsequent history has borne out the view taken of her case. Within a year or so she got perfectly well and has re- mained so, not having had an attack for nearly eight years. Much more commonly there is pallor with the coldness. In women the attacks are apt to recur at or before the men- strual period. Mrs. R (Case VIII), aged forty years, consulted me in 1890 about attacks of severe pain in the region of the heart, which had recurred at intervals for eight years, since the birth of her last child. They were particularly liable to come on dur- ing the menstrual period, or whenever she was subject to any special mental strain or worry. The pains were very severe, im- mediately under the left breast, and passed up the neck and down the left arm. She did not flush with them, but, on the contrary, got pale and felt very cold, particularly in the hands and feet, which sometimes sweated. The pains were not con- tinuous, but recurred at intervals extending over a period of several days. Diet, she thinks, had no special i ..' ence. She slept badly and dreamed a great deal. The patient was a stout, well-nourished woman of good color; the pulse was regular, about 80; the arteries wcxc not sclerotic. There was no heart disease. In women, as you will have noticed in the reports I have read, the features of coldness of the extremities with numb- ness and pallor are very common. In men this type may occur in a most marked degree, and the diagnosis may be for some time in doubt. L i ANGINA PECTORIS VASO-MOTORIA. 101 Case IX. — A. B., aged forty-two years, seen December 30, 1895, complaining of paroxysmal attacks of terrible intensity, characterized by a feeling of suspended animation, as though the breath had left the body; at the same time the hands and feet get cold, and there is a sensation of stricture about the root of the neck. The patient, who occupies a prominent position of trust, looks a healthy, vigorous man. His family history is excel- lent. As a young man he was very well. He has never had syphi- lis; is a moderate drinker, and has used tobacco freely. Seven years ago, following a period in wliich he was very much over- worked, he first had the attacks, which recurred for nearly eighteen months. At that time they caused him great alarm, but with the exception of two, they were not very severe. The present attacks date from just two months ago. He has been in his usual health, and knows of no special cause why they should have come on. A majority of the paroxysms have oc- curred at night, just as he was beginning to doze to sleep. He has had tliem also on the street, and seven years ago in one he had slight vertigo, ..i.d had to sit down on some steps, and he felt as he sat upon them as though they were rising and falling. The attacks may come on while he is sitting at his desk, or while he is reading quietly in his chair. Exercise is very apt to bring them on, and if he runs for a car or hurries upstairs he is apt either to have a severe attack or to experience a chilly feeling and the sensation which he constantly speaks of as though his breath had all left him. The sensations which he describes in the attack are very curious. He lays special stress on the feeling that the respira- tion had ceased, and it gives him some relief to draw several deep breaths. With this is associated a sense of great stricture about the lower part of the neck, and a terrible sensation about the heart, as though it was his last minute. He feels strangely in the head, and thinks he has a very wild look. The face be- comes pale, the hands and feet get cold as ice, and become very clammy with perspiration, and in several attacks he has had a feeling of numbness in the legs from the knees down. He lays f'i >i ' I i 102 ANGINA PECTORIS AND ALLIED STATES. very great stress upon the sensation of coldness in the arms and legs, and says that on one occasion he took a warm bath, and even though the water was quite hot he still had a feeling of great coldness and numbness in his legs. In one attack the face and neck became very red and congested, and the nose bled profusely. There is invariably palpitation of the heart, and he has been told by his doctor that the pulse at the wrist becomes scarcely perceptible. In a paroxysm, seven years ago, he thinks he lost consciousness for a moment. He staggered and fell. In one attack at this time he had vertigo. As the paroxysm passes oit' he belches a great deal of wind. In several spells there has been a good deal of itching of the skin, and in one or two a marked twitching of the muscles. The duration of the entire paroxysm varies from two or three to ten or fifteen minutes. He linds that a strong drink of whisky will sometimes cut short an attack. In the two months since they recurred he has had on an average about four in a week. They have not all been severe. He has been much alarmed about them, and in several of the attacks both he and his wife have been greatly terrified. Patient was a tall, well-grown, healthy-looking man. There was no arcus senilis; the pupils reacted readily to light. The pulse was soft and full, regular, tension low. The apex-beat was just within the nijiple line, not forcible; slight throbbing in the vessels of the nock. The percussion note was everywhere clear; there was no increase in the area of heart dullness. The heart sounds were clear; the aortic second was not accentuated; the breath sounds were equal on both sides; there was no dull- ness in cither interscapular region, and no bruit in the course of the descending aorta (a diagnosis of aneurysm had been made). The cervical glands were not enlarged. The examina- tion of the abdominal organs was negative. The knee-jerks were normal. There was no Komberg's symptom, and the pupil reflexes were active. January 1, 189(5. The patient's wife came to-day to speak about her husband's condition. She says that last summer he had a few slight attacks. She mentions several features of in- terest, particularly the suddenness of the onset. For example. !!■! ■!i, PSEUDO-ANGINA PECTORIS. 