THE OCCURRENCE OF Angina Pectoris and Epilepsy in Vary- ing Forms in the Same Subject WITH A BRIEF CONSIGNATION OF THE ALLEGED IDENTITY OF^^fESE MALADIES By RICHARD C. NEWTO^M.D. MONTCLAIR, N. J. LATE CAPTAIN AND ASSISTANT SURGEON UNITED SPATES ARMY Reprinted from the Medical Record, April za, 1893 NfeW YORK TROW DIRECTORY, PRINTING AND BOOKBINDING CO. 201-213 East Twelfth Street 1893 THE OCCURRENCE OF Angina Pectoris and Epilepsy in Vary- ing Forms in the Same Subject WITH A BRIEF CONSIDERATION OF THE ALLEGED IDENTITY OF THESE MALADIES By RICHARD C. NEWTOK M.D. MONTCLAIR, N. J. LATE CAPTAIN AND ASSISTANT SURGEON UNITED STATES ARMY Reprinted from the Medical Record, April 29, 1893 NEW YORK TROW DIRECTORY, PRINTING AND BOOKBINDING CO. 201-213 East Twelfth Street 1893 THE OCCURRENCE OF ANGINA PECTORIS AND EPILEPSY IN VARYING FORMS IN THE SAME SUBJECT. With a Brief Consideration of the Alleged Iden- tity of these Maladies.1 F. B , aged forty five, single; American; General Service Clerk United States Army. Treated in the United States Army Recruiting Depot Hospital, David's Island, New York Harbor. Family History.-B 's father lived to old age and died of some kidney trouble. His mother died in child- bed. Of several children B was the only one that reached maturity. No history of any nervous or other hereditary taint could be obtained. Previous History.-B denies any serious illness in his life until two or three years before coming under my observation. He was an intelligent and well-informed man, and had the appearance and manners of a gentle- man and a man of the world. He was a General Service Clerk; that is to say, a man of especial capacity as a clerk, enlisted expressly for the higher class of clerical work in the army. He had always borne an excellent character. His principal failing was a fondness for ar- dent spirits, in which he indulged pretty freely, but gen- erally managed to perform his duties acceptably. At the time I first saw him he had served in the army nearly thirty years. He had contracted a chancre six or eight years before this history begins, which had been followed 1 Read before the Society of the Alumni of Charity Hospital. 4 by non-suppurating buboes, a large cervical abscess, and osteocopic pains. He could not recollect any cutaneous manifestations.1 For his syphilis B was treated in the United States Naval Hospital at Brooklyn, N. Y. Shortly after I had reported for duty at David's Island, in November, 1887, B brought me a note from Dr. H. S. Oppenheimer, of New York, requesting me to apply a gentle galvanic current to the muscles of B 's left eye. B was suffering from divergent squint and ptosis on the left side, and had been under Dr. Oppenheimer's care. He was taking pills of the protoiodide of mercury, and twelve or fifteen grains of the iodide of potash daily. The lat- ter drug had to be frequently intermitted on account of the diarrhoea which it excited. Dr. Oppenheimer's idea in the application of the galvanic current was to stimu- late the ocular muscles, especially the internal rectus, and if this should evince more tone than it then seemed to have, the doctor intended to do a partial or complete tenotomy to the opposing external rectus, with a view of straightening the eye. This treatment was carefully fol- lowed out, three applications being made weekly, but no effect was observed from it. B 's case then came entirely under my care. I found that for two or three years the man had suffered from occasional attacks of angina pectoris, the attacks of which were sometimes at least traceable to sexual in- tercourse or some unusual excitement. There was a loud, blowing, double-heart murmur and considerable enlarge- ment of this organ. The patient was pale and some- what anaemic, but not emaciated. He was able to do his clerical work, wearing a ground glass over the squinting eye. He had a paronychia, which was exceeding difficult to cure, but which finally yielded to the use of chrysarobin. About February 1, 1888, B had a typical attack of 1 Hare and others call attention to the fact that syphilitic epilepsy generally occurs in subjects who have not shown the eruptions of the disease. 5 angina pectoris, which was not affected by morphine hy- podermically, but quickly yielded to inhalations of amyl nitrite. B was prostrated for several days after this attack, probably from the morphine which had been ad- ministered, since his next attack of angina, in which no morphine was used, was not followed by sickness or pros- tration. On July i, 1888, B had two severe epilep- tic convulsions, about half an hour apart. After the first convulsion the heart stopped beating. Respirations were also suspended, the extremities were cold, the sur- face was covered with a clammy perspiration, and to all appearance B was dead. Inhalations of amyl nitrite, heat to the extremities, and vigorous rubbing were fol- lowed after a time by gasping and shallow respirations. The heart started with a jerk, and then the beats became regular. Instead