It can hardly be doubted that neuralgic spasm is the true cause of sudden death in some cases of stenosis of the aortic orifice, which, but for some accidental circumstances, would not have died suddenly at all, but would have gone through a long and gradual course of deterioration. I particularly remember an instance in which extreme and calcareous constriction of the aortic orifice, in a boy not yet come to puberty, was entirely unsuspected, until one day, in running fast, he screamed out and fell down, and was almost instantaneously dead. I remember another case very similar, in which extreme mitral constriction produced almost as sudden death, apparently from painful spasm, under the same kind of exertion. On the other hand, sudden death, when produced by the form of heart-disease which (as Dr. Walshe points out) is most likely to cause such a catastrophe, viz., aortic regurgitation pure, without hypertrophy, does not seem to be due to painful spasm, but to simple and complete failure of the muscular power, and is perhaps partly of the nature of paralysis from a syncopal condition of the brain, the unhypertrophied heart having become for the moment unable to supply blood enough to the brain to carry on nervous function at all.
A good instance of the form which angina takes, when the element of organic cardiac change is well pronounced, was afforded by the case of a young gentleman recently under my care. He was twenty-one years of age, and from early boyhood had been accustomed to a great deal of muscular exercise; in fact, it is probable that he had undermined his health by the frequent and extraordinarily long walks which he took, for his frame was particularly small and slight, and the muscles small and soft. He came of a family in whom the tendency to neurotic disorders is obviously very strong; both his father and his brother are subject to bad attacks of migraine, and he had himself repeatedly suffered from the same thing. The family disposition, altogether, is highly nervous and excitable. The remarkable circumstance in this young gentleman's case is, that although he had taken for years an extraordinary amount of pedestrian exercise (including mountain-climbing), and latterly had exchanged this for the even more trying exertion of rowing, he had never suffered from any noticeable symptom of cardiac distress up to the very day of his anginal attack. For some months, however, he had been growing thin and pale, and I had given him certain cautions, and had made him take cod-liver oil and steel, as I entertained some fears of his becoming phthisical. On the day of the attack there was nothing particular in his appearance, but he complained of a slight cold, and had no appetite for his six o'clock dinner. He retired to rest at eleven o'clock, having taken a small dose of laudanum and chloric ether for his cold. In less than half an hour he awoke out of his sleep in fearful agony; so severe and prostrating was the anginoid pain that he had the greatest difficulty in crawling out of bed to unlock his door. I found him bathed in cold sweat, pale as a sheet, and with livid lips. He groaned with pain, which he described as "cutting him across" from the sternal notch to the nipple, and going down the left arm; and there was so marked a catching of the breath as to make it almost certain that there was diaphragmatic spasm; in fact, it was this which alarmed him, and made him say that he was certainly dying. The heart, however, appeared to be pushed up somewhat, and it was thought that this might be partly due to stomachic distention, but a mustard emetic produced little effect. The heart-sounds were so weak that the presence or absence of bruit could not be safely predicated; meantime, the pulsations intermitted in a most alarming manner. Large doses of brandy and sulphuric ether at length (after several relapses) seemed to subdue the pain and spasm, and in an hour and a half from the commencement of the attack the patient, though utterly worn out, sank into a tolerably quiet sleep. The spasms did not recur, but for the next three or four days he was in a state of great exhaustion. When his tranquillity of mind had been somewhat restored, a careful physical examination was made, and it was discovered that there was a moderately loud and somewhat thrilling systolic bruit at the site of the aortic valves, and extending some distance into the vessels. The pulse still remained strikingly intermittent, and, though of fair volume, was very compressible. Percussion indicated considerable enlargement of the heart, and the physical signs pointed, on the whole, to dilatation without hypertrophy. Some doubtful signs of consolidation were observed at both apices of the lungs.