103 rms ith, ing he will awaken from a perfectly sound sleep in a most alarming paroxysm, and his hands and feet will become cold; the face is usually pale, and the heart will throb most forcibly. Within a minute or two his hands will become as wet as though they had been dipped in water. She remembers two or three attacks in which the face became quite congested and ful instead of pale. lie is greatly terrified, and always feels that he is going to die. "What has reassured her always is the fact that within ten or twelve minutes, sometimes less, he is laughing and talk- ing, quite free from pain. She does not think that he has been a very nervous man, and he has not had any special worries. April 1, 1890. For the past two months this patient has been very much bettor, and, as he tells me, has almost recovered from his attacks. June 1st. He has not had an attack for nearly four months. (f) lieflex Angina. — And lastly, in addition to the purely hysterical and vaso-niotor forms, there are cases in which the angina apjiears to be excited reflexl}', either from pe- ripheral or visceral irritation. You will find an interesting chapter in Iluchard devoted to these reflex pseudo-anginas, and he has collected a number of cases from the literature. Tliere are instances of anginous attack following a cervico- brachial neuralgia, of either traumatic or spontaneous origin. You remember in the histories of the cases of true angina how insistent many patients were as to the influence of diet. There is also a so-called gastro-intestinal form of pseudo-an- gina, in which attacks follow indigestion. The following is the only instance in my list in which the visceral irritation appeared to induce the paroxysms, or, to speak more cor- rectly, in which the two conditions were associated: Case XII. — ]\riss A., aged twenty-two years, seen April 4, 1893, complaining of severe attacks of pain in the region of the heart. She belongs to a nervous family, and she has never been m ' 'M lali! Iu4 ANGINA PECTORIS AND ALLIED STATES. i i ■m ill I I very strong. She denies having had hysteria. Several times, as a chihl, she had slight rheumatism, and three years ago she was hiid up with a more acute attack. Several members of her family have also had it. For years she has been subject to dys- pepsia, particularly after eating too many sweet things. For a year or more she has had occasional attacks of i)ain in the chest, coming on particularly when she has indigestion. The pains are neuralgic in character, chiefly about the lower part of the chest, yet sometimes, to use her own expression, " they fly all over her." Lately she has been much alarmed by the occur- rence of two attacks of great severity, the first about two months ago and the second a month ago. There was agonizing pain in the region of the heart with shortness of breath. Both were severe enough to require hypodermic injections of morphine. The pain, so far as she could localize it, was in the left side, in the region of the heart, not in the abdomen. On both occasions, though the severity of the pain was only, as she said, for an hour or so, yet for two or three days after she had more or less pain and distress. On both occasions she had dyspepsia, but slie hsd not been specially nervous or run down. She does not know whether she got pale dur- ing the attacks, but she sweated after them. She takes a great deal of exercise, but has never had an attack brought on by exertion. She looked a nervous girl and flushed easily. The examina- tion was negative, with the exception of slight dilatation of the stomach. II. Toxic Angina. — The second division of functional or pseudo-angina embraces cases due to the abuse of tea, coffee, and tobacco, substances harmless in themselves, but which if taken in excess may disturb the action of the heart. My experience with this form is extremely limited. In tea or coffee drinkers I have never seen attacks of cardiac pain which could be called angina ; though paroxysms of severe palpitation, with distress about the heart and gasping respiration, are not uncommon in nervous women much addicted to tea. Tobacco, i TOXIC ANGINA PECTORIS. 105 «s a rule, produces only slight and transient disturbance of the heart's action, but which may culminate in attacks of angina. When one considers how universal is the custom, the infre- quency of severe heart symptoms in users of tobacco is re- markable. I pass months without seeing, in hospital or con- sultation work, an instance in which symptoms of any kind are due to it. You all know, some of you have experienced, the acute toxic symptoms in beginning to use tobacco. The effects of the habitual use are very varied. To the large majority of persons the habit, in moderation, is harmless, to mmy i; is beneficial. Among the injurious features those relating to the heart are perhaps the most important, certainly they are the most common. There are three groups of cases of so-called tobacco heart: 1. The IrritaUe Heart of SmoTcers. — Palpitation, irregu- larity, and rapid heart action are very common symptoms, particularly in young boys. They are often combined with dyspepsia; pain is not a special feature. There may be slight enlargement of the heart. It is a condition readily relieved by stopping the use of the weed. Disturbance of rhythm is the most constant effect of tobacco, and intermittence is more common than either slowing or hastening of the heart's action. Weakening of the vagus control is the more frequent, though in my own case the slightest excess in the use of tobacco causes intermission with slowing, not increase of the pulse- rate. An opposite effect — great rapidity with feebleness of impulse — is more common, and may develop suddenly in an habitual smoke». 