of coming out of his state of coma, he went into another well-marked epileptic (grand mal) con- vulsion, with its customary clonic and tonic spasms, after which he slowly regained consciousness. It was some time before he could realize where he was, etc. He was sent to the Depot Hospital, and underwent a prolonged course of treatment. He cannot be truly said to have ever been as well after these two seizures as he was be- fore. His urine was carefully examined on several occa- sions, and the daily quantity noted. The specific gravity was 1.010 to 1.020; reaction, alkaline; odor, offensive; appearance, turbid; albumin, abundant - about one- third of the amount of urine by volume. By the micro- scope were seen triple phosphates, oxalates, amorphous urates, and a few granular and small hyaline casts. The urine improved in appearance under treatment, and the amount of albumin diminished so that in one or two spe- cimens it was absent. The reaction became acid, and the odor natural. Daily quantity, about forty ounces. The patient was put into a private room, and every at- tention was shown him.1 1 Steward Mead and Acting Steward Foster, U. S. A., deserve credit for their unremitting care of this troublesome case. 6 The heart's action was weak and irregular. Infusion digitalis was employed up to the point where the stomach refused it, or it excited the ever-sensitive bowels to diar- rhoea. The diet was carefully regulated. Bromide and chloral, alternating writh Dover's powder, were adminis- tered for the extreme nervousness and night terrors. Several mild attacks of angina pectoris supervened, and were easily controlled by inhalations of the amyl nitrite. B , in common with most hard drinkers, had piles which easily bled and were the cause of much discomfort. For two weeks the treatment above outlined had been carried out, supplemented by complete rest and quiet. B began to improve. The cardiac action was better, and the murmur less distinct. The urine also improved in character. As the severity of the symptoms already noted began to diminish, sciatic neuralgia, especially on the right side, appeared, together with numbness of the right hand and forearm. As the paralysis of the ocular muscles was on the left side, the symptoms in the right arm and leg would point to a cranial lesion above the de- cussation of the nerve-fibres in the pons, or to multiple lesions. The patient, like other epileptics that I have observed, was very reticent; and only by patience and perseverance could I extract from him, a portion at a time, the history of his case. He acknowledged sciatica, chiefly on the right side, for two or three years, and that for a similar period he had gotten up several times at night to make his water. In order to hasten if possible his improvement, the gal- vanic current was ordered applied as a general nerve tonic and to mitigate his sciatic pains. During this time the anti specific medication had not been intermitted. Daily inunctions of blue ointment were practised, and the iodide of potash given as freely as his irritable bowels would allow. The applications of galvanic electricity had to be dis- continued after the third sitting. Their effect upon 7 B 's mind was remarkable. He grew suspicious, morose, and fractious, refused his medicine, because he al- leged that it was poison, etc. After the last application of the battery he ran down-stairs from his private room on the second floor of the hospital, and spent the night in one of the wards. In the morning he was greatly aston- ished on waking up to find himself in the ward, and seized his clothes and hastened back to his room without much ceremony. The electrical treatment having been discontinued, in another week B seemed much better, his intellect was unclouded and the general condition was encourag- ing. His principal complaint at that time was of pain in the right arm and leg. The muscles of these extremities were weaker and the surface less sensitive to the testhesio- meter than those of the left side. No change was noted in the ocular muscles of the left side, the squint and ptosis remaining about the same as when I had first seen the patient nine months before. The neuralgic pains seemed to bear some relation to B 's other troubles, disappearing as the latter ap- peared, and vice versa. Of course it may have been that they would always have been present had they not been masked by the more strenuous conditions. The patellar reflex was tested and found to be greatly exaggerated. About six weeks after the two epileptic convulsions above described, which, so far as I know, were the only well-marked grand mal seizures which B had ever suf- fered, B began to exercise somewhat by walking in the open air. As I was sitting one day in the office at the hospital, B passed by the door and stopped for a moment, when he saw me. I addressed him, when in an agitated manner he muttered something quite indistinctly and walked very rapidly out of the hospital and across the parade ground. I was