Angina Pectoris.

Synonyms.—Stenocardia; Breast-Pang; Neuralgia of the Heart.

Definition.—Angina pectoris is an affection characterized by paroxysms of excruciating pain in the precordial region, extending into the neck, shoulder, and down the left arm, and attended by a sense of impending death. Nearly all writers agree that angina pectoris is not an independent disease, but is symptomatic of various cardiac affections, though it is occasionally due to some disturbance of the nervous system.

Etiology.—Angina pectoris is a rare disease, occurring usually after the fortieth year, and affecting mostly males. It may be divided into symptomatic, or true angina, and essential angina.

Symptomatic stenocardia is associated with cardiac affections, such as chronic myocarditis, various degenerations of the heart, aortic valvular insufficiency, stenosis of the aorta, arteriosclerosis of the coronary arteries, and adhesive pericarditis.

Essential stenocardia is due to some disturbance of the nervous system, and is reflex. Thus it may be associated with wrong's of the stomach and bowels, the liver, uterus, ovaries, and rectal irritation. The excessive use of tobacco, and the inordinate use of coffee, tea, and alcohol, may act as producing causes. Influenza, Bright's disease, gout, and syphilis are also to be reckoned as disturbing forces.

It also occurs in hysterical patients and in emotional subjects.

Pathology.—While organic heart disease is found in all cases of true angina pectoris, there is no one lesion that is characteristic, and the same structural lesions that exist in angina, are often found without there ever having been any anginoid attacks.

The physiological explanation of anginoid paroxysms is summed up by Pepper in his work on practice as follows:

"1. Changes in the cardiac nerves have been noted by a number of observers, and angina is sometimes regarded as a neuralgia of the cardiac plexus. The close relation of the latter to the root of the aorta and of its continuation, the coronary plexus, to the coronary arteries, seems to offer an explanation of the frequency of angina pectoris in diseases of the aorta and coronary vessels. Lauceraux, Haddon, Leroux, and Rokitanskv demonstrated pathological lesions of the plexus, the vagus, and the phrenic nerve, and Putjakin found alterations in the intercardial ganglia.

"2. Spasm or cramp of the cardiac muscle naturally suggested itself to Heberten and the older observers generally, but convincing proof of the existence of such a condition is lacking.

"3. Increased arterial tension and intracardiac tension seem undoubtedly the occasion of paroxysms in certain cases, as in aortic regurgitation and in the vasomotor angina of Nothnagle. The explanation would likewise apply to the cases of angina occurring in association with sclerosis of the aorta."

Symptoms.—One of the distinguishing features of angina pectoris is its paroxysmal character. In rare cases there may be premonitory symptoms, such as dizziness, ringing in the ears, nausea, or hot and cold flashes: but usually it comes on suddenly, and without the slightest warning. The patient suddenly experiences excruciating pain of a lancinating or rending character in the precordial region, which extends to the shoulders and neck and down the left arm to the finger-tips, which sometimes become numb and cold. Occasionally the pain extends to both arms. To the intense, stablike pain is added the undefinable and fearful sense of impending death, which is unmistakably written on the face, in the drawn features, the leaden, ashen gray, or livid color, and the surface covered with a cold, beady sweat. The patient rarely cries out, though suffering untold pain. He is afraid to make the slightest movement or outcry for fear of sudden death.

The breathing is shallow and irregular. The pulse is usually tumultuous and irregular, though it may be but slightly disturbed. The paroxysms usually last but for a few seconds, though they may last for an hour or more. Generally the pain subsides as abruptly as it began, though the paroxysms frequently terminate with nausea and vomiting, or eructations of large quantities of gas; or the patient, not infrequently, voids a large quantity of pale urine or has a loose bowel movement.

Following the paroxysm, the patient seems quite exhausted, and may remain so for several days. The attacks vary in frequency from a few days' interval to several years.

In rare cases the paroxysm terminates in unconsciousness, and in still rarer cases in sudden death.

In false angina, the patient is more apt to be restless and to cry out with pain.

Diagnosis.—The diagnosis is usually not difficult. The sudden onset, the excruciating character of the pain with no outcry, the agonized expression portending death, the ashen-gray color and bedewed face, the shallow, irregular breathing, and the equally sudden termination of the paroxysm, the age and sex of the patient (the case being usually that of a male past forty years of age),—are characteristics that can hardly be mistaken for any other disease.

Prognosis.—The prognosis depends almost entirely upon the causes giving rise to it. True angina, however, is always a grave disease, and may terminate fatally during a paroxysm. The extent of the cardiac changes would, of course, determine largely the outcome. If there be extensive sclerosis of the coronary arteries, the prognosis would be unfavorable, and we might reasonably expect a sudden termination of life. On the other hand, if it be neurotic in character, the prognosis will be favorable.

Treatment.—The treatment consists of two parts. I. Prophylactic; 2, to relieve the paroxysm.

Prophylactic.—The conditions that give rise to the paroxysms should be carefully studied, and the remedies directed, as far as possible, to correct such wrongs. Crataegus, cactus, strophanthus, nux vomica, digitalis, apocynum, and the iodide of arsenic should be thought of in this connection.

The diet should be nourishing and easily digested, and all fluids restricted at meal-times. Severe physical work or exercise should be abandoned, and everything tending to greatly excite the emotions, as well as the heart's action, avoided. Dissipation of all kinds should be stopped; late hours and irregular habits corrected. Change of climate and an out-of-door life, such as would improve the general health, would be beneficial.

Lobelia.—During a paroxysm, a teaspoonful of the specific tincture of lobelia will give prompt relief, or we may combine with it a half-teaspoonful of macrotys. As to local applications, both hot and cold are recommended. Nitrate of amyl also gives prompt relief when inhaled. A perle containing two to five drops, may be crushed in the handkerchief and inhaled.

A physician of my acquaintance who suffers with angina tells me that he gets greater relief from iodide of arsenic than from any other remedy. He makes a tincture by adding ten grains of the crude drug to one ounce of alcohol, and of this he adds ten drops to a half glass of water, and takes a teaspoonful every twenty, thirty, or sixty minutes.

Nitroglycerin will also give speedy relief in some cases. The patient should be quiet for a few days following an attack.

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.