2. Heart Pain. — Sharp shooting pains about the heart are not very uncommon in persons who smoke or chew too much. They may occur alone without disturbance of the cardiac rhythm or without the intensity and associated features of 1 W I •fv 106 ANGINA PECTORIS AND ALLIED STATES. ?: an attack of tobacco angina. The following is a good illus- trative case; I. B., aged twenty-nine years, seen ^March 2i, 1890, com- plaining of pain in the region of the heart just below the nipi)le. The first attack was four or five years ago, and it has recurred at intervals ever since. Sliortly after the onset his physician suggested that it might be due to tobacco; and wlicn he gave up smoking the attacks disappeared altogether. Since he re- sumed the habit they have recurred, and for tlie past year he has had them more frequently. The attacks occur at night, just after he has fallen asleep. lie is awakened with a severe pain in the region of the heart, which almost takes his breath away, and makes him cry out at once. It rarely lasts more than a minute or two. The heart's action is not increased. He never has had any sweating and does not change in color, nor do his hands and feet become cold. lie has never had any i)ain down the arm. It is always of the same character, sharp and stab- bing, just below the nipple, and is intense enough to cause him to cry out. He has had as many as four or six attacks in the twenty-four hours. In the daytime the pain is not so severe, and the spells are more transient. He has never had an attack following exertion, and neither emotion nor errors in diet have any influence upon them. He was a member of a very nervous family. He was himself a healthy, vigorous man. He had smoked from his boyhood three or four strong cigars, and when traveling, five or six cigars a day. He felt himself that the tobacco was responsible for the pain. He was a healthy-looking man, a little pale. The pulse was 76, regular, and without increased tension. The apex- beat was in normal situation; the heart sounds were everywhere clear. The second aortic was perhaps a little accentuated. There was no pain on pressure, and no hypera3sthesia. He was advised to stop smoking altogether. 3. Tobacco Angina. — I have seen but two cases in which the severe paroxysms of cardiac pain appeared to be due to the abuse of tobacco. M illii TOXIC ANGINA PECTORIS. 107 us- Dr. , of , ngod thirty-five years, consulted me April 13, 1891, coinplaining of severe pains in his chest and of nunih- ness in the left arm. The patient has a very gouty history on both sides. ]le has been a hard-working practitioner, has been a moderate drinker, and has used tobacco to excess, both smok- ing and chewing. Four years ago, when he had been smoking very Ijeavily, he had an attack of pain about tlie heart and down the arm, for which he consulted Dr. Pepper. lie had very little trouble again until six or seven montlis ago, when the attacks recurred. He then consulted Dr. DaCosta, who said that he was gouty and without organic disease of the heart. Irately the attacks have been very severe, chiefly under the left margin of the sternum and reaching down the arm, which be- comes numb and tingles. He has never had an attack in which there was a sense of impending dissolution. The patient was a healthy-looking num; the pulse was 78, the tension a little plus, but there was no sclerosis of the arteries. The examina- tion was negative, with the exception that the aortic second sound was perhaps a little sharper and clearer than normal. He was told that he had no heart disease, and he was urged to live a temperate life, to give up tobacco, and ordered ten grains of iodide of potassium three times a day. After seeing him the first day I dictated the following note: " In this case the gouty history and the acientuated second sound are perhaps suggestive of true angina. On the other hand he has been a very heavy smoker, is evidently nervous and worried about his condition, both of which factors must be taken into consideration." Ill f u I have seen this patient at intervals during the past five years. lie lays very great stress upon tobacco as the cause of the attacks, and any indulgence is apt to be followed by severe pain. On February 17, 1894, in a letter lie laid stress again upon the part played by tobacco; in a letter received recently he gives a very satisfactory account of himself, though he still smokes, and still has attacks. There is a feature in this case upon which Huchard lays a great deal of stress in tobacco an- ? 108 ANGINA PECTORIS AND ALLIED STATES. \t^^. ( gina — namely, the oeeurrciicc of ('ortaiii not'turnal spells al- most like syncope. The patient states in the recent letter that " the strangest symptom of all is that jnst as I lose myself, and am abont to drop to sleep, and often jnst after losing conscious- ness, r choke, sit np ([nickly, and feel for the moment as if * the game was np.' There is no jjain, no excitement of the heart, and yet this often occnrs after having a choking fnlliiess ant. Sensory nerve endings have been dem- onstrated in the arterial walls, and it has been suggested fre- quently, in recent discussions on angina pectoris, that the main element of the attack may be vessel j)ainj due to either angeiospasm or thrombosis. There may be — there is not al- ways — great pain in the blocking of a large vessel, artery, or vein by a thrombus or embolus. The name phlegmasia alba doleiis emphasizes a prominent character in th'» plugging of the femoral vein, and, as I have just said, the pain after liga- tion of the femoral or the api)lication of the tourniquet is often very intense. Nothnagel refers also to the pain in the head in blocking of large cerebral vessels. It is not unrea- sonable to suppose that pain of the same nature may occur in blocking of the coronary arteries, though I do not call to mind the existence of special pain in embolism or thrombosis of arteries of the size of the coronary vessels in other organs. Moreover, as I have already said, we can not suppose that in each attack a thrombus develops. Angeiospasm is a much more likely cause of the pain, and it may be associated in gome cases with blocking of a vessel. There are the analogous conditions of migraine with its vascular spasm and intense pain, and the vascular changes with pain in Raynaud's dis- ease. Balfour has an interesting paragraph upon this ques- tion of pain in the arteries: " That ischffimia docs give rise to pain, even of