astonished at the speed with which he walked, and sent two of the attendants after him. He was not conscious of what he wTas doing nor where he was. The attendants were told not to use any 8 violence, and to wait until B was ready before lead- ing him back to the hospital. In a few minutes he re- covered himself, and came quietly back with the attend- ants. As I had not seen B walk any distance before for some weeks, I was interested in observing whether or not he dragged his right leg. This he did not do. But he seemed to have lost in a measure the use of his right hand. The performance just related, and the previous running into the ward and spending the night there, were evidently attacks of epilepsy procursiva. In September B was sent into the country and re- mained away three or four weeks. He continued his in- unctions of blue ointment and took as much iodide of potash and cod-liver oil as his weak digestion would allow. He had learned to subsist mostly upon milk. After B 's return from the country he resumed his duties in the adjutant's office, doing a small amount of work him- self and directing the work of the other clerks. He said that he felt well when he woke up in the morning, but that toward noon he would feel " queer " and would not know what was the matter with him. He developed a paronychia on the ring-finger of the left hand, similar to the one which had troubled him in the winter. This was also quite intractable ; but finally yielded, as its prede- cessor had done, to chrysarobin. In November, 1888, I left David's Island and lost sight of B . He died suddenly, February 22, 1889, thirteen months after first coming under my care. A partial autopsy was made by Assistant Surgeon A. E. Bradley, which revealed great hypertrophy and some dila- tation of the heart. The organ weighed twenty-eight ounces. There was considerable disease of the aortic valves, which were incompetent and thickened and altered in shape by atheroma. The muscular structure of the heart-walls " showed light-colored striae, signifying a probable former myocarditis." The aorta was dilated and showed calcareous deposits on its walls. Pleural cavities show some old adhesions. Small mass of ap- 9 parently cicatricial tissue at right pulmonary apex. In the abdomen extensive old adhesions were noted over most of the peritonenum, especially in the splenic and hepatic regions. The liver was enlarged and congested, and showed signs of old hepatitis. Spleen enlarged and congested. Its substance was soft and friable. Kidneys enlarged and congested, capsules adherent. Brain and spinal cord not examined. Intestines and stomach not examined. I have given this history with much, and perhaps tire- some, detail. To me, at least, it was exceedingly inter- esting, and many questions have presented themselves in regard to it. Perhaps the first inquiry which natu- rally comes up is, i, Were the different nervous phenom- ena in this case all due to the same cause ? in other words, 2, were they in reality only different phases of the same constitutional state ? It is a thousand pities that no post- mortem examination of the brain and cord was made. It' seems fair to assume, however, that a gross cerebral lesion, probably a gumma or gummata, existed of which the ptosis and strabismus were symptoms, as well as the anaesthesia, paresis, and neuralgic pains of the right limbs. What the underlying trouble with the entire nervous system was may afford room for doubt. The impres- sion which a prolonged study of the case made upon me was that syphilis, with alcohol for its congener, was to blame for B 's many afflictions. Whether there had been present a syphilitic myocarditis I leave to better judges to decide. It seems, however, that the atheroma of the endocardium and aorta had its start in syphilis and was aggravated by alcohol. Although I carefully in- quired, I could get no history of rheumatism independent of the syphilis. We must not forget that uraemic poison- ing probably played its part in this complicated case. As to the identity of the various nervous phenomena, I confess my inability to decide. The condition of the heart itself would, it seems, account for the angina, and perhaps for the epilepsy, both grand mal convulsions, and 10 the epilepsy procursiva, but it could hardly have caused the ptosis and strabismus and partial right palsy, except, of course, by an embolus. And this hardly seems as likely as that the syphilis, with which the man was satu- rated, had caused a gross cerebral lesion. It is fair to assume that the epileptic explosions and the angina be- came gradually milder from the prolonged anti-specific treatment. But the mental state grew gradually weaker, perhaps from cerebral anaemia due to the increasing in- competency of the heart. As to the alleged identity of epileptic fits and attacks of angina pectoris, so respectable an authority as Trous- seau declares that both conditions are due to the same cause; in other words, that angina is a form of epilepsy. Gairdner, