Synonyms:—Neuralgia of the heart; stenocardia; breast-pang.
Definition:—An acute paroxysmal pain in the heart and throughout the precordial region, radiating into the left shoulder and arm, characterized by a sense of impending dissolution, agonizing fear and great prostration.
Etiology:—While the condition is a neurosis, it is dependent upon disease in the heart of some character, although the evidences at first may not be pronounced. It may be hereditarily transmitted, though this is questioned, or it may be acquired. If hereditary or of purely nervous origin, it may occur at any age; if acquired it is more apt to occur in middle or advanced life, as the conditions which induce it are usually chronic in character and of slow development. It is somewhat more frequent in males than in females. Trousseau referred to it as a masked epilepsy. The attacks may alternate with epileptic seizures in epileptics, may precede an outbreak of insanity and will accompany hysterical paroxysms.
It occurs with fatty degeneration of the heart and with diseases which affect the coronary arteries or impede the circulation in those arteries. It accompanies atheroma or arterio-sclerosis.
It is more common in neurotic individuals and is induced by the use of cigarettes and by tobacco in any form and by alcoholic intemperance. It accompanies Bright's disease and rheumatism and gout, either directly or as a result of the heart mischief these conditions induee.
Symptomatology:—The immediate symptom is the agonizing pain in the heart, which occurs unannounced, and in irregular paroxysms. In the intervals between the paroxysms there are no symptoms. There are no premonitory evidences of the approach of the pain. It may occur when the patient is in good health, or there may be other disease present of a more or less exhausting character. It may occur after physical exercise or during a period of mental excitement, or it may occur while the patient is quiet or during sleep. There is a sense of immediate suffocation, intense alarm and indescribable distress throughout the precordial region. The patient braces himself in a fixed position as if he feared to move; the eyes become set and staring; the countenance assumes an expression of anguish and terror combined; a deathly pallor overspreads the countenance and he breaks out in a cold sweat, in some cases a dripping sweat, and the teeth chatter as if the patient were in a severe chill. The attack may last but a few seconds or it may continue several minutes. The patient may faint during the paroxysm and die from syncope, or he may suffer from extreme vertigo and disordered vision for the moment, to soon recover when the pain has ceased. The respiration is not necessarily influenced by the pain, although it may be greatly oppressed. The heart usually beats irregularly with greatly increased power at first, but soon the pulse becomes small, hard and frequent, finally rapid and feeble. The heart may intermit or beat with great irregularity, both in time and rhythm.
The recovery of the patient is quite rapid, although there is often immediate prostration. The attack may be followed with vomiting, eructation of gas, occasionally a loose bowel movement with colicy pains, and the passage of a large quantity of pale urine of a high specific gravity.
The paroxysms will recur after a longer or shorter period, usually with increasing severity. There may be only a few days between them, but usually several months or even a year may intervene.
Prognosis:—It is seldom that the patient survives a third attack. This is especially true if the disease is accompanied by a serious heart lesion. It is rare that death occurs in the first paroxysm. The prognosis in all cases is bad.
Treatment:—While there is but little premonition of a typical attack of agina, there are symptoms which are sufficiently plain to enable a physician to prescribe with the object of preventing the attack, the use of nitroglycerin and amyl nitrite are the most available measures for an immediate influence, the use of a hypodermic of morphin or the application of chloroform over the heart and over the spinal cord in the cervical region at the same time will sometimes prevent an attack. Half of a dram of chloroform, in the palms of the hands, applied one over the heart and one over the spinal column should be pressed closely against the skin until an intense burning sensation is induced. The use of full doses of gelsemium and macrotys will prevent or abridge an attack. During the pain five drops of the amyl nitrite, inhaled directly from pearls cnished on a handkerchief, will prove satisfactory.
The treatment between the paroxysms of existing conditions will depend upon the cause, which must be determined by a most careful examination, and this alone may receive treatment without reference to the possible later occurrence of the angina. Where nervous excitement results in irritation or vice versa, nerve sedatives should be used with reference to the removal of any possible irritation. If there is feebleness the sedative must be of the stimulating type, as the ammonium valerianate or the ammonium bromid. Constitutional conditions and the condition of the stomach and appropriative organs must have careful attention.