the most atrocious character, is sufficiently attested by the agony that attends compression of an artery for aneurysm, especially at the moment the vessel becomes completely occluded; the ^,?V:.:':'' \i m' 124 ANGINA PECTORIS AND ALLIED STATES pains, arising from a similar cause, tliat precede tlie appear- ance of gangrenous patches in a limb affected with senile gan- grene; and those which precede, accompany, and follow at- tacks of local asphyxia (Raynaud's disease). There is every reason to suppose that the arterial spasm, which is so evidently the cause of local asphyxia, and which takes so prominent a share in the production of an attack of angina vasomotoria, occasionally invades the heart, either as part of a general con- dition or, it may be, as a distinctly local affection, and that this is a very possible cause of those anginal attacks where no other seems obvious " {The Senile Heart). {d) That the Pain is a Neuralgia, either Functional or due to a Neuritis. — This most widely held view regards angina pectoris as a form of neuralgia or neuritis affecting the nerves of the heart. Iluchard mentions twenty-two modifications of this theory, which dates from the early part of the century, when, in 1808, Baumes ranked the disease as a retrosternal neuralgia (sternalgia). Laennec gave it his strong support and held that either the pneumogastric or sympathetic divi- sion of the cardiac nerves might be implicated, and with either of them the brachial plexus. Corrigan, Romberg, Bamberger, and others held the same opinion. Then in 18G3 came the observations of Lancercaux on changes in the car- diac nerves and ganglia, which were confirmed by Peter and others. Iluchard states (second edition, 1803) that there were onlv twelve observations on neuritis of the cardiac nerves, of which six were associated with disease of the coronary arteries. IMore recent literature, so far as I know, does not furnish additional cases, and the whole quesiion of minute his- tological changes in the sympathetic nerves and ganglia in various disorders must be reviewed with the help of the new technique. Against this theory may be urged the common observa- VASO-MOTOR CHANGES IN ANGINA. 125 tion that the cardiac nerves may be seriously implicated iu aneurysm, in mediastinal tumors, in adherent pericardium, and in the exudate of acute pericarditis without causing the slightest pain. Again, in the attack of angina, though the pain is a promi- nent feature, it is a part, and in a severe attack the minor part, of the paroxysm. The angor animi is very unlike anything met with in neuralgic affections. Moreover, the mode of onset following exertion or emotion is not a feature of neuralgia, and this view affords no solution of the sudden death which sometimes follows. In its paroxysmal charac- ter and radiation, and in its intensity, the pain is much more like that of biliary and renal colic; with the latter, indeed, I have heard a patient who had experienced both compare it. Of course, the pain suffered in an attack of angina is a manifestation of disturbed function of the nerves. Such dis- turbance, when associated with pain, may be called neuralgic, but it is evident, from what has been stated, that there is something in addition, which puts the attack out of the cate- gory of ordinary painful affections of the nerves. There are many conditions about the heart in which the nerves are di- rectly implicated with which neuralgia occurs. I have already told you that there is no constancy in this, and there may be old pericardial adhesions, fresh epicarditis with direct involve- ment of the superficial nerves, or there may be sclerosis of the root of the aorta, aneurysm or tumor with pressure on the pneumogastric, without any pain whatever. But again, in all of these conditions there may be recurring attacks of pain about the heart, sometimes of great intensity, and even simulating that of true angina. III. Vaso-motor Changes in Angina. — In Lecture III I mentioned the striking vaso-motor phenomena of the attack — the pallor, the coldness, and the sweating — and in the last I \ Ih rfi m ii { i 1- *1 1 1 126 ANGINA PECTORIS AND ALLIED STATES. lecture I spoke of a special type of pseudo-angina in which these features dominated the scene. They play a conspicuous role both in the functional and organic forms. Naturally, one approaches a vaso-motor problem with a good deal of caution, since it lends itself with singular aptness to theo- retical vagaries and to all kinds of speculation. It is well to remember that, as Foster remarks, the vaso-motor nerves are servants, not masters, in the matter of regulating the calibre of vessels and altering the blood pressure. I have already spoken of -ho ei'le8 containing three to five niininis, which can bo rai)idly broken in a hand- kerchief and inhaled so soon as the very earliest symptoms of the attack are noticed. The introdnctiroduce its effect with great ra])idity, as shown by the flushed face of the patient and the increased volume and soft- ness of the ])ulse, witlumt relieving the pain. It sometimes acts better, given by the mouth, combined with the tincture of capsicum in peppermint water. !^^orphine hypodermically is the most useful drug in the attack, and if the pain is not relieved quickly by the nitrite of amyl an injection of a quarter of a grain should be given, and re]K>ated in a half or three quarters of an hour if the patient is not relieved. In one case the nitrite of amyl failed repeatedly to give the slightest relief, but from a quarter to a third of a grain of morphine, liypodermically, never failed to allay the terrible distress, and seemed also to steady and im- TRKATMKXT OF THE COMPLICATIONS. 