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the fatal termination appears to be intimately dependent upon the pre-
vious anginoid attack. It should be remarked in this place that we
often have both anterior conditions, viz., that of fibrous myocarditis or
of fatty degeneration, without having attacks of true angina. Accord-
ing to Gibson, the relations of angina with endocardial lesions is
not so distinct. It is true, of course, that degeneration of cardiac
walls may often cause it, and, therefore, it is frequently found at the
autopsy. The earlier writers, like Morgagui, certainly attached angina
directly to the existence of aortic disease, and in one of Heberden's
cases, where the autopsy was made by John Hunter, this affection is
duly recorded. On the other hand, we know that the most advanced
changes with ossification may exist at the aortic orifice, and yet there
may be present during life no morbid symptoms at all. 2 These instances
must be somewhat exceptional. What is true is, where aortic lesions have
been proven at autopsy, often pain has been noted prior to death. No

1 British Medical Journal, 1891, vol. i. p. 747. Quoted by Osier.

2 Sernple, p. 104 et seq.



ANGINA PECTORIS. 127

doubt, this pain has been in part due, at least, to interference with the
coronary circulation, caused by accompanying aortitis, with which there
may also be a certain degree of dilatation, or, indeed, a sacculated
aneurism. Arterial degeneration, especially arterio-sclerosis, is often
adjoined to attacks of angina. Where the coronary arteries are degen-
erated, and where the angina is seemingly dependent upon this condi-
tion, we should not lose sight of the fact that the other arteries, being
degenerated, are also doubtless contributory. The affection of the
coronary arteries through sclerosis and consequent narrowness, prevents
a sufficient blood supply reaching the heart, and hence interferes with
its nutrition. A thrombus or embolus may obstruct the vessels, but it
is doubtful whether one or the other of these conditions causes angina.
(Gibson.) One thing is sure, viz., we often find calcification of these
arteries without previous anginal attacks. Adherent pericardium may
be found, but does not occasion anginal attacks unless accompanied by
a lesion at the aortic orifice,

Angina has been observed following injuries to the chest walls. In
these cases the aorta may have been affected. Broad bent states its
presence occasionally in malarial fever. It may also be present in
advanced diabetes where the arteries may become thickened, thus giv-
ing rise to increased tension, and followed by attacks of true angina.
It is not infrequent to find anginoid attacks occasioned evidently by
the presence of the gouty poison. In these cases the prognosis is
only serious where the intracardiac changes are already advanced, as
shown by the weakness and irregularity of the heart's pulsations. In
some of these cases we find notably fibroid myocardial changes in
patches or disseminated. Even in these instances, prior to death, there
may have been a few or no threatening cardiac symptoms. In a few
rare cases neuritis of the cardiac plexus and also of the phrenic nerve
has been noted (Lancereaux, Peter) where anginoid attacks have
occurred. The view of Semple is, indeed, that angina considered as an
idiopathic disease is connected with an affection of the pneumogastric
or phrenic nerve. Of course, it is difficult always to pronounce what
the precise structural changes are. Still, they are doubtless present,
and later will be discovered. Meanwhile we are forced to rank a few
such instances among the " neuroses." Frequently, doubtless angina
is associated with minute structural changes which only subsequent
close investigation will determine Flint is evidently of the opinion
that the connection between angina and organic lesions of the heart is
rare. Thus he has only observed fifteen cases in 388 cases of the latter.
Again, Flint says that in ten years he has noted only four cases of true
angina, that is to say, where the disease was unconnected with cardiac or
aortic lesions. It is clear that in all instances where there is present an
organic lesion of the heart or arteries, whatever suffering, if any, the



128 ANGINA PECTORIS.

patient may experience should be directly explained by them. This
leads to the conviction that only those cases in which no such lesion is
discoverable should be ranked among the true cases of angina. As a
rule, when sudden deaths occur in what has been called angina,
pathological lesions sufficiently explanatory are found at the autopsy.

The condition of the heart during an attack of angina has been
believed to be one of spasm. At least, this is the opinion of some
writers. It is certainly true of Heberden, who first so accurately de-
scribed these attacks in his commentaries. This does not seem to be
altogether a tenable opinion, if one has regard to the fact that the heart
has rarely been found thus contracted.