It is remarkable that, notwithstanding the serious degree of cardiac mischief indicated by the above signs, the patient, a very few days later, took a walk of some ten miles, and, though much exhausted, suffered no recurrence of his formidable spasmodic symptoms in consequence of this imprudence. He was sent to the mild climate of Mentone, and subsequently to Nice; the angina never recurred, but the patient remained weak, and liable to more or less dyspnœa for fifteen or sixteen months; now he lives an ordinary life, doing his duty as a Swiss citizen and officer. The cure of some hæmorrhoids, about twelve months after the anginal attack, seemed greatly to benefit him. What the future of this case may be it is impossible to say, but of course there is no security against the angina recurring on extraordinary excitement or over-exertion.
Of the purely neurotic variety of angina it is impossible to determine the frequency; but it seems certain that the affection is common, and I suspect that it occurs more often than is supposed, as a sequel to asthma. The probable relationship between the two affections was long ago indicated by Kneeland.8 I have certainly seen several cases of asthma in which spasmodic pain of the heart has occurred on various occasions after or during a very severe asthmatic paroxysm. One case was that of a gentleman, of a highly delicate and neurotic temperament, who had suffered for fifteen or sixteen years from well-marked spasmodic asthma: this case is remarkable as an illustration of several points which will be dwelt upon in other parts of this volume. For some time before the outbreak of cardiac neuralgia, he had suffered repeatedly from severe facial neuralgia, and these attacks on more than one occasion culminated in facial erysipelas, or what was entirely indistinguishable from that affection. He then began to suffer from cardiac pain and spasm after his asthmatic paroxysms, and these new symptoms speedily assumed the form of a very severe intermittent angina: in several of the attacks he appeared about to die. The pain in these attacks is very severe; it occupies a large area in the centre of the chest, and runs down both arms; and, what is strange, the arms become remarkably swollen and hot after an unusually long bout of pain, I presume from vaso-motor paralysis. At present (nearly five years from the commencement of the cardiac neuralgia) the cardiac attacks, though of frequent occurrence, are decidedly more tolerable than they were at first, and the sense of squeezing or pressure, though never quite absent, does not amount to the dreadful sort of feeling which used to convince the patient that he was at the point of death. In this case, the heart has been repeatedly explored without any positive result, and the pulse has been frequently tested by the sphygmograph. The latter instrument is the only mode of examining by which I have been able to elicit even suspicious evidence that there is any organic change of the heart; by means of it I have lately obtained some grounds for suspecting that there is slight dilatation of the heart, but it is uncertain whether anything of the kind existed at the commencement of the anginal symptoms. In this case I am inclined, on the whole, to doubt whether the angina will ever prove fatal, unless the bronchitis, with which the patient's asthma has for some time past been liable to be complicated, should occur in a severe form; in that case it is likely that the additional embarrassment of the heart's action may bring on fatal spasms.
One of the best examples I ever saw of cardiac neuralgia (ultimately proving fatal) was one of which the origin was entirely nervous. It occurred in a gentleman in the prime of life, and naturally of a powerful physique, whose very active and capacious mind had been greatly overwrought. The whole weight of responsibility for an undertaking of national importance, and which involved great difficulties and much anxiety, for a long time rested on his shoulders. Under these influences he broke down, and never effectually recovered himself. At first, the symptoms were those of mere ordinary nervous exhaustion, but after a time he became subject to frequently recurring attacks of agonizing spasmodic heart-pain, with a sense of impending dissolution; from these he was invariably relieved by the inhalation of a small amount of chloroform. Not the slightest organic heart mischief could be detected, either during life or after death.