151 prove tlie heart's nction. A point about the use of morpinno in angina which I have never «een mentioned except in tlio jMiper by Dr. Ii»irney Yeo in the PradUlonar, already re- ferred to, irt the reinnrkahh' toh'ranco of ni<>ri)hine in certain cases. In re})(»rting Case XXXll 1 mentioned tliat this pa- tient received between ten oVdock on Saturday nip,ht and 1 I*. ,M. on Sninhiy five grains of morphine liypodermically and by tile moutli, winch relieved the pain but did not give him sleej). Inhere are cases in which a hyi)odermic injection of a quarter of a grain of morphine given at the first indication of the attack, as a nnnd)ness in the hand or tingling in the fingers, checks it at once. And third, in any jiaroxysm of great intensity, while waiting for the nitrite of amyl or mor])hine to take effect, chloroform may be droj)ped u])on a handkerchief and iidialcd. Balfour recommends that it be poured on a sjxnige in a smell- ing bottle, and the patient t(d(l to breathe it through the nose as deeply as possible. In a minute or two relief is obtained, and as the patient comes under the influence of the drug the bottle drops from his hand, and there is in this way no dani>(>r of an overdose. The chloroform acts much more promptly and is much ])leasanter to take than other, and I have never seen any dangerous effects from its use, even in persons with very weak heart's action. {(I) Treatment of the Co?)}j)lf cat ions. — For the syncope of serious attacks the aromatic spirits of ammonia with Hoff- mann's anodyne and brandy may be given, or hypodermic injections of ether or camphor. For the dilatation of the heart and cardiac weakness, whic.i sometimes follow the at- tack, the nitroglycerin with strong fr>tions to the limbs may favor the circulation at the periphery, while digitalis or digi- talin may be given freely to stimulate the heart's action. Digitalin sometimes acts well, as in Case XXXVIII, and may (' II 152 ANGINA PECTORIS" AND ALLIED STATES. I fit II fli be given livpoclcrmically. Ko hard-and-fast rule can bo laid down regarding the use of digitalis. It sometimes acts badly, as in a case very carefully studied by AV. T. Sharplcss, of West Chester. Caffeine and camphor may also be employed. If all these measures seem futile, I would not hesitate to em- ploy puncture of the heart — cardiocentesis — which may arouse to (juite vigorous action a dilated and paretic organ. I do not know that this has been employed in the cardiac asystole following a severe paroxysm of angina, but there are instances on record, notably the case of Sloane {Edhihnrgh 3fedicalJournaly\o\. xl), in v;hich puncture of the heart with a needle driven firmly into the ventricle has aroused the flag- ging action apparently without doing the slightest injury. For the condition of chronic ttat de mat amjlneux^ in which, for a period of many days or even weeks, the patient has recunnng attacks with cardiac asthma and feebleness of the circulation, yor.v resources will be taxed to the uttermost. For the dyspnoea ai\d the Cheyne-Stoke'^, breathing full doses of strychnine, hyix»dermically, may be employed, from a for- tieth to a twentieth of a grain, threo or four times a day. Special care should be taken that the bowels are ke{)t freely opened. The cardiac measures already spoken of may be em- ploye d, and flying blisters to the prsrcordia and tj the bases of the Irngs may sometimes give relief. Trealv.icnt of Pseudo-angina Pectoris. — The measiires Uiust usually be directed to combating the underlying con- dition of neurasthenia or hysteria. Occcasionally it hapjiens, particularly in medi.-al men, that the mental relief afforded by a positive diagnos'o of pseudo-angina is in itself suflicicnt to effect a cure. Cases II and III, given in Lecture V, are good illustrations of the improvement and permanent cure, up to the present date, of attacks of maximum severity. It is not easy to say to what the rapid relief could be attributed, as the TREATMENT OP PSEUDO-ANGINA PECTORIS. 153 patients were given only general tonics. In other cases the attacks recur for years, as in the wife of the physician from the Province of Quebec, of whom I spoke, who had had attacks for twenty-five or thirty years. In the severe form, particularly when associated with much vaso-motor disturb- ance, the Weir Mitchell treatment may be tried with ad- vantage. The effects of seclusion, systematic massage, and electricity, particularly t)ie static form, are sometimes most satisfactory. Where this is not feasible hydrotherapy should be tried, either a systematic course at some institution, or, if this is not practicable, the systematic use of the wet pack at night, followed by thorough friction, will bo found advan- tageous. Some of these cases, particularly if treated at the patient's home, tax to the uttermost the resources of the physi- cian. Tl\e change of air and scene in traveling will often be found of advantage. Drugs are of uncertain and doubtful benefit. We often have to order the bromides and valerian, and in cases with much cardiac irritability and vaso-motor disturbance the use of nitroglycerin in large doses seems sometimes to aid in equalizing and steadying the circulation. In looking over the notes of my cases of pseudo-angina I notice this hopeful feature, that with but one or two exceptions the patients are at present not only alive and well, but free from attacks. When the attacks of angina are due to the abuse of to- bacco, the patient should give up the habit entirely. I do not think there is much risk, either, in stopping abruptly. Counter-irritation over the heart by means of the Paquelin cautery or blisters, the use of strychnine in full doses, and, if the pulse tension is high, of nitroglycerin, are measures which, will be found ifficacious. In the worry and strain of modem life arterial degcnera- 11 154 ANGINA PECTORIS AND ALLIED STATES. ^ ii .1 a ^y kf'ii Ii -li'i tion is not only very common, but develops often at a rela- tively early age. For this I believe that the high pressure at which men live, and the habit of working the machine to its maximum capacity, are responsible, rather than excesses in eating and drinking, or than any special prevalence of syphi- lis. Angeio-sclerosis, creeping on slowly but surely, " with no pace perceived," is the Nemesis through which Nature ex- acts retributive justice for the transgression of her laws — coming to one as an apoplexy, to another as an early Bright's disease, to a third as an