Discussion on the surgical treatment of angina pectoris.

Date:
[1940]
Catalogue details

Licence: Public Domain Mark

Credit: Discussion on the surgical treatment of angina pectoris. Source: Wellcome Collection.

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    soon as the patient rests. The question ‘‘ does exercise make the pain worse ? ”’ is an insufficient question, the point being whether pain is brought on during exercise, not whether pain is produced after exercise ; and further, whether the pain diminishes during rest, or whether it is still felt for a period of possibly hours, although the patient is at rest. Other helpful points are the central position of the pain, relief by nitro- glycerin, absence of superficial hyperzesthesia over the chest wall, and changes in the electrocardiogram indicating coronary disease. Here again it must be remembered that the presence of organic coronary disease is of itself not exclusive of a functional type of pain. This functional pain, which is sometimes known as left mammary pain, pseudo-angina, or as I have somewhat provocatively named it, angina innocens, may follow a coronary thrombosis, although, of course, angina of effort is the usual sequel in this case. Angina of effort indicates insufficient coronary dilatation during exercise, or rigidity or narrowing of the coronary vessels also appearing during exercise. In angina of effort, the more full the information the higher is the percentage of patients found to have coronary disease. Dr. Bodley Scott and I (Brit. M. J., 1938 (i), 55) in 112 cases of angina of effort, strictly. chosen, found only 13 in whom evidence of cardiovascular disease was absent. In a subsequent electrocardiographic investiga- tion Dr. Courtenay Evans and I, also in classical angina of effort (Lancet, 1938 (ii). 1354) found in a series of 80 cases no change in the electrocardiogram, in Leads 1, 2, 3, and 4, in 30% of cases. Subsequent examination of these negative cases, by means of exercise or exposure to a temperature of 10% or 12% oxygen, has reduced the percentage of negative cases to about 20°. A number of papers on the post-mortem appearances in cases of angina of effort corroborate this position. Surgical measures are undertaken for two objects in this condition, relief of pain, and revascularization. J. C. White, in a long series of patients treated by alcohol injection, concludes that the analgesia produced is harmless, and my own series of 15 cases, treated by thyroidectomy, corroborates his conclusion. Exercise should benefit the hypertrophy and health of the remaining muscle fibres, and should stimulate the re-canalization of thrombosed vessels, and help also to induce re-vascularization of an area previously partially deprived of its blood supply. My experience of sympathectomy has not been particularly favourable, but, with the newer methods introduced by Professor Ross and others, this opinion will probably need to be revised. ; Alcohol injection is attended by the minor accidents of partial pneumothorax and local pleurisy, and by the more unpleasant alcohol neuritis in a few cases. Thyroidectomy is the surgical measure of which I personally have had most *. experience. The prominence I give to it here is due to this fact alone. The series of cases which I am showing seem to indicate that thyroidectomy definitely has a place in the treatment of severe cases of anginal pain (Geoffrey Bourne and J. Paterson Ross, Lancet, 1938 (ii), 815; St. Barth. Hosp. Reports, 1938, 71, 61). The mode of action of this measure is explained by three different hypotheses. ay Firstly, it-is said to decrease the blood-flow, secondly it is said to be due to injury of ie the nerve plexuses placed behind the thyroid at the time of operation, and thirdly, it may decrease the sensitivity either of the visceral sensory nerve-endings or of the motor nerve-endings in the coronary vessels. The first of these hypotheses would . not appear to stand critical analysis. A patient has very severe pain on walking me across a room, dressing, or on experiencing very slight emotion. After thyroidectomy the same patient can carry a suitcase to the station, or can bicycle for 20 miles without pain. Is it conceivable that thyroidectomy has kept the coronary rate of DOONAN | /
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