Pathology.– Angina stands in so peculiar a position that I deem it well to discuss it as a whole, and not merely its clinical history, in this place. As I have already said, there is nothing in the morbid appearances found after death which is characteristic of fatal angina, and in the milder kinds of cardiac neuralgia we are driven back upon the general probabilities which we deal with in reasoning as to the origin of neuralgias in general. As to morbid changes, it is impossible to say any thing more exhaustive of the facts known than the following words of Dr. Walshe:9 "First, there are few, if any, structural diseases either of the heart, its orifices, and its nutrient arteries, or of the aorta, found recorded in the narratives of the post-mortem examination of different victims of angina pectoris. Secondly, there is no conceivable disease of these structures and parts which has not in various individuals reached the highest point of development, without anginal paroxysms, even of a slight kind, having occurred during life; to this proposition extensive calcification of the coronary arteries perhaps furnishes a solitary exception. Thirdly, the organic changes most frequently met with have been fatty atrophy and flabby dilatation of the heart; obstructive disease of the coronary arteries by atheroma and calcification of the orifice and arch of the aorta. Fourthly, the rarest have been hypertrophy and hypertrophy with dilatation. In truth, it may be doubted whether these conditions in their genuine form, without any combination of fatty atrophy, have ever been the sole morbid states present." From all this Dr. Walshe concludes that the fundamental mischief of angina is neurotic; and, while he believes that some textural change in the heart is necessary as an irritant to generate this neurotic susceptibility to dynamic disturbance from slight causes, he recognizes only one common quality in these various cardiac lesions, viz., that they indicate mal-nutrition and weakened power. Dr. Walshe does not appear to believe the neurotic disturbance can arise without the kind of irritation which is kept up by such cardiac changes. In spite, however of the great authority of this author, it certainly seems very probable that organic cardiac change is by no means necessary to the occurrence of angina, and this for two reasons: In the first place, though full reliance may be placed on the details of the post-mortem examinations made by Dr. Walshe himself, they are very few (twelve or fourteen) in number; and other observers who have recorded cases are as little trustworthy, considering their evident tendency to find some disease where none exists, as the older narratives which Dr. Walshe naturally distrusts were unreliable when they declared that no morbid change was present. And, secondly, his view hardly takes it into account that there are still two other alternatives, even supposing that one or other of the above changes is always present: (a) it is possible that the neurotic disturbance and the cardiac lesions might both be the result of a common cause; and (b) it is even possible that the alterations of tissue in the heart and vessels are due to a morbid influence proceeding from a diseased nervous centre, either spinal or sympathetic.
As for the state of the muscular fibre which immediately causes death, Dr. Walshe is of opinion that it is paralytic rather than spasmodic; and he urges in favor of this view the fact that in his large experience he has never known the pulse to intermit during the attack – it was always regular, however feeble. In this respect he is in opposition to some distinguished authors, however, and, as he allows that he has not seen original attacks in their height, but only when they were subsiding, it would be possible that the spasm stage had subsided. However Dr. Walshe admits that there may be exceptional cases in which spasm, or cramp (i. e., spasm with rupture or dislocation of fibre), really occurs, and suggests that this is very probable in the rare cases where death is attended by general tetanic spasm of the muscles. As far as my own opinion is worth anything, I could insist that at least Dr. Walshe must be right as against Dr. Latham and Dr. Inman, in affirming that cardiac cramp, if it occurs, is the consequence and not the cause of the neuralgic pain.
Causes.– In some respects it is impossible to deal with the etiology of angina apart from the pathology, just as we remarked with regard to neuralgias in general. But there are certain special features in the causation of angina pectoris which require separate notice, just as there are special features in its pathology.
Of predisposing causes, the majority are the same as those of which we have spoken in our general remarks on the etiology of neuralgia. A family history of a tendency to the graver neuroses is I believe universal, and, indeed, direct inheritance of angina from father to son, as in Arnold's case, has happened in many recorded instances. A very remarkable fact is the time of life at which the disease originally appears: Walshe says it is rare before the age of fifty, but excessively rare before forty. This is very interesting, as placing angina in the same category with the severe and intractable forms of facial and other neuralgias which are so highly characteristic of the period of bodily degeneration. One may even gather a suspicion, though it goes but a short way toward proof, that the essence of angina is an atrophy either of the cardiac plexus or of the nucleus of the vagus, or of that part of the spinal cord, already mentioned, which seems to be the centre of the major part of the propulsive force of the heart.