aneurysm, and to a fourth as angina pectoris, too often slitting " the thin spun life " in the fifth decade, at the very time when success seems assured. ^No- where do we see such an element of tragic sadness as in many of these cases. A man who has early risen and late taken rest, who has eaten the bread of carefulness, striving for success in commercial, professional, or political life, after twenty- five or thirty years of incessant toil roaches the point where he can say, perhaps with just satisfaction, " Soul, thou hast much goods laid up for many years: take thine ease," all un- conscious that the fell sergeant has already isf ued the warrant. How true to life is Hawthorne in the lionise of the Seven Gables! To Judge Pyncheon, who had experienced a mere dimness of sight and a throbbing at the heart — nothing more — and in whose grasp was the meed for which he had " fought and toiled and climbed and crept "; to him, as he sat in the old oaken chair of his grandfathers, thinking of the crown- ing success of his life, so near at hand, the avenger came through the arteries. " With wdiat strife and pains we come into the world wo know not, but it is commonly no easy matter to get out of it," Sir Thomas Browne says; and, having regard to the uncer- tainties of the last stage of all, the average man will be of Caesar's opinion, who, when questioned at his last dinner party CONCLUSION. 155 as to the most preferable mode of deaiu, replied — "That which is the most sudden." Against this, one in a string of grievous calamities, we pray in the Litany, though De Quincy insists that the meaning here is " unpiepared." In this sense sudden death is rare in angina pectoris, since the end comes but seldom in the first paroxysm. Terrible as are some of these incidental conditions accompanying coronary artery lesions, there is a sort of kindly compensation, as in no other local disease do we so often see the ideal death— death like birth " a sleep and a forgetting." H APPENDIX. NOTE A. — Rougnon's claim (page 6). "While these lectures were in course of publication in the New York Medical Journal I had the following explanatory letter from Professor Gairdner, which it is only due to him to publish: 225 St. Vincent Street, Glasgow, Sept. SS, 1896. My dear Osler: I have only to-day had my attention directed to your most interesting lectures on angina pectoris in the New YorTc Medical Journal, and while appreciating them very much, I must confine my remarks to one point at present, on which I have no doubt you will desire to have my opinion inasmuch as you have formally indicated your own as differing. (Page 178, column 2, as to the case of M. Charles.) The cause of the difference, however, is this: I was curious to see the original paper of Rougnon, and when in Paris made a special inquiry after it, in vain, both in the Biblioth^que Ra- tionale, and in the library of the Ecole de Medecine (I think). I afterward engaged M. Lereboullet in the search, and he was kind enough to hunt up for me what he thought to be the only copy accessible after considerable research (I think it was at Besangon, but am not sure). He further was good enough to copy, or get copied, for me all that he thought essential in the paper, and sent it over with the remark that lie could find noth- ing like A. P. in it. To me it was just the same, but as I unfor- tunately mislaid his extract I could not precisely refer to it in writing to the Lancet 167 158 ANGINA PECTORIS AND ALLIED STATES. You have been more fortunate in finding what I can not help supposing to be a quite different document in your marvelous library at Washington. I can only plead that my remarks applied quite correctly to the extract sent to me, and I should be glad if this were made clear, though I can not now fully explain it. Have you any idea, in America, as to the proper pronuncia- tion of angina? For years I always pronounced it with the i long, and never once heard it otherwise till Dr. Houghton, of Dublin, pulled me up. I then made an elaborate inquiry into the classical authorities, and found that it comes out apparently clearly that the i is short, as in the test passage in Plautus's Trinummus, which has been annotated, so my colleague Pro- fessor Ramsey tells me. Is it worth while to make the change? In haste, Yours very truly, W. T. Gairdner. si '?« NOTE B. — THE CASE OF MR. MATTHEW ARNOLD (PAGE 25). Matthew Arnold, the distinguished son of Dr. Thomas Arnold, died suddenly on Sunday afternoon, April 15, 1888, in his sixty-sixth year. The various stages in the progress of his disease are well given in his letters. The first intimation we have of any trouble is in a letter to his son, dated May, 1885: " I have been having a horrid pain across my chest, and on Friday mamma carried me to Andrew Clark, who has put me on the strictest of diets for one week — no medicine, but soup, sweet things, fruit, and, worst of all, all green vegetables entirely forbidden, and my liquors confined to one small half glass of brandy with cold water at dinner. I am to see how this suits me. He thinks the pain is not heart, but indigv»stion. At present I feel very unlike lawn tennis, as going fast or going uphill gives me the sense of having a mountain on my chest; luckily, in fishing, one goes slow and stands still a great deal." "• To his daughter about the same time he writes: " I can not get rid of the ache across my chest when I walk; imagine my having to stop half a dozen times in going up to Pains Hill! What a mortifying change 1 But so one draws to one's end." On August 26th he writes to his wife from Wales: " On the I APPENDIX. 