1847.] Cases of Angina Pectoris. 357 destroying the elasticity of the aorta at every part, had greatly narrowed its calibre at a small space of its descending portion within the chest, and so produced some real impediment to the passage of blood. We did not examine the state of other blood-vessels. Other viscera of the chest and abdomen were healthy, except that there was a close and complete adhesion of the pleura of the right lung to the ribs without the least apparent detriment to the lung itself." The most remarkable feature in this case was the shortness of the interval between the first paroxysm and the one which proved so suddenly fatal; and this too in a man who had previously appeared, and felt himself to be, in perfect health. In the second case, which occurred in a robust man 64 years of age, the heart was found on auscultation to be "beating with a perfect rhythm, and neither with excess nor defect of impulse. The sounds were natural but loudly intonated, and conveyed over the front of the chest far beyond the præcordial region." The respiratory murmur was normal every where. The patient had believed and felt himself to be in perfect health, when he was suddenly, and without any apparent cause, seized with a paroxysm of severe pain, passing from the upper part of the sternum through the chest to the back, and down both his arms to the tips of his fingers. The second attack occurred four days subsequently. From that time, the paroxysms were numerous by day and night. The change from the erect to the recumbent posture always produced them. Their duration was from five to ten minutes. Dr. Latham saw him on the ninth day (from the first seizure), and on the following day, after having had eight or nine paroxysms, he died. Dissection." The pericardium was found to contain two ounces of clear serum, and upon its surface covering the heart it presented a few small white spots. The heart itself had an appearance of general enlargement. Its internal lining and all its valves were healthy, except that the processes of the mitral valve might be thought a little thickened, but not so as to hinder the circulation. The coronary arteries too were quite healthy. But the muscular substance of both ventricles was so soft as to be pierced through with the slightest pressure of the finger. The aorta was entirely free from all morbid deposits. Both pleura were free from adhesions, and contained no fluid in their cavities. Both lungs were entirely healthy, and so were all the abdominal viscera." In this case, too, the fatal rapidity of the disease is the circumstance most worthy of notice. The last instance, related by our author, is that of the late most estimable and deeply-regretted Dr. Arnold of Rugby, the history of whose last illness is so feelingly recorded in his "Life and Correspondence." In his case, (he was 47 years of age,) up to a very few hours before his death, both body and mind seemed equally to give proof and promise of health. He still took his accustomed pleasure and refreshment in strenuous exercise. He retired to rest at midnight on the 11th of June, 1842, feeling and believing himself to be in perfect health. About five o'clock next morning, he was seized with a very severe pain seated at the upper part of the chest towards the left side, and extending down the left arm. It recurred at intervals. When Dr. Bucknill saw him at seven o'clock, the breathing was not disturbed; but the pulse was exceedingly feeble, and scarcely to be felt at the wrist. Brandy and water was given, and the pulse became natural. The pain returned, and again the pulse became very weak. The paroxysm was short, and he soon recovered himself. While Dr. B. was mixing an anodyne draught, he heard a rattling in the throat, and a convulsive struggle. He turned round and saw that his patient was in the agony of death. The eyes were fixed, and the teeth set. The breathing was very laborious, the chest heaved, and there was a severe struggle over the upper part of the body. The pulse was quite imperceptible, and, after deep breathings at a few prolonged intervals, all was over. Dr. A. died in little more than half-an-hour after Dr. Bucknill's arrival. Dissection. Both lungs posteriorly were gorged with blood and serum, and about eight ounces of bloody serum were found in each pleural cavity. "The pericardium was healthy. It contained about an ounce of serum of a straw-colour. The heart was rather large. The external surface was healthy. It was very flaccid and flat in its appearance. It contained but little blood, and that was fluid. There were no coagula of any kind in it. All the valves were quite healthy, and so was the lining membrane throughout. The orifices of all the great vessels were quite natural. The muscular structure of the heart in every part was remarkably thin, soft and loose in its texture. The walls of the right ventricle were especially thin, in some parts not much thicker than the aorta, and very loose and flabby in their texture. Its cavity was large. The walls of the left ventricle too were much thinner and softer than natural. And the muscular fibres of the heart generally were pale and brown. The aorta was of a brownred colour throughout its internal surface, probably from putrefaction. A few slight atheromatous deposits were observed in the descending thoracic The pulmonary artery was of the same brown-red colour with the aorta. There was but one coronary artery, and, considering the size of the heart, it appeared to be of small dimensions. It with some difficulty admitted a small director. It was slit open to the extent of nearly three inches. Its internal surface was red but healthy, with the exception of a slight atheromatous deposit situate about an inch from the orifice of the artery. This however did not appear to diminish its cavity." aorta. In the two first cases, we counted the duration of the disease by days; in this we must count it by hours. Not three hours elapsed between the earliest intimation that any thing was wrong with the functions of the heart, and the moment when "the spirit returned unto God who gave it." Very rarely does the stroke follow so quickly upon the first not-to-bemistaken announcement of its imminence. In most cases of Angina Pectoris, the life of the patient is prolonged for months, and even years; and, very generally, there is complex organic lesion of the heart and great blood-vessels present. The three cases, therefore, which we have now briefly recorded, are especially interesting from their fatal rapidity. It is unnecessary to analyse their peculiarities, or the differences that may be traced either between themselves, or between them and other cases on record. Suffice it to say that they cannot be very satisfactorily quoted to prove the organic or mechanical theory of the cause of Angina. The 1847.] Heberden on Angina Pectoris. 