On the other hand, there is a fact, even more remarkable than the influence of age, which tells somewhat in a contrary direction. There is a most extraordinary preponderance of males among the victims of angina. Sir John Forbes found eighty males among eighty-eight patients suffering from this disease. On the first blush it would seem natural, indeed almost necessary, to explain this by supposing that, as men take a much larger amount of strong physical exercise than women, they will furnish a much larger proportion of subjects in whom an ill-nourished heart will break down under its work and be seized either with paralysis or cramp (for the two states are, after all, not opposed to each other, but only varying shades of debility.) Upon this theory one would have to believe that the origin of angina was far more peripheral than central, if we are to suppose that spasm is the ordinary condition of the heart during the anginal paroxysm. But we do not know that this is the case; indeed, there are many arguments against it; and at any rate we must suppose that in a considerable number of cases the muscular state is one of relaxation from want of power. And certainly it is infinitely more probable that paralysis or spasm of a muscular viscus should occur as a reflex consequence of neuralgia occurring in a nerve whose central nucleus was closely connected with the motor centre of the organ, than that mere paralysis of the viscus should convey a reflex impression to sensitive nerves which should express itself in the form of acute pain. It must be confessed that the matter hangs in doubt; but the evidence is, on the whole, very strong for the belief that central nervous mischief is the most important element in angina.
Another very important class of predisposing causes of angina is the mental emotions. It is notorious that the disease is one not common in humble life; it chiefly assails the more cultivated class, and especially men who are much engaged in affairs in which great mental anxiety or emotion is mingled with severe toil of intellect. Thus the professional class has always shown a sad predominance in tendency to this disease; a large number of the victims have been found among overworked clergymen, lawyers, doctors, engineers, etc. The various forms of heart-lesion which have been already mentioned must doubtless be considered highly predisposing, when there is already a neurotic susceptibility, more especially those which, like fatty degeneration of the muscular structure, greatly enfeeble the heart's action. I do not believe that these diseases will cause angina in a person who is free from the peculiar nervous susceptibility.
The immediately exciting causes are very various. The most common of all is doubtless some exertion of body, or distress of mind, which at once agitates and embarrasses the heart's action; and, where the tendency to cardiac neuralgia has once declared itself by an actual attack, very slight excesses of this kind will usually suffice to re-excite the paroxysm. Sexual excitement is particularly provocative of the attacks, in the predisposed. But much slighter causes suffice, in those cases where the irritability of the cardiac nerves has become very intense: thus a mere puff of cold air upon the face, and other similar slight peripheral impressions, by acting in a reflex manner, have frequently produced the paroxysm. I have seen an extremely severe anginal attack brought on by the slight shock of the sudden slamming of a door. And it would even appear that some peripheral excitements of a powerful kind may operate with such force as to generate angina in persons who are merely in weak health, but who cannot be supposed to be specially predisposed to angina; it is in this way, I presume, that we must explain the extraordinary occurrence, reported by Guelineau,10 of an epidemic outbreak of angina, in which numbers of men, belonging to a ship's crew, were simultaneously affected. The men had been badly fed, and their quarters were very unhealthy; but the powerful exciting cause seemed to be the rapid change from a very hot to a very cold climate. Not only were there many cases of severe angina, but other forms of neuralgia, and severe colics, were observed in others of the crew. Among the sources of peripheral irritation which ought to be particularly considered, in relation to angina, are the diseases and injuries which produce powerful irritation of the branches of the trigeminus. Lederer's cases11 of violent vomiting and cardiac pain, from the operation of pivoting teeth, and Remak's instances12 of violent palpitation and cardiac distress, produced by disease of the last molar tooth, seem to show that, both through the vagus and the sympathetic, the most powerful reflex action may be produced in the heart and stomach by irritation of the fifth cranial.
Another occasional excitant of angina is an interesting link in the chain of proof that angina is au fond a neuralgia, namely, the malarial poison, which has in a good many well-observed cases distinctly induced the disease.13 Finally, the occasional influence of excessive tobacco-smoking in producing anginal attacks, in persons not affected with any discoverable organic heart-disease, affords the strongest corroborative evidence of the essentially neurotic character of angina pectoris. M. Beau14 has recorded many serious, and some fatal, cases from this cause. Probably in both the malarial cases and those induced by tobacco-poisoning the special neurotic tendency existed already.
