Angina Pectoris.

ANGINA PECTORIS.

877

the normal, which Sir CLIFFORD ALLBUTT interprets indicating that the exciting focus of the disease is

THE LANCET. LONDON: SATURDAY, SEPTEMBER 18, 1909.

Pectoris. characteristic severity of the pain, intense bodily suffering and

FEW diseases possess more striking features than angina pectoris. The ,Nvith its dual

or more

qualities of of grave anxiety of mind reaching what is without doubt the most acute anguish that human nature is called on to bear; the dramatic suddenness of its onset, and of the fatal termination in a certain proportion of the casesall these combine to render it

one

of the most dreaded of

so

sensitive that even a slight rise in pressure may agitate it. This form of the disease is not infrequently fatal, sometimes in a first attack, and, as Sir CLIFFORD ALLBUTT

maintains, usually

in

the

early stages of the attack. The essential nature of his theory, expressed in brief, is that the supra-sigmoid portion of the aorta with its investments is the actual site of the change which leads to the disease.

Angina

as

Clinical observations have led him to

suspect that this region is peculiarly susceptible

to

changes

of blood pressure. He lays special stress upon the investments of the aorta and their involvement in the lesion, and

suggests that the Pacinian bodies which are found in region may be concerned in the process. He points out

even

this

that recent observations have shown that the pain in intestinal colic and in other forms of visceral pain is not due to the contraction of the the

dragging

non-striped

upon the mesenteric

or

muscle but to

other attachments.

entirely repudiates any suggestion of the cardiac origin of the pain in angina. He believes that there exists a morbid susceptibility of the supra-sigmoid interest and with a tragic history, as witness the deaths of of the aorta and its investments, and that the increase JOHN HUNTER and of ARNOLD of Rugby. Characteristic as region of pressure produces a dragging upon those investments, are its clinical manifestations, it is somewhat remarkable to a summation of stimuli which affects the that the pathological lesion underlying it has proved so leading and leads to the referred ,difficult to establish, which no doubt accounts for the corresponding spinal segment The vaso-motor so well known in this disease. ,plethora of theories which have been propounded to explain pains Sir ALLBUTT so often CLIFFORD present its pathogenesis-theories, indeed, almost as numerous as the phenomena regards as incidents not partaking of the essential writers on the subject. diseases.

the toll it has claimed from among learned and distinguished men has invested it with a special

Moreover,

He therefore

and the sudden death he characterises

nature of the

disease, opening the discussion on angina pectoris at the Section as accidental and due to vagal inhibition, analogous to, and of Medicine of the meeting of the British Medical Associathe sudden death which occasionally tion at Belfast, of which a report has already appeared in comparable with, occurs from blows on the testicle, from operations upon the our columns, Sir T. CLIFFORD ALLBUTT exposed the slender or upon the root of the lung, from injec- character of the evidence on which most of these theories are generative organs tions into the pleura, or even in association with gall-stones based ; indeed, certain of them, as he showed, are mutually in rare cases. In other words, he regards this special region antagonistic. After dealing destructively with some of the of the aorta to which he attributes the anginal paroxysm as best known of these he proceeded to expound an explanation so sensitive that it may lead to sudden and immediately which he brought forward so long ago as 1894-a theory fatal cardiac arrest from vagal inhibition. He brings which many think has not received the notice or recognition forward some interesting observations showing that which the evidence he offered should command. Preparatory whereas this may in rare cases occur with a healthy to the enunciation of this theory he gave a classification of it does so much more frequently when the heart the types of the disease which differs in certain features heart, is the subject of coronary disease, and also others indicating from those in common use, a classification which we think that in old people vagal arrest is more likely to occur than has certain advantages. He dismisses at the outset all in young ones. He also suggests that the fear of death may consideration of those cases which are frequently called In

be

an

echo in consciousness of this vagus

effect.

Sir

pseudo-angina, which he bluntly characterises as pseudoCLIFFORD ALLBUTT adduces as a strong argument against diagnosis, thus recalling an aphorism quoted by HUCHARD the view that the disease has its origin in irreparable damage -that there are no false diseases but only false diagnoses. to the heart the admitted fact that some cases, especially in The cases of genuine angina he divides into two classes on to complete recovery. -angina major and angina minor. In the latter the young subjects, go It will be seen from this resume that Sir CLIFFORD ALLBUTT attacks are usually the sequel of muscular effort, the arterial admits of but one explanation of the phenomena of the blood pressure is definitely raised, the attacks are as common and his theory has the merits of comprehensiveness in women as in men, and the pain, although associated disease, and simplicity. Recently JosuÉ of Paris has adopted it in with an apprehension of evil, is not necessarily accomits entirety without acknowledging its source, and a somepanied by the fear of impending death. In angina what similar view has been propounded by Dr. H. WALTER major, which is commonest among males, on the other but in a form adapted to include the functional hand, the pain is more severe and radiates in the well-known VERDON,2 or so-called pseudo-anginal attacks. It must be directions. The blood pressure need not necessarily exceed cases, 1

THE LANCET,

July 31st,

p. 336.

2

THE

LANCET, July 24th,

p. 244.

AFRICAN ENTOMOLOGICAL RESEARCH.