159 whole, I did more yesterday, and did it easier, than I have done since I was first visited by this pain." On January 11, 1886, in a letter to his daughter, he writes: " I got on very well, and the skating did not bring on the chest pain; smooth motion does not, but laborious motion — making my way uphill or through snow." During his second visit to America in 1886 he had a very narrow escape from drowning. " The accident was nothing; a wave carried me heavily against a taut rope under water, put there for the safety of bathers; but the shock exhausted me rather, and was followed by a week or so of troublesome attacks of pain across the chest." On November 27tli of the same year he writes to his daughter: " I am quite my old self again — walked about Lon- don all yesterday in the fog without choke and pain." On December 2 2d, in a letter to Professor Norton, he writes: "If I go too quick I am stopped by a warning in my chest; but I can go about as much as I like if I go leisurely, and I have no attacks of sharp pain. There were some nights in America when I thought that my ' grand climacteric ' — an epoch in life which I used to hear a great deal of from my dear mother — would see the end of me; and I think, by the way you looked at me once or twice at Ashfield, you thought so too." In a letter to Mrs. Coates, January 29, 1887, he wrote: " One should try to bring one's self to regard death as a quite natural event, and surely in the case of the old it is not difficult to do this. For my part, since I was sixty I have regarded each year, as it ended, as something to the good beyond what I could natu- rally have expected. This summer in America I began to think that my time was really coming to an end. I had so much pain in my chest, the sign of a malady which had suddenly struck down in middle life, long before they came to my present age, both my father and grandfather." In a letter to Professor Norton he again refers to the " bad attacks of pain while I was with you, the worst I had in America, the worst I have ever had." There are no further references, and we know that he went down to Liverpool to meet the steamer Aurania, and on Sun- 160 ANGINA PECTORIS AND ALLIED STATES. day afternoon, April 15, 1888, died suddenly in liia sixty-sixth year, about three years after the first manifestations of angina. f 111 M!: NOTE c. — hetextion of consciousness after apparent CESSATION OF IIEART's ACTION (PAGE 55). A very remarkable fact in certain cases of angina is the per- sistence of consciousness, with the ability to engage in con- versation and even to walk, after pulsations have ceased at the wrist, or even after the heart beats can no longer be felt. Dr. Macrae, of Council Bluffs, has sent me notes of the following remarkable instance of the kind. A physician who had been the subject of angina, while waiting for Dr. Macrae in his re- ception room, was seized with an attack. " When I came into the room he was unconscious, with his head dropped over the back of the chair. He was pulseless; no cardiac sound could be heard. He regained consciousness and, with my assistance, walked into the other room and lay upon the lounge. Careful examination again failed to reveal any cardiac movements. He was not in pain, was sensible, but seemingly dazed. He asked me whether his heart had ceased action. I told him it had. He gave a short loving message to his wife, ejaculated, ' Lord have mercy on mc! ' became unconscious, and died then in a few sec- onds. He must have lived at least five minutes after I found him. When laid on the lounge he burst into a most profuse perspiration, and breathing was somewhat labored. The point I wish to make is that he lived, was rational, could almost walk by himself, and talked for several minutes after his heart, so far as could be determined, had ceased to beat." In Case XXIII I was very much impressed by this retention of complete con- sciousness and capability of engaging in conversation when the pulse at the wrist could not be felt. a g V i r \ nii i :i\ THE END. !i:! 4 Cifl a I. e [1 MEDICAL GYNECOLOGY: A TREATISE ON THE DISEASES OF WOMEN FROM THE STANDPOINT OF THE PHYSICIAN. By Alexander J. C. Skene, M. D., Professor of Gynecology in the Long Island College Hospital, Brooklyn, N. Y. ; formerly Professor of Gynecology in the New York Post-Graduate Medical School ; Gynecologist to the Long Island College Hospital, etc. 8vo, ^j6 pages. With Illustrations. Cloth, $^.oo. " The direction of modern gynecology has been almost entirely surgical, and it is really refreshing to open a book of this description. The distin- guislisd author has filled a much-felt want in placing this volume before the profession. . . . Dr. Skene has covered an almost untrodden ground, the great importance of which can not be too highly appreciated. This work com- mends itself not only to the general practitioner but to the specialist as well, who will find in its pages much important information." — A.inals of Gynecology and P THE PRINCIPLES OF SURGERY AND SURGICAL PATHOLOGY. General Rules governing Operations and the Application of Dressings. By Dr. HERMANN TILLMANNS, Pro/i'ssor at the Uiincnity of Lei(^{ig. Translated from the third German edition by JOHN ROGERS, M. D., New York, and BENJAMIN TILTON, M. D., New York. Edited by LEWIS A. STIMSON, M. D., Professor of Surgery in the University of the City of New York, Medical Department. 8vo. 800 pages. With 441 Illustrations. Cloth, $5.00 ; sheep, $6.00. " It was a wise combination of subjects in considerinp the principles of sur- gery and its pathology in the same treatise. It enables the surgeon to refer to both branches of the subject without loss of time, and each serves to accentuate the importance of the other. Not since IJillroth's classic treatise on surgical pathology, that appeared some twenty-three years ago, has there been a more satisfactory exposition of surgical pathology than here given by Tillmanns. It is brought down to the immediate present uniler the light afforded by the most modern researches in bacteriology. A student should be taught pathology before he is instructed in surgical diseases and injuries. These latter he will then understand with a clearness that coidd not be possible if the method of teaching were reversed. The editor and the translators appreciating this fact have duly emphasized it in bringing out and making available as a text-book one of the best treatises on the princii)Ies of surgery and surgical pathology that has yet been written. It is impossible in the space now at our disposal for us to do more than express our opinion of this excelbnt work and to commend it to student and practitioner as a safe and scientific guide, which we do here and now." — Buffalo Medical and Surgical Journal. "It is strange that this excellent work has been allowed to pass to a third edition in German without a translation in English until this time. The ar- r.mgement of the book is different from that of the average text-book on the subject. It is divided into three sections : First, General I'rinciples governing Surgical Operations ; second, Methods of ajijjlying Surgical Dressings ; and third. Surgical Pathology and Thcrajiy. The work of translators and editor has been excellently done. 