Diagnosis.– The diagnosis of angina pectoris, in those severe forms with which the popular idea of the disease is chiefly connected, can hardly be a matter of much difficulty. When we see an elderly man lying in a state of deathly collapse, which has suddenly come on, with cold sweats and nearly extinguished pulse, gasping for breath, and complaining of intolerable pain in the chest and arm, and a sense of oppression more dreadful, even, than the pain, we can hardly doubt that the case is angina in its worst form. On the other hand, when a young person, especially a young female, complains even of very severe pain in the cardiac region, together with breathlessness, especially if the heart be palpitating and the face flushed, the diagnosis, though not immediately certain, already very strongly indicates the probability that the case is not one of primary cardiac neuralgia at all. These are extreme instances, however. In more doubtful cases, the following are the principal materials for decision:
It is scarcely necessary to say that no single one of the above signs is individually of positive worth for the decision, which must be made after a careful review of the comparative arguments, pro and con. The disorders with which angina is most likely to be confused are (1) Myalgia of the intercostal or pectoral muscles; (2) intercostal neuralgia; (3) acute commencing pleurisy. Either of these may very perfectly simulate the more formidable disease, as regards the two elements of acute pain and catching of the breath; but the condition of the circulation, taken together with the consideration of the above named points, will generally decide the question. Especially important is the deep persuasion of impending dissolution, when present, as a positively affirmative symptom.
It should be born in mind that, if we are summoned to a patient's assistance, and have no previous history to guide us, our diagnosis, to be useful, must be rapid; and it is always better to err on the side of angina than in other directions, and to employ remedies boldly in that sense, if there be any reasonable ground for believing the case to be of that nature. A more mature and careful diagnosis may be made when the patient has recovered from the severe symptoms of the paroxysm.
Prognosis.– The prognosis of cardiac neuralgia is at best doubtful, and, in many cases, positively bad in the highest degree. If the attacks occur for the first time in a patient who has passed middle life, and is physiologically old for his age, i. e., shows tendency to degenerative changes of vessels, arcus senilis, gray hair etc., they are of very gloomy import; more especially if any signs exist which make a fatty change in the ventricle probable, or if there be serious valvular lesions. The probability here is greatly in favor of a speedy fatal termination; if the first attack does not kill, a second or third very probably will; at any rate, the patient is not likely to survive any considerable number. If the attack occurs in a younger person, in whom there is not much likelihood that arterial degeneration has seriously commenced, or the heart-muscles become fatty, more especially if the attacks have been brought on by such an accidental circumstance as a very exhausting bout of mental or physical toil, then there is considerable reason to hope that the disease may soon wear itself out. Even patients who have serious valvular lesions may, with young and undegenerated tissues in their favor, quiet down again into a regular habit of semi-health, in which they may live for a long time without any recurrence of cardiac neuralgia. The more purely neurotic form, again, especially when it develops gradually out of some pre-existing chronic neurosis, such as asthma, is usually slow in its progress; and it may well happen, in such cases, that the danger to life is more on the side of serious nervous lesions than from the anginal attacks themselves. At the same time, it must be remembered that, even in the milder cases, any very unusual excitement, bringing on an unwontedly severe attack, may produce fatal results at any period of the disease.
There is some reason to believe that cardiac neuralgia is occasionally produced in a reflex manner in consequence of a severe existing intercostal neuralgia. I cannot say that I have witnessed any thing which can be considered as completely proving this; but it certainly seems likely that, in some of the few cases of excessively painful herpes zoster which have proved fatal (of which I have given one example), cardiac spasm or paralysis may have been secondarily induced, and may have occasioned the catastrophe. It is likely enough that, if this was the case, the reflex irritation operated upon motor centres which themselves were predisposed to take on the morbid action; but this again is a fresh illustration of the uncertainties to which prognosis is liable in a disease like angina, the very fundamental character of which is that, upon increase of the irritation, the gravity of the resulting functional affection is liable to be indefinitely and most rapidly increased.
Treatment.– The treatment of cardiac neuralgia is (1) prophylactic, and (2) palliative of the attacks.