Usually the heart stops in diastole, and is found after death in a
relaxed condition. Again, during life, while the pulse at the wrist is
sometimes irregular and weak, it never disappears entirely, which it
certainly would if the heart were in a state of forcible, spasmodic con-
traction.

It has been supposed that the heart during an attack presented a
sort of hour-glass contraction not dissimilar to that of the uterus. This
may be, and yet it would be difficult to prove. Broadbent confesses in
this connection that he has a very imperfect notion of what the condi-
tion of the heart really is during an attack. The evident fact is that
during a paroxysm of angina stress is put upon the heart to which it is
quite unequal to respond, and thus it shows its considerable lack of
power. Often the stress put upon the heart is due to the continuous
high tension of the peripheral arteries. Occasionally, however, there
is low tension in the peripheral circulation, and in these instances, if
there occur a sudden general arterial spasm, the amount of work thrown
upon the heart becomes rapidly much greater, and consequently the
heart shows relatively greater distress than where the peripheral resist-
ance is continuously high and exaggerated. In those cases where there
is marked and continuous high tension in the peripheral arteries we
might suppose that pain in angina was explained by greater pressure
thrown upon the heart. This can scarcely be true when we consider
how many such cases escape any such pain. Again, in acute dilatation
of the ventricles, we have great pressure brought upon the heart walls,
and yet no pain results. Neuralgic predisposition is occasionally given
as an explanatory cause. This is scarcely true if we mean by that an
acquired or evident neurotic tendency, since this disease occurs more fre-
quently with men than with women. It would seem as though from the
fact that when the attack occurs immediately, the patient stops doing
anything he is occupied with, or exercising, if that be what he is about,
that there is a certain pre- ordered protective arrangement internally
to guard against these outward manifestations of man's life. (Broad-
bent.)



ANGINA PECTORIS. 129

Pain, according to Bramwell, 1 is due to irritation of the nerve ter-
minations in the walls of the heart itself. He admits, however, that
the theory of irritation due to spasmodic contraction is plausible, and
compares this opinion with what occurs in the calf muscles, spasmodi-
cally contracted, in ordinary cramp.

Attacks of false angina often resemble those of the real kind. Some-
times the description of the attack by friends will enable us to reach a
correct diagnosis. If the patient becomes pale, anxious, and shows
signs of great distress, it may not of necessity be true angina. If, on
the contrary, there be no such changes evident, we can be very sure
that it is only an attack of pseudo-angina. There is much unreliability
in the patient's accounts, mainly because they are apt to read up about
these attacks, and often give an exaggerated idea of their own sensa-
tions. Age will throw some light upon the diagnosis. Under forty
years of age in the male, angina occurs very rarely, unless there be a
pronounced lesion at the aortic orifice or aortitis. In females it is rare
at any age, although attacks of pseudo-angina are not infrequent with
them, especially those of an undoubted neurotic temperament. Heber-
den, for example, in speaking of the cases observed by him, being in
number over 100, states that three occurred in women, one in a boy
twelve years of age, and the others in men near or over fifty years.

Usually the first attacks of angina occur during physical exertion.
Later on they may come on severely and more readily, and then we
may make the diagnosis surely, even though the determining cause is
slight. The physical examination will reveal, in case of true-angina, the
changes mentioned in the aorta or at aortic orifice. Where the attack
at first comes on without exertion and at a fixed period after ingestion
of food, it would seem to be of digestive provenance or pseudo-angina,
and ordinarily due to a dyspeptic attack. Unless history, nature, and
onset of attack all concur together with physical signs to establish diag-
nosis of true angina, we should lean strongly to diagnosis of pseudo-
angina, and almost invariably, if we can discover any facts to support
this diagnosis. If we leave out attacks of pseudo-angina which are
evidently neurotic or of hysterical nature, we can usually find in some
digestive disorder, particularly of the stomach, a sufficient explanation
of them. There are eructation, marked flatulence, pain, occasional
attacks of nausea, or vomiting, which all point in this direction. A
combination sometimes found is that of dilatation of the stomach, with
high arterial tension. If the heart be affected in these cases and they
are improperly treated, a fatal result may not infrequently follow. If,
for example, digitalis or nitroglycerin be alone used, or the Schott
treatment advised and carried out without any care of the stomach, and

1 Diseases of the Heart, p. 676.



130 ANGINA PECTORIS.

especially if the subject be old, such a denouement may not be a
surprise.

