Dr Heberden was the first who described this disease, though it is an extremely dangerous, and, by his account, not very rare affection. It seizes those who are subject to it when they are walking, and particularly when they walk soon after eating, with a most disagreeable and painful sensation in the breast, which seems to threaten immediate destruction; but the moment they stand still, all the uneasiness vanishes. In all other respects the patients at the beginning of this disorder are well, and have no shortness of breath; from which the angina pectoris is totally different. After it has continued some months, the fits will not cease instantaneously on standing still; and it will come on not only when the patients are walking, but when they are lying down, and oblige them to rise up out of bed every night for many months together. In one or two very inveterate cases, it has been brought on by the motion of a horse or carriage, and even by swallowing, coughing, going to stool, speaking, or any disturbance of mind. The persons affected were all men, almost all of whom were above 50 years of age, and most of them with a short neck and inclining to be fat. Something like it, however, was observed in one woman, who was paralytic; and one or two young men complained of it in a slight degree. Other practitioners have observed it in very young persons.
When a fit of this sort comes on by walking, its duration is very short, as it goes off almost immediately upon stopping. If it comes on in the night, it will last an hour or two. Dr Heberden met with one in whom it once continued for several days; during all which time the patient seemed to be in imminent danger of death. Most of those attacked with the distemper died suddenly; though this rule was not without exceptions; and Dr Heberden observed one who fainted under a lingering illness of a different nature.
The os sterni is usually pointed to as the seat of this malady. It seems as if it was under the lower part of that bone, and at other times under the middle or upper part, but always inclining more to the left side; and in many cases there is joined with it a pain about the middle of the left arm, which appears to be seated in the biceps muscle.
The appearance of Dr Heberden's paper in the Medical Transactions very soon raised the attention of the faculty, and produced other observations from physicians of eminence; particularly Dr Fothergill, Dr Wall of Worcester, Dr Haygarth of Chester, and Dr Percival of Manchester. It also induced an unknown sufferer under the disease to write Dr Heberden a very sensible letter, describing his feelings in the most natural manner; which, unfortunately, in three weeks after the date of this anonymous epistle, terminated in a sudden death, as the writer himself had apprehended.
The youngest subject that Dr Fothergill ever saw afflicted with this disorder was about 30 years of age; and this person was cured. The method that succeeded with him was a course of pills, composed of the mass of gum pill, soap, and native cinnabar; with a light chalybeate bitter: this was continued for some months, after which he went to Bath several successive seasons, and acquired his usual health: he was ordered to be very sparing in his diet; to keep the bowels open; and to use moderate exercise on horseback, but not to take long or fatiguing walks.
The only symptom in this patient that is mentioned, was a stricture about the chest, which came on if he was walking up hill or a little faster than ordinary, or if he was riding at a very brisk trot; for moderate exercise of any kind did not affect him; and this uneasy sensation always obliged him to stop, as he felt himself threatened with immediate death if he had been obliged to go forward.
It is the sharp constrictive pain across the chest, which (according to Dr Fothergill's observation) particularly marks this singular disease; and which is apt to supervene upon a certain degree of muscular motion, or whatever agitates the nervous system.
In such cases as fell under the inspection of Dr Fothergill, he very seldom met with one that was not attended with an irregular and intermittent pulse; not only during the exacerbations, but often when the patient was free from pain and at rest; but Dr Heberden observes, that the pulse is, at least sometimes, not disturbed; and mentions his having once had an opportunity of being convinced of this circumstance, by feeling the pulse during the paroxysm.
But no doubt these varieties, as well as many other little circumstances, will occur in this disease, as they do in every other, on account of the diversity of the human frame; and if those which in general are found to predominate and give the distinguishing character be present, they will always authorize us in giving the name to the disease: thus, when we find the constrictory pain across the chest, accompanied with a sense of strangling or suffocation; and still more, if this pain should strike across the breast into one or both arms; we should not hesitate to pronounce the case an angina pectoris.
As to the nature of this disease, it appears to be purely spasmodic: and this opinion will readily present itself to any one who considers the sudden manner of its coming on and going off; the long intervals of perfect ease; the relief afforded by wine, and spirituous cordials; the influence which passionate affections of the mind have over it; the ease which comes from varying the posture of the head and shoulders, or from remaining quite motionless; the number of years for which it will continue, without otherwise disordering health; its bearing so well the motion of a horse or carriage, which circumstance often distinguishes spasmodic pains from those which arise from ulcers; and, lastly, its coming on for the most part after a full meal, and in certain patients at night, just after the first sleep, at which time the insomnus, convulsive asthma, and other diseases, justly attributed to the disordered functions... tions of the nerves, are peculiarly apt to return or to be aggravated.
From all these circumstances taken together, there can be little doubt that this affection is of a spasmodic nature; but though it should be admitted, that the whole distress in these cases arise from spasm, it may not be easy to ascertain the particular muscles which are thus affected.