359 truth seems to be that, although a structural change of the heart is unquestionably present in a very large majority of cases, the lesion is not the immediate or direct, but only the predisposing, cause of the disease; the essential one being a spasm or cramp of the muscular substance of the heart.* "From what we know of pain and spasm, and the things causing and pertaining to them, in other parts of the body, we might be prepared for the same sort of things causing, and pertaining to, them when they belong to the heart. Thus we might expect to find angina pectoris incident to any form of organic disease of the heart, but constant to none. And such is the fact. We might expect to find angina pectoris where there was no organic disease of the heart itself, but such organic disease elsewhere as might injuriously interfere with the functions of the heart. And such is the fact. And finally, we might expect to find angina pectoris, where there was no detectable organic disease either of the heart or of other parts, but where itself (namely spasm) constituted the whole disease; a disease purely vital, a disease of feeling and function alone, operating by and through sound structure, it may be fatally, always perilously. And such is the fact."-P. 387. The following most judicious remarks on the management of patients, who are subject to the formidable disease of angina pectoris, will not fail to be read with interest by every one engaged in practice. "The paroxysm is often put off and its severity mitigated and life prolonged by no means more surely than by keeping the vascular system in a just balance between fulness and emptiness, between rich blood and poor blood. In some constitutions, very happily born, the balance maintains itself; and then there is no need of interference on our part. In the majority it is not exact, yet exact * This seems to be the meaning of the word "distensionem" used by Heberden in his excellent description (the first that was given), to designate the probable proximate cause of the disease. Possibly, also, the idea of the cavities of the heart being so distended with blood as to be unable to contract and propel it forward is implied in the term. The following is the passage alluded to: Angina pectoris, as well as I have yet understood its nature, seems to pertain to distension, and not to inflammation: For, first, it comes suddenly and goes suddenly. Next, it has long and complete intermissions. Then, wine and spirituous drinks and opium afford considerable relief. Then, it is aggravated by agitation of the mind. Then, for many years, it distresses a patient without other injury of the health. Then, at first it is not excited by carriage or horse exercise, as is usually the case when there is scirrhus (induration or organic disease) or inflamma tion. Then, the pulse is not accelerated even in the paroxysm. Lastly, in some the attack occurs after the first sleep; a circumstance which is common in diseases arising from distension." After alluding to the absence upon dissection of all organic lesions in the heart and great vessels, save only a few small bony specks in the aorta, of one of his patients who died from this disease, Dr. H. remarks that, in several cases, he had observed that the blood retained its fluidity after death, so that it continued to ooze from a wound in a vein, as long as the body remained unburied.—Commentarii de Morborum Historiâ et Curatione. "The fact is not within my own experience; but I must admit what is credibly reported." enough for the ordinary purposes of health, but not enough when there is some grave infirmity to be palliated and made tolerable elsewhere. A small habitual deviation on this side or that is readily felt and resented by the heart, when it has undergone some form of unsoundness rendering it obnoxious to spasm. "Thus there have been cases in which my treatment of angina pectoris, in the intervals of the paroxysms, has chiefly turned upon reducing the nutritious and stimulant quality of the patient's diet, abridging his animal food, and denying him wine and fermented drinks altogether. There was one case, and only one, in which I was driven to draw blood even more than once from the arm; an unusual and a hard necessity! There have been more cases, on the other hand, in which the general habit of the patient has made me fearful of withdrawing support, and experience has shown me the need of supplying a well-regulated amount of stimulus in the shape of wine daily. The administration of steel in the intervals of the paroxysms has (I have convinced myself) in some instances been instrumental to their postponement. "Truly a volume might be spoken upon the subject, if one were to enter into the detail of all the indications, which the general vascular system may offer to the observant physician, for the employment of remedies as a safeguard, within all possible limits, against the attacks of this awful disease. "And truly the same may be said of the nervous system, and how it notifies indications of treatment by its various states of disorder; and how it presents itself as an avenue for remedies, which may carry a salutary impression to the heart and withhold it for a time from falling into spasm. Loss of sleep, disturbed sleep, and painful irritation and troublesome wants, such as frequent micturition, may be among the bad habits of the patient, or they may be induced by his disease, or they may be aggravated by it. At all events they contribute to bring on the paroxysm more frequently and more severely. It is wonderful what a small quantity of opium, administered dexterously upon such indications, will sometimes do in keeping angina pectoris from advancing to a greater degree of suffering, or in bringing it back from a greater to a less."