The prognosis of true angina is often uncertain ; and yet we have
certain conditions which guide us to make it correct. We should
estimate carefully the relative predominance of the two factors often
producing it — on the one hand, degenerated heart walls, on the other,
vascular changes. If there be high arterial tension present, and if at
the same time the heart action is forcible and the aortic second sound
marked, we may hope by proper treatment to modify these conditions
for a while with the use especially of nitroglycerin and the nitrites.
Again, if over-exertion and excitement bring on the attacks, or if flatu-
lent dyspepsia be a decided and powerful influence in producing them,
we should hope to avoid with care and treatment their natural outcome.

On no account should the patient walk hurriedly, especially in going
up hill. He should also never take even a moderate walk until a
certain time had elapsed after his last repast.

Attacks of angina which accompany aortic disease may last a con-
siderable time without bringing on a fatal result if carefully watched
and guarded. The worst cases are those which recur in the night or at
times where no accidental cause is present and avoidable which occa-
sions them. Again, if examination is relatively negative, if the heart is
of normal size, without manifest lesion of any kind, and yet its action
is feeble, its impulse scarcely felt, and the pulse usually, if not invari-
ably, of low tension, these give great anxiety by reason of the vagueness
and uncertainty as to the conditions which may be present and at any
time become imminently threatening.

The apparent severity of two attacks may be similar, and yet the
relative danger of them may be absolutely different. It is difficult,
therefore, at times to make anything like a sure forecast. Of course,
where there are pronounced cardiac and arterial changes, and where,
in addition, heart failure has followed hypertrophy, the outlook is
assuredly very grave indeed. If, at the same time, aortic regurgitation
also be present the prognosis becomes even more serious. In a similar
way, if chronic renal changes exist the future of the patient must
appear dark and imminent. Gibson states that the prognosis of those
affected with fatty degeneration is far less serious than the preceding.
Provided always the external and avoidable causes of aggravation are
prevented, such patients may often live many years. Of course, toxic
angina is far less grave. As a rule, with the removal of the cause the
case becomes curable. In neurotic cases, while we should expect fre-
quent recurrences of the paroxysms, it is wholly improbable to have a
fatal termination.

In this catagory may be placed frequently the so-called idiopathic
cases. They are often extremely painful, but as no incurable lesions



ANGINA PECTORIS. 131

exist, they tend to improvement or recovery if properly managed. Of
course, we should be careful in making even in these cases too favorable
a prognosis, since there may be some underlying structural change of
the heart walls or coronary arteries which, during life, could not be
determined. There are unquestionably, according to Semple, cer-
tain cases of pure angina in which the autopsy reveals no organic
changes.

The treatment of angina depends upon what is the apparent or
obvious cause. In many instances, owing to the difficulty of tracing
accurately to what the attack is primarily due, our treatment must be
essentially empirical. First of all, we must consider the general health,
and from this point of view our treatment should be hygienic. The
means at our command are here what pertain to air and light, rest and
exercise, food and drink. After these have all been inquired into and
regulated, as far as may be, we' naturally seek for the proper medicinal
remedies to meet the indications of each special case. In general, also,
the efficiency of our treatment will depend much to what degree we may
be able to relieve peripheral resistance to a heart frequently weakened.
If, perchance, we find between the regular pulse beats evidence of
increased tension to our tactile sensations, we may often reduce this by
appropriate remedies. Still, in order to recognize it, we must at times
examine the heart and arteries at different periods, before and after
exertion. Not infrequently the arteries are notably degenerated, hard,
thickened, tortuous, and even calcareous. We can then do little to
affect them directly. Yet, the capillary system, in which there may be
notable resistance without excessive changes, and which has caused in
a measure the arterial and cardiac changes, may be still favorably
influenced by appropriate drugs, and account should be kept of this
fact. In gouty conditions the peripheral circulation may show increased
tension, although not visibly degenerated, and this condition, of course,
may be favorably influenced by appropriate medication.