878

propagation of certain diseases of man and animals. The composition of the committee leaves little to be desired, for it numbers among its members men who have already disfurther evidence serves to confirm it, it is only just tinguished themselves by their researches in this and From the labours of that he should receive the credit of his 15 years’ other branches of the subject. look forward to a material this must we We that at the confess, however, body may confidently priority. present evidence seems hardly complete, though it offers the only increase in our knowledge, with a coincident improveexplanation of the origin of the disease. The remarks of ment in some at least of the conditions produced by admitted that the evidence adduced by Sir CLIFFORD support of his views is very suggestive, while the simplicity of the theory renders it attractive, and if

the

Professor WILLIAM OSLER at the Belfast discussion in which he summed up the present state of our knowledge in regard

insect life which have hitherto retarded the economical development of certain of our African colonies. It is intended to despatch a trained entomologist to

ALLBUTT in

to the

the

problem represent

accepted opinion

with

the east side of

He admitted that there was a admirable conciseness. with local aortitis and periof cases associated group aortitis of which Sir CLIFFORD ALLBUTT’S theory affords an

excellent

explanation,

but

pointed

out that there

was

the into

insects

which

and another to the west, observe and report upon are there to be found.

observers, official and other,

and

the

are

service

all the

from the

supra-sigmoid

area

downwards.

among other authorities

opinion typical

seems

A

of

consensus

to indicate that

angina

of

character may occur in the absence of lesions of the aorta, so that Sir CLIFFORD ALLBUTT has to defend his views from a many-sided attack with all his scientific

experience and great learning. We hope that the Belfast discussion will serve to draw more attention to Sir CLIFFORD ALLBUTT’S work and to his

theory,

and will lead to

a more

systematic examination of this part of the aorta as well as of the heart and coronary arteries in all fatal cases of General

systematic examination of the aorta and its investments in this region in such cases should surely go far to elucidating the problem.

angina pectoris.

Entomological

Research.

ENGLAND may have lagged somewhat behind in the investigation of the relationship of biting insects to disease. But if

this

reproach

has

ever

Secretary our

been well

grounded we are glad to

be

fair way to be removed. The of State for the Colonies, as announced briefly in

able to state that it is columns of

now

Sept. 4th,

in

experiments

made

by the

local collectors, in

appointed

an

Entomological

Research Committee which is to make Africa the site of its

investigations inquiry

with

a

view to the

carrying

out of further

into the relation which exists between insects and 3

THE LANCET, August 14th, p. 490. THE LANCET, August 21st, p. 571. 5 THE LANCET, Sept. 18th, p. 889.

4

6

THE

LANCET, August 7th, p. 413.

a

journal

With identification

of the insects which convey disease to man and animals, as as those which are injurious to farm or garden produce

well

or which are detrimental to trees and shrubs of commercial value, will doubtless follow the which identification of those insects which may act as benefactors or friends of man by preying upon blood-sucking flies and the other insect pests which abound in tropical Africa. In this

in the

tropics, are

connexion we draw attention to the observations published in THE LANCET of Sept. 4th by Dr. J. M. ATKINSON, principal medical officer, Hong-Kong, who believes that he has discovered there of

mosquitoes and a fly which

a

form of

the

of

natural enemy devourer of their larvas, in the

has been classified

a

as

belonging to the

flower flies.

Should Dr. ATKINSON’S observations be confirmed a wide possibility may be opened up for the amelioration of malarial regions infested by anophelines, through the importation and acclimatisation, if possible, of these natural enemies of the

anthomyidas

or

mosquito. Pioneer work in economic

a

has

pressed

which would focus all the knowledge gathered from workers, British and foreign, in various parts of the world, in somewhat similar fashion, we presume, to that which is done for its special subject by the excellent monthly bulletins

family

African

be

to

symptoms of the anginal attack, while Dr. ALEXANDER MORISON6 would attribute the symptoms to stimulation of the cardio-vascular nerves in any part of their course issued by the Sleeping Sickness Bureau.

explain

to

assist the entomological experts in their inquiries. By this means it is expected that organised investigations will be carried out in a number of localities in East and West Africa, and that the collections of specimens along with the reports of the observers will be transmitted to the research committee in London, where the specimens will be classified and the named varieties distributed to such institutions as may require them for instructional purposes at home and abroad. It is also proposed that the committee should publish the scientific results obtained, including the observations

large group of cases associated with disease of the coronary artery but without disease of the aorta, and a third group of exceptional occurrence in which neither disease of the aorta The validity of nor of the coronary artery was found. Sir CLIFFORD ALLBUTT’S explanation in regard to these two latter groups now requires establishment. In the correspondence which has since been published in our columns a similar criticism has been put forward by Sir R. DOUGLAS POWELL,3 who, while admitting that stretching of the supra-sigmoid region of the aorta will account for some cases of angina but not for all, affirms that the mechanism of a

this condition consists of one or other of at least three or Dr. E. H. COLBECK4 and Dr. A. P. BEDDARD5 do not think that aortic stretching is adequate to

noxious

Local

also

four combinations."

collect

to

tropical Africa specimens and to

done a

in Africa.

part

Sleeping

Among

may mention the Sickness Bureau, and

we

the Wellcome Research

have

also those attached to

Laboratory

at

would mention the staff

specially History Department we

has

already been performed experts belonging to the

entomology others who

Khartoum; of

and

the Natural

of the British Museum. Some time ago the then director of that department, Sir E. RAY LANKESTER, had before him a scheme for-