-P. 407. A dose of Paregoric and sulphuric Ether on going to bed, and again in the morning before rising, will often be found an excellent remedy in keeping the uneasy feelings about the heart at bay. The application of epispastics over the region of the heart, or the establishment of a perpetual irritation there by seton or otherwise, will in many cases be found to exert a decidedly beneficial effect in diminishing the frequent recurrence of the cardiac paroxysms. We need not say any thing on the score of bodily exercise or of mental excitement. The poor invalid soon discovers how inevitably any indiscretion, either of mind or body, aggravates his distress. And surely it is nothing but the duty of a good physician to endeavour to direct his patient's thoughts to the habitual contemplation of those subjects, which will assuredly bring him more perfect tranquillity and a more settled evenness of feeling than all the resources of art or the unaided resolves of weak humanity can accomplish. Nothing but the deep and assured conviction that "all is well with him," can enable the sufferer to anticipate and meet with composure the fearful inward agony, which is never far distant, and which may overtake him in a moment, snapping the cord of life ere relief can be found, or the slightest preparation for death can be made. The thought is indeed a solemn one to all-what ought it to be to one who may be suddenly "Cut off even in the blossoms of his sin, 1847.] Causes of Endocardial Disease. 361 M. Bouillaud slurs over the subject of Angina Pectoris, as if it were a matter of little interest. Indeed, it may be remarked generally of his bulky work, that the reader will find but very little to engage his attention in the description of those diseases which may be said to be rather vital than physical or material in their phenomena and effects. He is, as might be expected, most elaborate and diffuse in his account of the inflammatory affections of the heart. We shall briefly allude to his opinions on one or two points in the history of those diseases. the He considers that there are two primary kinds of Endocarditis-1, actively inflammatory, such as is so often present in Rheumatism, and in severe Pneumonia and Pleuritis; and 2, the septic or putrid, as is found (so he says) to exist in Typhus, and Typhoid affections. "Doubtless," he adds, 66 there may be a gangrenous form of the disease also;" but he very wisely reminds us of our utter ignorance as yet of the subject.* The description, which he gives of the necroscopic appearances of Endocarditis, is strangely unsatisfactory. For example, we are told that the redness of the endocardium is "owing not to any (at least appreciable) injection of its capillaries, but rather to a sort of dying or imbibition of * M. Bouillaud appears to have his mind so entirely occupied with the connexion between acute Rheumatism and Carditis, that he does not seem to be at all aware that the inflammatory affections of the heart, and more especially of its inner membrane, have been of late shown to be, in many cases, associated with granular degeneration of the Kidneys. The recent very elaborate paper of Dr. Taylor, in the Medico-Chirurgical Transactions, (vide the No. of this Journal for April, 1846,) has added much to our hitherto imperfect acquaintance with this important ætiological question. Our readers are probably aware, that we have long advocated the doctrine that endocardial disease is (in all probability) often induced by vitiated conditions of the circulating fluid; and recent researches have certainly tended to confirm the truth of this opinion. The last occasion, on which we alluded to this subject, was in our review of the first volume of Dr. Latham's Lectures. 66 Having thus, at a very considerable length, examined the history of endocardial and pericardial inflammation, more especially in reference to its symptoms and its predisposing causes, the question naturally arises, what is the more immediate cause of the disease, and what peculiarity is there in Rheumatism for example, or in Scarlatina, that should be liable to induce an inflammatory affection of the Heart, rather than of any other organ? For our own part, we have long been inclined to believe that it is to a state of the circulating fluids that we must look for an explanation of this pathological phenomenon. Is it not reasonable, to say the least of it, that an altered condition of the blood may occasion an irritation of the lining membrane (more especially) of the heart? That such an alteration exists in the diseases which we have named-Rheumatism and Scarlet Fever-will be denied by none; and may not the same be said of the other states of the system, with which active cardiac disease has been observed to co-exist? The etiology of Heartaffections is yet but very imperfectly made out. In the general run of cases, it will be difficult or utterly impracticable to ascertain the probable cause. In a good many, indeed, it may be found that the patient has, at some period or another, suffered from Rheumatism; but certainly not in the majority. Let us hope that the great attention that is now paid to humoral pathology will, ere long, throw some light upon this subject."-Medico-Chirurgical Review for July, 1845. |