In these latter cases the ordinary treatment with a mercurial, fol-
lowed by a saline, once or twice a week, will lower arterial pressure.
Between times the use for a while continuously of iodide of potash and
colchicum may be of signal benefit. The employment of bitter tonics,
if the indication presents, and the proper regulation of the diet is,
of course, useful. According to Powell, hop, columba, and chiretta are
better tonics in these cases than quinine and strychnine. In the " neu-
ralgic bouts," to which they are prone, he praises quinine and phen-
acetin. Where angina occurs with marked aortic disease it is difficult
sometimes to know to what extent we may be able to help the attacks
by reducing tension of the pulse. Where the pulse remains feeble
between the attacks, and the heart has a weak impulse, we should care-
fully endeavor to help with cardiac tonics, but frequently we can be of



132 ANGINA PECTORIS.

little real service in view of the pronounced degenerative changes
present in the heart and arteries. Occasionally arsenic, combined with
iodide of potassium and nux vomica, is useful where the arterial tension
is not too pronounced. Preference may be given in many instances to*
the sodium salt of the iodide, both between and during the attacks.
According to Schott, it is less prone to cause heart failure ; but even
this salt is "apt to destroy the molecules of albumin" if continued too
long or in increasing doses. Milk is the best menstruum for either
salt, as in this way stomachal intolerance is less likely to occur. In
these and other cases we should try to preserve the use of the nitrites
and nitroglycerin for the attacks. Formerly the diffusible stimulants,
like brandy, ammonia, lavender, camphor, etc., were much used for
these attacks. Now they are almost abandoned for nitroglycerin and
nitrite of amyl. These latter are particularly useful in relieving pain,
and to accomplish it they dilate peripheral arteries. Nitrite of amyl
by the rapidity of its action is preferably employed. Nitroglycerin
and the sweet spirits of nitre produce similar effects in different degrees.
All of these are free from dangerous effects, as a rule; not so of nitrite
of sodium, which may produce alarming results. (Gibson.) Nitrite of
amyl and nitroglycerin dilate arteries, increase frequency of pulse and
respiration, and reduce irritability of the nervous system. Where
increased acceleration of the pulse and respiration are already present
the nitrites must be employed with great care, as they might possibly
cause greater distress. While they are said to be heart stimulants, they
mainly cause relaxation of the arteries and also of the cardiac muscular
fibres. (Broadbent. 1 )

The nitrites have their drawbacks also in the fact that patients find
so much relief from their use that they use them too frequently and
injudiciously. A word of warning should be thrown out because life
is sometimes shortened by their inconsiderate use. Glycosuria has been
produced by them, it is stated. In many instances the nitrites are less
useful than iodide of potash. Nitrite of amyl may be carried about
with one so as to be used immediately. The nitrite of amyl in glass
globules, of 3 to 5 minims, may be in a silk bag and broken upon a
handkerchief and inhaled as required. The nitroglycerin tablets, one
one-hundredth of a grain, may also be taken in doses of one or two when
attack occurs. They do not act as rapidly as the nitrite of amyl, but
their effect is more prolonged, and on that account may be more valu-
able in certain cases.

Some cases, however, are not relieved by nitroglycerin tablets and are
relieved by nitrite of amyl. According to Broadbent, such cases have
seemed to him to originate in the right ventricle.

1 This opinion about heart fibres I do not share save very exceptionally.



ANGINA PECTORIS. 133

It is the belief of Dr. B. Addy 1 that we have in erythrol tetranitrate
a remedy superior even to "nitroglycerin," its effects being very rapid
and more lasting. Tablets of one-half grain each were given by him
twice or three times a day. They did not cause headache, and the
remedy soon checked the attacks. It is true the patient died after a
fortnight of syncope, but during this period great relief from suffering
was experienced.

