- Email: [email protected]
Localized sweating, a sympathetic reflex phenomenon in angina pectoris
Department
of Clinical Reports
ALONG the less usual and marc interesting manifcstatious of augina pectoris are those symptoms t,he undrrl~iug mechanism of which appears to be a sympathetic reflex arc connecting the heart. anal is the aorta wit,11 visceral organs 01’ glandular tissue. The following report of such a case.
A
CASE
REPORT
A robust, somewhat florid physici;~n of sixty-one years was se1~n ten days after hariug been awakened at 3 A.M. by wwl’c precordinl pain radiating into the left aI’m, lasting one hour, requiring niorl)hine fur w&f. The patient bad suffered two similar attacks six anh tlvo years prt~viously. After tlus tivst attack the patietlt remained iu bed three days and wt,unlccl to his l)r:tctiec after five days, though hc experienced precordial pain or substernal gripping ou lrurr:;iup, usually relievetl by rest. This passed away after four months :rnd he tolrratc~tl strenuous exercise, wen plpying tennis without discomfoit. 4ftpr the swon~l attack t,\vo ~XUS b&ne, the patient led a somewhat less strenuous lift% thougl~ coutinuiug iii active pra(*tie~~. With all three attacks he noted light-colowtl stools ant1 ~~~~c~~si~~t~ss iu the l,iglrt LI~I1”“’
qu:ldmllt.
Both lxreuts of the patient wwe long lived, dying at scwwty-uinc and tGght,yeight ycais rcspectivelq-. One brother (lied elf Iwart diswse at sixty-two. One sister nom has hypertension. The patient hatl rheumatic, fercr Iasting one wwk at thirty gears of age. 11~ had iuflnenea with pueumonin iu l!tlS. Anwers to routine, rluestions 38 to previous symptoms wc~re ueg:r tire (swept, for some indigestiou, cow sisting chiefly of gas after meals. There \\:Is no hist,ory of frank gall l,l:i~ld~~r attacks, jaundice, OP constipation. The physical examination was negative aside from :I few vales at the basca. 7%~ rxaminatiou of the heart w7as as follow: Cardiac dullness to prwussion iu thr fifkli space was 11 cm. to thcl left , 2..3 cm. beyoud tllo midcln\~ic~~l:tr line. The left The trnnsversc supr:~border of the heart was 7 cm. to the left in tha tbirtl slwce. cardiac dullness \vas 6.3 cm. There was :I uiotlwat~c~ to lout1 systolic murmur heard o~cr the precordium, best heard at the, apex. Tlw t:ttc !vas 90 an11 a well-nuirkt!d gallop rhythm was noted. The blood pwssuw was 14.5 mui. mewury systolic and 110 cliastolic. Alternation of the lu~lse XLS ol~servcd. During absolute rest iu bed t,he p:itieut suffwt~tl some precordial distress :tn(l son,,8 iudigestion with gnu. On one wcasiou hr 11211 llaiu :Itlil tru6lcrnesx in tlw right upper quadrant and gaseous eruct:ltious rluri~ig tile night. Tliis rceurred the next morning after taking a cup of w~fYw and \\:Is :~wompauictl by p:iin in the left upper chest radiating into the arm. The most interesting symptom of wliieh this patieut cou~l~l:tinc~~l o(*eurretl txvvc, weeks after the onset of the third attack. 11~ :iw~~k~~ to firIll tllc prwor~lilun, left .jl!l
520 shoulder
THE
and
left
arm
pulse
rate
was
HEAR.T
to the elbow drenched with There was no pain, pressure somewhat accelerated.
mokkure elsewhere. his
AMERICAN
JOURNAL
sweat. The or heaviness.