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THE New York Medical Journal A WEEKLY REVIEW OF MEDICINE. EDITED BY FRANK P. FOSTER, M. D. i THE PHYSICIAN who would keep abreast with the advances in medical science must read a live weekly medical journal, in which scientific facts are presented in a clear manner ; one for which the articles are written by men of learninj;, and by those who are good and accurate observers; a journal that is stripped of every feature irrelevant to medical science, and gives evidence of being carefully and conscientiously edited ; one that bears upon every page the st?.mp of desire to elevate the standard of the profession of medicine. Such a journal fulfills its mission — that of educator— to ihe highest degree, for not only does it inform its readers of all that is new in theory and practice, but, by means of its correct editing, instructs them in the very important yet much-neglected art of expressing thoir thoughts and ideas in a clear and correct manner. 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They appear in frequent issues, whenever called for by the article which they accompany, and no expense is spared to make them of superior excellence. Subscription price, ^^.oo per annum. Volumes begin in January and July. PUBLISHED BY D. APPLETON & CO., 7a Fifth Avenue, New York. DISEASES OF THE EAR. is Ik A TEXT-BOOK FOR PRACTITIONERS AND STUDENTS OF MEDICINE. By Edward Bradford Dench, Ph. B., M. D., Professor of Otology in the Bellevue Hospital ^Tc(!^cal College ; Aural Surgeon to the New York Eye and liar Infirmary, etc. 8vo, 645 pages. With 8 Colored Plates and 132 Illustrations in the Text. Clof/t, $^.00; sheep, $6.00. "An pxamination of the contents will prove that this volume carries its raison cTelre. It embodies in a most satisfactory manner the known facts o' otolojjy, hav- ing; incor|)orated must successfully, and witli little bias, the reci^nt advancements that have been made in this branch. KecoKnizing the aiil which comes from a faithful reproduction of the anatomical structures concerned, an*^' f.om showing the site of operative pmcetlures, the plates have been prepar»".! .vith all the care and precision of nKxlern ennravinj; art from the specimens thenifL-lves. '1 he hijjh c!:is.s of illustrations in the work is worthy of special praise. The text maintains a character that will rank the author as one of our best otolo^jical writers. He I'as paid marked attention to the physioUjtjical basis of aural studies and to the functional examination in cases of ear disease. In mentionin}^ tnatment he has t;one into manipulative details that olhtc writers have omitted, and yet which are very necessary to the student and practitioner who may have never had a chance to study and observe these matters in s])ecial aural clinics. The author is perhaps more fond of oi)erative procedures in middle-car dis- ease than some of his colleagues, but he has jjiven us what we have desired a j^ood modern resume on the benefits to be derived Ircni such operations."— C't>/ttw^//.f Med- ical yourita!. " One ha« only to read this volume in order to see its worth. Whether there was need at present for a new text-book on olnluf^y must l:e seen from the success wnich will be met with by this work f)f Dr Dench. However, we have no hesitancy in say- ing; that it is the best work of its kind by an Amerir.in author. l)r Dench is j;erhaps one of the leadin;,' exponents of intra-tympanic surgery, and while his views upon this si'.bject are perhaps more radical tiian the majority of aural surgeons, yet they must be thoutjhtfully considered, coming as they do from one who is so well and favorably known. It is almost imiiossible to display any originality in writing a work upon the ear, yet in this texi-biok the autlior has dealt in no superficial va(;aries, but he speaks as one with a !ar„'e amount of clinical experience, and thus pives to the reader those points wliicli are of practical importance." — Atlanta Medical aHu i>ingtcal Journal. " In this valuable work minute patholojjy has not been considered extensively, be- cause it has been the aim of the author to adapt it to the needs of the (general prac- titi'inerand special sur^;eon. Dr. Dench h.as written at len;jth U|)on the importance of a thorou};h functional examination, which many W( rks upon otoloj.;y have failed to eriphasize. He has placed the results of recent investijjations at the disposal of the re.'.der in such a manner as to enable him to use them in diap;nosis. The author has w -itten from his extensive personal experiL'nce in tdvocatinjj operative pi,/>.Jures upon the middle ear. 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It enters into the practical details of all the varyiiif,' eoiulitioiis of the apiilii'Mtion of the antiseptic method as hrought about by emergencies. Every important principle is clearly il!u>tr.ited by eitations from actual cases occurrinj,' in tliu author's practice. It is not intended to take the place of any text-booU on .-urL'i ry, but rather to sujiply a need which exists in every work on the Kul)ject in the Kufrlish huitrua;,'e, by furnishin^' information on the subjei't of Asci>>is and Anti>epsis, with which no hook on Hiir^^cry deals to an extent demanded by modern inethiHls. It is, in sliort, a su]>plement to all suri,'ieal text-books. 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