As regards the prophylactic treatment, it is unnecessary to repeat the remarks which we have made elsewhere upon the general principles of tonic and nutritive medication in neuralgias of every kind. One especial prophylaxis, in the case of this formidable variety of neuralgia, is concerned with the preservation of the heart from certain disturbing influences which would render the occurrence of the fit more probable. All violent emotions and all strong physical exercise (but especially such forms of it as, like boating, are well known to "pump" the heart severely) are to be carefully avoided. Even indigestion and flatulence are to be carefully guarded against since these are quite capable of embarrassing the action of the heart to a degree which, though it might be trivial in the case of ordinary health, may prove fatal by exciting a flabby ventricle to irregular and embarrassing contraction. It is even possible that the strong irritation set up by some varieties of indigestible food might propagate an irritation to the spinal cord which would produce an interbitory paralysis at once.
But besides these obvious precautions against interference with the regular and tranquil action of the heart, there are some special medicinal remedies which deserve particular notice. Whether we really possess any means of so influencing the nutrition of the muscular tissue of the heart as to prevent its lapsing into a fatty degeneration, it is impossible to say; but this may be affirmed with some confidence, that, in cases where awkward threatenings of cardiac neuralgia have occurred, and simultaneously it has been noticed that the heart-sounds become weak and the circulation languid, a most marked improvement has been produced in all respects by the administration of iron and strychnia. I usually give tincture of sesquichloride of iron, ten minims, and strychnia, one-fortieth of a grain, three times a day. Still better, where it can be borne, is the syrup of the triple phosphate of quinine, iron, and strychnia, which undoubtedly has an extraordinary influence upon tissue nutrition, as exemplified in its remarkable effects in many cases of phthisis. It must be observed, however, that it is not every neuralgic patient who will bear the combination of quinine with iron; it has occurred to me to meet with several in whom the union of these two remedies proved violently disturbing to the nervous system, causing distressing headache and palpitation of the heart, which could not be attributed to any want of care in the apportioning of the dose, or in the mode of administration. Iron is more especially indicated, of course, in cases where there is anæmia; but there are some cases in which strychnia given alone seems to produce a very beneficial influence. (vide Chapter V., on "Treatment.")
By far the most important prophylactic tonic against cardiac neuralgia, however, is arsenic. That this drug should prove useful in cardiac neuroses might readily be anticipated from its very great utility in many cases of asthma, a disease which, as already remarked, has a close relationship to the former. Dr. Philipp has recently recorded a case which is perhaps an extreme instance of this beneficial influence of arsenic, but is none the less encouraging, especially as it only corroborates what has been advanced by other observers. Given in doses of from three to five minims of Fowler's solution, twice or thrice daily, arsenic is an invaluable remedy in cardiac neuralgia; the one objection to it being that some neurotic patients possess such an irritable intestinal canal that the remedy cannot be borne, as it produces diarrhœa. Even here we may sometimes succeed by combining it with very small doses of opium. It is more especially with regard to those cases in which the neurotic character of the disease is very prominent —i. e., in which the nervous temperament of the patient betrays itself in other ways besides the tendency to spasmodic embarrassment of the heart's action, that arsenic holds such a very high place as a remedy. And it should be carefully remarked that the prophylaxis of angina extends itself, in such cases, beyond the limits of actually-declared and well-defined angina, which is, of course, an uncommon disease. This remedy is important, and may be most usefully employed in the far larger group of cases in which a marked tendency to spasmodic pain in the chest, on the occurrence of some comparatively trifling excitement, is observed in patients who either have some organic heart-disease, or who are liable to severe attacks of asthma. It cannot be too often repeated that there is no intelligible separation, except one of degree, between these cases and the malignant forms of angina. It may be added that, in my experience, I have found the whole group of cases to be bound together in a singular way by the tolerance of arsenic which, with certain exceptions already referred to, they display. Commencing with the small doses above mentioned, I have found it possible, in many cases, to advance to the administration of twice or thrice the quantity, and to continue this medication for months together, not only with no evil effect, but with the best results.