body He
was of noticed
normal that
Mackenziely ’ noted flushing or sweating of forehead or body with attacks of angina. Vomiting, salivation, gaseous eructations and increased BOW of urine were also observed by him, Vaquez” mentions fleeting vasomotor phenomena in angina pectoris, such as diffuse redness of hands and forearms accompanying or preceding the attack, and refers to observations by others of this flushing extending to face and chest. Misch and Lechner4 have recently reported two cases showing a sympathetic reflex similar to that reported in the present case except that the area of hyperhidrosis was the left side of the face supplied by the upper two branches of the trigeminal nerve. One of these patients had luetic heart disease, aortitis, aortic regurgitation and angina pectoris. The second patient was diagnosed as coronary sclerosis and angina pectoris. Both patients showed dilatation of the left pupil. These same authors refer to two other cases. One of these, similar to the subject of the present report, was described separately by Conzen and Bittorf.6 A woman forty-six years of age had attacks of angina pectoris and occasionally with these attacks flushing and sweating of the left side of the face. The left pupil was twice as large as the right and was known to have been so for ten years. Gibson’s7 patient was a man forty-five years old who complained of constant pain in the left upper back and chest and in the arm with exacerbations of greater severity, relieved by amyl nitrite. This patient showed prominence of the left eye and dilatation of the left pupil, changes of which were more marked during attacks of pain. There was no sweating or skin changes except some pallor during an attack. The patient’s symptoms X-ray examination of heart and improved under potassium iodide. great vessels was negative. These cases clearly represent a reflex from the heart or aorta to the sweat glands, or ciliary muscle in those showing dilatation of the left pupil, conveyed by the sympathetic system and passing from the cord in the lower cervical and upper dorsal regions which experimental and clinical research has shown is the pathway in typical angina1 pain of the usual distribution. Head9 produced a unilateral reflex hyperhidrosis in certain cases of gross cord injury, the stimulus being somatic, such as scratching or pinching the skin. The reflex in the above cases is evidently initiated by a visceral stimulus, namely anemia of the myocardium or a stimulus arising from aortic disease. Recently the gastric and abdominal manifestations of angina peetoris and the differential diagnosis between cardiac and abdominal disease have claimed the attention of. clinicians.l’* 11,“3 I33I4 It is certainly very likely that a similar sympathetic reflex, the end organ
PALMER
:
LOCALIZED
SWEATING
IN
ANGINA
PECTORIS
521
being in the abdominal viscera, is responsible for the disordered funcA very common and familiar manition giving rise to the symptoms. festation is the indigestion characterized by gas, sour eructations and heartburn which so often accompanies attacks of angina pectoris or occurs with fatigue or slight overexertion in patients subject to angiThe mechanism is probably a sympathetic reflex from nal attacks. heart or aorta causing pylorospasm. SUMMARY
One case is reported and three cases are quoted from the literature representing an unusual sympathetic reflex phenomenon in angina pectoris, which consists of localized sweat~ing. REFERENCES Angina Peetoris, London, 1923, p. 82, Henry Froude. 1. Mackenzie, Sir James: 2. Mackenzie, Sir James: Diseases of the Heart, London, 1925, ed. 4, p. 337, Oxford University Press. 3. Vaquez, H.: Diseases of the Heart. Translated by Laidlaw, G. F., Philadelphia, 1924, p. 410, W. B. Saunders Co. Ueber ein kardio-svmDathisehes Reflexnhlnomen. 4. Misch. W.. and Lecbner. A.: ., L A Klh. kchnschr. 8: 560, 1929. 5. Conzen, F. A. H.: Ueber die periphere Sympathicusaffektion insbesondere ihre Aetiologie und Symptomatologie, Leipzig, 1904, B. Georgi. 6. Bittorf. A.: Zur Symptomatoloeie der Aortensklerose. Deutsche Arch. f. klin. Med: 81: 65, 1904. 7. Gibson, G. A.: Some Hitherto Uudeseribed Symptoms in Angina I’tBctoris, Brain 28: 52, 1905. 8. Swetlow, G. I.: A Clinico-Pathological Study of the Pathway of Pain Impulses in Cardiac Disease, Am. J. M. SC. 178: 345, 1929. 9. Head, M.: Studies in Neurology, London, vol. 2, p. 491, 1920, Oxford Uuiversit? Press. 10. Faulkner, J. M., Marble, H. C., and White, P. D.: Differential Diagnosis of Coronary Occlusion and of Cholelithiasis, J. A. M. A. 83: 2080, 1924. 11. Foster, N. B.: Clinical Pictures of Cholecystitis Induced by Bacterial Endo. carditis, M. Clinics N. America 9: 325, 1925. 12. Riesman, D.: Myocardial Disease and Its Gastric Masquerades, J. A. M. A. 91: 1521, 1928. 13. Friedenwald, J., and Morrison, T. H.: Clinical Observations on Relation of Gastric and Cardiac Affections, Southern M. J. 21: 453, 1928. 14. Palmer, R. S.: Case Records of the Massachusetts General Hospital, New Eng. J. Med. 200: 145, 1929.
of Clinical Reports
ALONG the less usual and marc interesting manifcstatious of augina pectoris are those symptoms t,he undrrl~iug mechanism of which appears to be a sympathetic reflex arc connecting the heart. anal is the aorta wit,11 visceral organs 01’ glandular tissue. The following report of such a case.
