An interesting set of heart symptoms, for the physician as well as the clergyman, are those which occur in what is called angina pectoris, heart pang, or heart anguish. Serious angina pectoris occurs in elderly people whose arteries are degenerate. Its main symptom is a feeling of discomfort which develops in the praecordia,—the region over the heart. [{142}] This discomfort may often increase to positive cutting pain. The pain is often referred to the shoulder, and runs down the left arm. This set of symptoms is accompanied by an intense sense of impending death. When the patient's arteries are degenerated, this train of symptoms must always be considered of ominous significance. A readily visible sign of arterial degeneration can sometimes be noted in the tortuous prominent temporal artery just above the temple.
Heberden, an English physician, a little over a century ago, pointed out that there existed in cases of true angina pectoris a degeneration of the coronary arteries. These are the arteries which supply the heart itself with blood. As might naturally be expected, their degeneration seriously impairs the function of the heart muscle. The first patient in whom the condition was diagnosed during life was the distinguished anatomist, John Hunter. Hunter was of a rather irascible temperament, and after he had had several of these attacks, and a consultation with Heberden convinced him of their significance, he is said to have remarked, "I am at the mercy of any villain who rouses my temper." Sure enough. Hunter died in a sudden fit of anger within the year after making the remark. Charcot, the distinguished neurologist, suffered from attacks of angina pectoris, and was asked by his family to consult a distinguished heart specialist for them. He said: "Either I have degenerated heart arteries, or I have not. I believe that I have not, and that my attacks are due to a nervous condition of my heart. If I should consult the physician you mention, and he were to tell me that my attacks are due to degeneration of the heart, he would advise my giving up work. That I am not ready to do, and so I prefer to take my own assurance in the matter." A few years later he was found one morning dead in bed. In many of the cases of death in bed, especially where some complaint of pain has been heard during the night, death is due to that condition of the heart arteries which causes angina pectoris, though it may be the first attack which proves fatal.
There is a condition similar to angina pectoris, sometimes called pseudo-angina, or false heart pang, which occurs in individuals from fifteen to thirty years of age. It is often a [{143}] source of great worry. It occurs in young persons of a nervous temperament who have been overworked or overworried and have run down in weight. There are always accompanying signs of gastric disturbance. The casual factor of the symptoms seems to be a more or less sudden dilation of the stomach with gas. As the stomach lies just below the heart, only separated from it by the comparatively thin layer of diaphragm, the heart is pushed up and its action interfered with. In healthy individuals this causes no more than a passing sense of discomfort and some heart palpitation. That it is which sends so many young patients to physicians with the persuasion that they have heart disease, when they have nothing more than indigestion. In nervous individuals, however, this interference with the heart action disturbs the nervous mechanism of the heart, which is very intricate and delicate, and gives rise to the symptoms of false "heart pang." One of these symptoms is always, as in true angina pectoris, an impending sense of death. This can not be shaken off, and is not merely an imagination of the patient. Pseudo-angina is, however, not a dangerous affection. Patients can usually be assured that there is no danger of death. This assurance is not absolute, however. For some of these cases have congenital defects in their coronary arteries, and the nervous system of the heart itself, which make them liable to sudden death. It is sometimes impossible to differentiate such cases of organic heart defects from the ordinary functional heart disturbance due to indigestion, which causes simple curable pseudo-angina. Young patients may usually be disabused of their nervousness in the matter, but absolute assurance can not be given until the case has been under observation for some time.
After the heart, the head is the most important factor in sudden death. The most frequent form of death from intra-cranial causes is apoplexy. Apoplexy, as the name indicates—a breaking out—is due to a rupture of one of the arteries of the brain, and a consequent flowing out of blood into the brain tissue. The presence of the exuded blood causes pressure upon important nerve tracts, and so gives rise to unconsciousness, to paralysis, and to the other symptoms which are [{144}] noted in apoplexy. There are a number of symptoms that act as warnings of the approach of apoplexy. First, it occurs only in those beyond middle life, that is, in individuals over forty-five, and in these only where there is marked degeneration of arteries. The degeneration of the arteries can be easily noted, as a rule, in other parts of the body. The condition known as arterio-sclerosis, that is, arterial hardening, can be detected by the finger at the wrist, or by the eye in the branch of the temporal artery, which can so frequently be seen to take its sinuous course on the forehead behind and above the eye. At the wrist the thickened artery is felt as a cord that can be rolled under the finger. It is not straight as in health, but is tortuous, because the overgrowth in the walls, which makes it thick, has also made it longer than normal, thus producing tortuosity.
Besides these objective signs, as they are called, there are certain subjective signs, that is, signs easily recognised by the patient himself, which should put him on his guard, and at the same time serve as a warning to the clergyman, should he hear of their presence. These signs are recurring dizziness, or vertigo, not clearly associated with gastric disturbance; tendency of the limbs, and especially the fingers and toes, to go to sleep easily, and when there is no external cause for this condition; tendency to faintness and to dizziness when the patient rises in the morning, especially if he assumes the erect position suddenly; tendency to vertigo when the patient stoops, as to tie a shoe, or pick up something from the floor, and the like; finally, certain changes in the patient's disposition, with a loss of memory for things that are recent, though the memory may be retained for the happenings of years before. When several of these symptoms occur, patients who are well on in years should take warning of the fact that they are liable at any time to have a stroke. Needless to say, this has no reference to the cases of young nervous persons who may readily imagine that they have some or all of these symptoms. Apoplexy is typically the disease of those over fifty years of age.
There may even occasionally be slight losses of power in the hand or foot that point to the occurrence of small hemorrhages in the brain, that is, slight preliminary "strokes."
Patients that have had these symptoms should not, as a rule, be allowed to leave home unattended. If the apoplexy occurs in the street they are liable to be mishandled by those ignorant of their true condition. The clergyman is usually summoned at once in these cases and may reach the stricken individual before the physician. Some words, then, with regard to the general management of such patients will not be out of place. As a rule, when a patient is taken with some sudden illness which causes him to fall down unconscious, the first thing done is to dash water in his face, force a stimulant down his throat, put his head low down, and loosen the clothing around his neck. Most of these proceedings are the very worst things that could be done for a patient suffering from apoplexy. The rough handling, particularly, and the administration of a stimulant, will surely do harm. The water on the face will certainly do no good.
Apoplectic patients can be recognised from those who are merely in a fainting fit, first, by the fact that they are usually old, while the fainters are young; and secondly, by the manner of the breathing. In a faint the breathing is shallow and faint, not easily seen. In apoplexy it is apt to be deep and long. It may be irregular, and it is always accompanied by a blowing outward and inward of the cheeks, and especially of the side of the face which is paralysed, as a consequence of a hemorrhage into the brain.
The lips are forced outward and drawn inward during the respiration. In such cases the patient should be moved as little as possible; stimulants should be avoided, and the head should be placed higher than the rest of the body, so as to make the hemorrhage into the brain as small as possible, by calling in the assistance of gravity to keep the heart from sending too much blood into the head. Besides this placing the head high, there is only one other helpful measure that even the physician can practise, except in rare cases, that is, to put an ice-bag on the head. For this a cloth dipped in cool water may be used in an emergency. Of course, as soon as the doctor arrives, the patient should be left entirely to his care.