On the Importance of Gonorrh a as a Cause of Inflammation of the Pelvic Organs
BMJ (Clinical Research Edition)
April 4, 1891.] THE BRITISH MEDICAL JOTURiNAL. 749 another factor mIlust enter into the causation. Nothing is nmlo-e coimmllioIn than high arterial tension, and it is met witlh in an extremne degree and produces fatal results without angina by ruining lheart or arteries, or both, in hundreds of cases for one in whichl angina is present. Acute dilatationi of one or both ventricles, again, in whichl stretching of the muscular fibres is obvious, frequently occurs without mngina. The importance,
... The importance, and even dominance, of this second factor becomes clear wlhein the cases of advanced fatty degenieration are borne in mini(l, wlheni the fibres must be incapable of producing anything like actual mechanical tension. It lnas beetn assumed that the other element is neuralgic, ;and in a senIse this is true, but Inot in the sense of a predisposing, neurotic tendency. It must be remembered that an-gTina is mlluchI nliore common in the male, whichl is tlle least neurotic sex. Mechanical stretclling and neuralgic predisposition being put otut of the (uestioIn, there remaiins the fact that the existcnc't of the patient is threatened at the moment of the attack by atrrest of thle heart's action, and were it not for the warning given by the pain and for tlle cessation of exertion <nforced by it, tlie subject of the particular coniditioni of the lie'ait would die. We lIlust, it seems to me, assume that annii-a is one of the defensive arrangements by wvlhicll the adjustierit of iiiteriial reactions to externial conditions is secure . I'lie prognosis of angina is beset w itlh uncertaiint. We can inevri tell ihen the next attack wvill come on, or whether it mnay not be the last. AVe are not, hlowevrer. alto<etlier witlho?ut guilanice, the elements of which will be an estimate of the relative l)Preonihiiance of the two chlief factors in the prodluctioin of the Cattack-whether inherent weakness of the heart wall, or obstruction in the circulation or otlher cause of embiarrassment of tI e heart's action. While the atttac('ks onlly conic on wh}ien iprovoked by exertion Or excitement, or by tlatulent indligestion (n(ot, of course, taking the patieiit's word for tlhe last-named cause), the hope may be entertaine(l that by care in avoiding all kiiolvn occa-3sions they may be postponecd ind(lefiniitely. The patient, for --xaniple, must not take exeicse immediately after food, mIlust ieNe r liur cvr wvalk ag,ainst a wind, and(I eveni ont level grounld must, a'apt lis paLe to hiis cond(litioni, and if coompelled to go upllill iiilust d( so very geitlyv aid circumspectly. If, furtlher, tl I's is hal)it nal Iliihii tensioin in the pulse, thlis is at the sarne time evidcleme of obstruction in tlie arterioles anid capillaiies ii( iicli m.ay be clpalp)de cf mitigation anld of sonicc degr e of vwiour in tme heart. So al-o will be acceiituation of thle aortic seco)n(d sound, anid still niore any recogiiisable impulse or apex beat. Angina, agaimi, iii connection w-ith aortic valvular disease, Iliay ril a v-ery p)rotiacted course. It is whleni the pulse is soft aiicl tIme lhart is nornial iii diinenisions, with imperceptible impulse aiid weak sounds-whleni, in fact, the results of careful examiiiation are negrative-that the greatest uncertaiiity and dang-r exist. The occurrence of unprovoked attacks and of iiocturimal angina will empliasise this conclusion. Tlle hygiene (and genieral treatmenit for angina will be such is lias already been described in speaking of dilatation and degeineratioii, w lichi, indeed, mostly underly the angina, and the special precautions against time provocation of attacks hiave beeni sullicieintly imldicated. Arsenic hlas lonig been lheld to exercise some influence preventive of the pa-roxysms, and my experience leads me to agree witlh this view. Plhosplhorus, wlhiicl belongs to the same chemical amid therapeutical series as arsenici, lhas a similar influence, which lhas, in some instances, seemed to be superior. The great m(%ins of cuttinshort tlle attacks is that placed in our lhands by 1)r. Lauder Bruiiton-nitrite of amyl or nitroglycerine: amid a patient subject to angina should iiever be without one or othier of these remedies. They are, no doubt, greatly abused, and many persons, feeling secure of obtaininig relief, mieglect the imiiportant precautions by which the real disease, of whlich angina is only a symptom, imay be held in cleck and so, if they escape suffering, hasteni on a fatal termiiiatioii.