A
CASE
REPORT
A robust, somewhat florid physici;~n of sixty-one years was se1~n ten days after hariug been awakened at 3 A.M. by wwl’c precordinl pain radiating into the left aI’m, lasting one hour, requiring niorl)hine fur w&f. The patient bad suffered two similar attacks six anh tlvo years prt~viously. After tlus tivst attack the patietlt remained iu bed three days and wt,unlccl to his l)r:tctiec after five days, though hc experienced precordial pain or substernal gripping ou lrurr:;iup, usually relievetl by rest. This passed away after four months :rnd he tolrratc~tl strenuous exercise, wen plpying tennis without discomfoit. 4ftpr the swon~l attack t,\vo ~XUS b&ne, the patient led a somewhat less strenuous lift% thougl~ coutinuiug iii active pra(*tie~~. With all three attacks he noted light-colowtl stools ant1 ~~~~c~~si~~t~ss iu the l,iglrt LI~I1”“’
qu:ldmllt.
Both lxreuts of the patient wwe long lived, dying at scwwty-uinc and tGght,yeight ycais rcspectivelq-. One brother (lied elf Iwart diswse at sixty-two. One sister nom has hypertension. The patient hatl rheumatic, fercr Iasting one wwk at thirty gears of age. 11~ had iuflnenea with pueumonin iu l!tlS. Anwers to routine, rluestions 38 to previous symptoms wc~re ueg:r tire (swept, for some indigestiou, cow sisting chiefly of gas after meals. There \\:Is no hist,ory of frank gall l,l:i~ld~~r attacks, jaundice, OP constipation. The physical examination was negative aside from :I few vales at the basca. 7%~ rxaminatiou of the heart w7as as follow: Cardiac dullness to prwussion iu thr fifkli space was 11 cm. to thcl left , 2..3 cm. beyoud tllo midcln\~ic~~l:tr line. The left The trnnsversc supr:~border of the heart was 7 cm. to the left in tha tbirtl slwce. cardiac dullness \vas 6.3 cm. There was :I uiotlwat~c~ to lout1 systolic murmur heard o~cr the precordium, best heard at the, apex. Tlw t:ttc !vas 90 an11 a well-nuirkt!d gallop rhythm was noted. The blood pwssuw was 14.5 mui. mewury systolic and 110 cliastolic. Alternation of the lu~lse XLS ol~servcd. During absolute rest iu bed t,he p:itieut suffwt~tl some precordial distress :tn(l son,,8 iudigestion with gnu. On one wcasiou hr 11211 llaiu :Itlil tru6lcrnesx in tlw right upper quadrant and gaseous eruct:ltious rluri~ig tile night. Tliis rceurred the next morning after taking a cup of w~fYw and \\:Is :~wompauictl by p:iin in the left upper chest radiating into the arm. The most interesting symptom of wliieh this patieut cou~l~l:tinc~~l o(*eurretl txvvc, weeks after the onset of the third attack. 11~ :iw~~k~~ to firIll tllc prwor~lilun, left .jl!l
520 shoulder
THE
and
left
arm
pulse
rate
was
HEAR.T
to the elbow drenched with There was no pain, pressure somewhat accelerated.
mokkure elsewhere. his
AMERICAN
JOURNAL
sweat. The or heaviness.
