ANGINA PECTORIS.
Definition. — Angina pectoris (steno cardia, breast-pang) is the name given to a. group of symptoms which usually depends upon organic disease of the heart or aorta. An attack consists in the sudden onset of agonizing pain in the prmcordial or sternal regions, accom panied by a feeling of constriction and in severe cases by a sense of impending death. The pain radiates into the back, the shoulders, and the arms, particularly the left. The patient is pale, haggard, motionless, and often bathed with cold perspiration.
Symptoms.—Suddenly, after exertion, excitement, or a hearty meal, the patient feels an excruciating, burning, or tearing pain in the heart or beneath the sternum, accompanied with a sense of constriction (angere, to throttle), as if the heart were in a vise. The pain radiates into the back, upward into the shoulders, and down the left arm, often even to the finger-tips. It may be felt in both arms, in the neck and head, and even in the trunk and lower extremities. "In true angina the seat of the pain may be en tirely way from the chest, and may he, as in Lord Clarendon's father, at the inner aspect of the arm, or about the wrist, or in rare instances confined to the side of the neck, or even to one testis." (Osier.) Attacks occur in which pain is slight or absent (angina sine dolore). Early attacks are often of this sort. At a later period there may still be no pain, or the paroxysms may sometimes be painful and at other times not.
A feeling of numbness accompanies the pain. There is a sense of impending dissolution. The sufferer sits or stands immobile and hardly dares to breathe. Yet there is no real dyspncea. The face is pale or livid, the forehead wet with perspiration. The pulse may remain strong and regular. Usually it is accel erated and of increased tension. It may intermit or vary. Exceptionally it is slowed. The paroxysm lasts a few sec onds or minutes,—sometimes half an hour or even several hours. At the end of it the patient often belches gas or vomits or has a movement of the bowels, with great relief. The attack may prove
immediately fatal. If not, the patient is left exhausted, but regains his usual condition in a few hours or days.
Study of twenty-one cases. The at tacks usually came on after a meal. In every case exertion increased the pain, and the sense of fullness was relieved by the eructation of gas. Most of the Patients attributed their trouble to in digestion. In all there was shallow respiration with an occasional deep in spiration. The heart was usually slow, occasionally palpitating or irregular, and the pulse was generally tense and sustained. In all arterial fibrosis could be recognized by a thickening of the palpable arteries; cardiac disease— manifested by accentuation of the sec ond aortic tone, feebleness of the first sound, cardiac murmurs, pres ent at some time in nearly all cases. During the attacks the second aortic sound was always much accentuated, while the first sound could be heard very indistinctly. Frank Billings (Chi cago Med. Recorder, Feb., 1901).
The attack is almost sure to be re peated. This may happen in an hour or not for weeks or months. The length of the interval depends greatly upon the persistence of the patient in avoiding the exciting causes. Successive paroxysms occur with gradually increasing readi ness.
Angina pectoris is probably due to increased intravascular pressure. We can reasonably infer the presence of dilata tion of the heart by the physical signs of displaced apex-beat; gallop-rhythm; a soft, regurgitant murmur in the tricuspid or mitral area; by venous phenomena; and by the congestions, cyanosis, and dropsy that attend this affection. The results of cardiac percussion may be con firmatory, but are not looked upon as essential in the diagnosis of cardiac dila tation. Five cases to illustrate the fol lowing propositions:— 1. When dilatation of the heart super venes in a patient the subject of an attack or attacks of angina pectoris, the subjective symptoms may subside. At the same time the physical type of the individual changes.