The violent sense of strangling or choking, which shows the circulation through the lungs to be interrupted during the height of the paroxysm; and the peculiar constrictive pain under the sternum, always inclining (according to Dr Heberden's observation) to the left side; together with that most distressing and alarming sensation, which, if it were to increase or continue, threatened an immediate extinction of life; might authorise us to conclude that the heart itself is the muscle affected: the only objection to this idea is, that the pulse is not always interrupted during the paroxysm.
The appearances in two of the affections, favour the opinion that the spasm affects the heart; as in one subject the left ventricle was found as empty of blood as if it had been washed; and in another, the substance of the heart appeared whitish, not unlike a ligament; as it should seem, in both cases, from the force of the spasm squeezing the blood out from the vessels and cavities.
If this hypothesis be allowed, we must conclude that the spasm can only take place in an inferior degree, as long as the patient continues to survive the paroxysm; since an affection of this sort, and in this part, of any considerable duration or violence, must inevitably prove fatal: and accordingly, as far as could be traced, the persons who have been known to labour under this disease have in general died suddenly.
The affections also show, that whatever may be the true seat of the spasm, it is not necessary for the bringing of it on, that the heart, or its immediate appendages, should be in a morbid state; for in three out of the six that have as yet been made public, these parts were found in a sound state.
On opening the body of the poor gentleman who wrote the letter to Dr Heberden, "upon the most careful examination, no manifest cause of his death could be discovered; the heart, in particular, with its vessels and valves, were all found in a natural condition."
In the case communicated by Dr Percival to the publishers of the Edinburgh Medical Commentaries, "the heart and aorta descendens were found in a sound state." And in Dr Haygarth's patient, "on opening the thorax, the lungs, pericardium, and heart, appeared perfectly found." Not to mention Dr Fothergill's patient (R.M.), in whose body the only morbid appearance about the heart was a small white spot near the apex. Thus the cause, whatever its nature might have been, was at too great a distance, or of too subtile a nature, to come under the inspection of the anatomist. But there was a circumstance in two of the subjects that is worthy of remembrance; and which shows that the crisis of the blood, while they were living, must have been greatly injured, namely, its not coagulating, but remaining of a cream-like consistence, without any separation into serum and clotted matter.
From all that we have seen hitherto published, it does not appear that any considerable advances have been made towards the actual cure of this anomalous spasm.
The very judicious and attentive Dr Heberden (to whom the public are highly indebted for first making the disorder known) confesses, that bleedings, vomits, and other evacuations, have not appeared to do any good: wine and cordials taken at bed-time, will sometimes prevent or weaken the fits; but nothing does this so effectually as opiates: in short, the medicines usually called nervous or cordial, such as relieve and quiet convulsive motions, and invigorate the languishing principle of life, are what he recommends.
Dr Wall mentions one patient, out of the 12 or 13 that he had seen, who applied to him early in the disease, and was relieved considerably by the use of antimonial medicines joined with the fetid gums: he was still living at the time the doctor wrote his paper, (November 1772), and going about with tolerable ease. Two were carried off by other disorders; all the rest died suddenly.
Dr Fothergill's directions are chiefly calculated with the view to prevent the disorder from gaining ground, and to alleviate present distresses. Accordingly he enjoins such a kind of diet as may be most likely to prevent irritability; in particular, not to eat voraciously: to be very abstemious in respect to every thing heating; spices, spirits, wines, and all fermented liquors: to guard most scrupulously against passion, or any vehement emotions; and to make use of all the usual means of establishing and preserving general health: to mitigate excesses of irritability by anodynes; or pains, if they quicken the circulation: to disperse flatulences when they distend the stomach, by moderate doses of carminatives; amongst which, perhaps, simple peppermint water may be reckoned one of the safest. But since obesity is justly considered as a principal predisposing cause, he insists strongly on the necessity of preventing an increase of fat, by a vegetable diet, and using every other practicable method of augmenting the thinner secretions.
These were the only means recommended by the practitioners mentioned above for opposing this formidable disease: but Dr Smyth of Ireland has, we are told, discovered that it may be certainly cured by influes, of which Dr Macbride gives the following instance.
"A.B., a tall well-made man; rather large than otherwise; of healthy parents, except that there had been a little gout in the family; temperate; being very attentive to the business of his trade (that of a watchmaker), led a life uncommonly sedentary; had, from his boyhood upwards, been remarkably subject to alarming inflammations of his throat, which seized him, at least, once in the course of the year; in all other respects well.
"In 1767, (then 48 years of age), he was taken, without any evident cause, with a sudden and very distressing throbbing under the sternum. It soon afterwards increased, and returned upon him every third or fourth week, accompanied with great anxiety, very laborious breathing, choking, a sensation of fulness and dilatation in the head, a bloated and flushed countenance, turgid and watery eyes, and a very irregular and unequal pulse. The paroxysm invaded," Appendix.