body He
was of noticed
normal that
Mackenziely ’ noted flushing or sweating of forehead or body with attacks of angina. Vomiting, salivation, gaseous eructations and increased BOW of urine were also observed by him, Vaquez” mentions fleeting vasomotor phenomena in angina pectoris, such as diffuse redness of hands and forearms accompanying or preceding the attack, and refers to observations by others of this flushing extending to face and chest. Misch and Lechner4 have recently reported two cases showing a sympathetic reflex similar to that reported in the present case except that the area of hyperhidrosis was the left side of the face supplied by the upper two branches of the trigeminal nerve. One of these patients had luetic heart disease, aortitis, aortic regurgitation and angina pectoris. The second patient was diagnosed as coronary sclerosis and angina pectoris. Both patients showed dilatation of the left pupil. These same authors refer to two other cases. One of these, similar to the subject of the present report, was described separately by Conzen and Bittorf.6 A woman forty-six years of age had attacks of angina pectoris and occasionally with these attacks flushing and sweating of the left side of the face. The left pupil was twice as large as the right and was known to have been so for ten years. Gibson’s7 patient was a man forty-five years old who complained of constant pain in the left upper back and chest and in the arm with exacerbations of greater severity, relieved by amyl nitrite. This patient showed prominence of the left eye and dilatation of the left pupil, changes of which were more marked during attacks of pain. There was no sweating or skin changes except some pallor during an attack. The patient’s symptoms X-ray examination of heart and improved under potassium iodide. great vessels was negative. These cases clearly represent a reflex from the heart or aorta to the sweat glands, or ciliary muscle in those showing dilatation of the left pupil, conveyed by the sympathetic system and passing from the cord in the lower cervical and upper dorsal regions which experimental and clinical research has shown is the pathway in typical angina1 pain of the usual distribution. Head9 produced a unilateral reflex hyperhidrosis in certain cases of gross cord injury, the stimulus being somatic, such as scratching or pinching the skin. The reflex in the above cases is evidently initiated by a visceral stimulus, namely anemia of the myocardium or a stimulus arising from aortic disease. Recently the gastric and abdominal manifestations of angina peetoris and the differential diagnosis between cardiac and abdominal disease have claimed the attention of. clinicians.l’* 11,“3 I33I4 It is certainly very likely that a similar sympathetic reflex, the end organ
PALMER
:
LOCALIZED
SWEATING
IN
ANGINA
PECTORIS
521
being in the abdominal viscera, is responsible for the disordered funcA very common and familiar manition giving rise to the symptoms. festation is the indigestion characterized by gas, sour eructations and heartburn which so often accompanies attacks of angina pectoris or occurs with fatigue or slight overexertion in patients subject to angiThe mechanism is probably a sympathetic reflex from nal attacks. heart or aorta causing pylorospasm. SUMMARY
One case is reported and three cases are quoted from the literature representing an unusual sympathetic reflex phenomenon in angina pectoris, which consists of localized sweat~ing. REFERENCES Angina Peetoris, London, 1923, p. 82, Henry Froude. 1. Mackenzie, Sir James: 2. Mackenzie, Sir James: Diseases of the Heart, London, 1925, ed. 4, p. 337, Oxford University Press. 3. Vaquez, H.: Diseases of the Heart. Translated by Laidlaw, G. F., Philadelphia, 1924, p. 410, W. B. Saunders Co. Ueber ein kardio-svmDathisehes Reflexnhlnomen. 4. Misch. W.. and Lecbner. A.: ., L A Klh. kchnschr. 8: 560, 1929. 5. Conzen, F. A. H.: Ueber die periphere Sympathicusaffektion insbesondere ihre Aetiologie und Symptomatologie, Leipzig, 1904, B. Georgi. 6. Bittorf. A.: Zur Symptomatoloeie der Aortensklerose. Deutsche Arch. f. klin. Med: 81: 65, 1904. 7. Gibson, G. A.: Some Hitherto Uudeseribed Symptoms in Angina I’tBctoris, Brain 28: 52, 1905. 8. Swetlow, G. I.: A Clinico-Pathological Study of the Pathway of Pain Impulses in Cardiac Disease, Am. J. M. SC. 178: 345, 1929. 9. Head, M.: Studies in Neurology, London, vol. 2, p. 491, 1920, Oxford Uuiversit? Press. 10. Faulkner, J. M., Marble, H. C., and White, P. D.: Differential Diagnosis of Coronary Occlusion and of Cholelithiasis, J. A. M. A. 83: 2080, 1924. 11. Foster, N. B.: Clinical Pictures of Cholecystitis Induced by Bacterial Endo. carditis, M. Clinics N. America 9: 325, 1925. 12. Riesman, D.: Myocardial Disease and Its Gastric Masquerades, J. A. M. A. 91: 1521, 1928. 13. Friedenwald, J., and Morrison, T. H.: Clinical Observations on Relation of Gastric and Cardiac Affections, Southern M. J. 21: 453, 1928. 14. Palmer, R. S.: Case Records of the Massachusetts General Hospital, New Eng. J. Med. 200: 145, 1929.