Sometimes, where the heart is weak and the nitrites do not relieve,
although they may relax the peripheral circulation, we must recur to
the old stimulants. In addition, a turpentine stupe, or mustard leaf, or
poultice may be applied over the chest and will occasionally afford a
measure of comfort. Whenever these local applications fail, great
relief is obtained from a hot-water bag at a temperature of 140° F.
to 170° F., "moved with light touches over the whole chest." 2 If,
despite all this, the attack is prolonged and unrelieved, we must give
a hypodermic injection of morphine and atropine, using at first small
doses, and later, if need be, becoming bolder, and using larger doses.
It is well to make injections deep in the muscle, where the circula-
tion is more active than in the cellular tissue under the skin. In
some instances we should recur to chloroform inhalations as being
the only hope of relief to the patient. At times they are undoubt-
edly dangerous, and " especially is this believed to be true if fatty
heart is present. As a matter of fact, however, fatty heart cannot
always be diagnosed with accuracy. The apex may be strong and the
pulse regular and good, and yet fatty heart may exist, and sudden
death follow. Again, moreover, it has been shown that chloroform
may be given safely where fatty heart later is known to exist by the
revelations of the autopsy. We must relieve intense pain, however,
even if there be risk, and it can only be done at times by such agents.
(Balfour.)

In cases where there is marked heart failure, ether or brandy should
be employed hypodermically in doses of gss to 3j. To each hypo-
dermic injection one or two tablets of one one-hundredth of a grain of
nitroglycerin may be added. The latter should be employed with
caution, however, as occasionally considerable soreness and even ulcera-
tion of the skin may result.

Theodore Schott does not value very highly digitalis or strophanthus
in cases where the heart requires stimulation, even in uncomplicated
forms of angina pectoris caused by sclerosis of the coronary vessels.

Oxygen inhalations are often also useful, not only to satisfy the air
hunger, due to obstruction of circulation in the lungs, but also to
stimulate cardiac circulation and help nutrition of its muscles, and thus

1 British Medical Journal, May 6, 1899, p. 1089. a Lancet, September 8, 1900, p. 726.



134 ANGINA PECTORIS.

get rid of effete material which interferes with proper metabolism.
(Powell.) In these cases the oxygen must be used with a funnel near
the nose and mouth, so that it may be inhaled frequently and without
effort. As corroborative of the extreme value of inhalations of oxygen
in the treatment of some severe cases of angina pectoris, I would refer
to one recently reported in the British Medical Journal for December 1.
1900, p. 1568.

Rest in bed for a time is often desirable after acute paroxysms have
passed, but later it is useful, as far as possible, to get the patient back to
his ordinary life, with judicious restrictions. The same rules apply
here, however, as in other heart affections. We must remember, also,
that exertion which one day may seem all right, another day may cause
distress and oppression. This is one of the objections to Oertel's system
of treatment. (Broadbent.)

Physical therapy is undoubtedly useful in some instances, but it
must be utilized with great care. This counsel pertains particularly at
the present time to the treatment as instituted at Bad Nauheim, where
the resistant movements in conjunction with carbonic baths are prac-
tised. In advanced arterio-sclerosis every increase of the blood press-
ure which is the result of this treatment might lead to fatal conse-
quences (embolism, apoplexy, rupture of aneurism of heart, or aorta).
"Advanced sclerosis is, therefore, a contraindication for this treat-
ment." (Schott.) The value of many medicaments in angina comes
from producing low blood pressure. The balneological and gymnastic
treatment exercises a tonic influence, and " by strengthening heart
muscle, as well as by acting on cardiac nerves, distressing symptoms
of angina are either removed or reduced." (Schott.)

Guidance should be had in regard to the bad effects of winds, great
heat or cold, or rapid changes. Also, an atmosphere heavily laden
with moisture is injurious. Internal conditions of dyspepsia and con-
stipation must be warded against. A great deal of tact and good
judgment are required, and the patient's disposition should be thoroughly
known. Rest, particularly after meals, should be insisted upon, as
patients are particularly liable to attacks at these times.

In general, supervision and counsel must be employed about exercise.
Where an attack has lately occurred, it is wisdom to refrain from
exertion for a while, especially if the heart is weak and fluttering, and
afford it time to re-establish itself.



TUBERCULOUS PERICARDITIS :

Followed by Remarks upon Paracentesis and Incision.



Two cases of this somewhat rare disease have been under my care
within the past eighteen months. In both cases autopsies were ob-
tained — the one complete, the other only embracing the examination


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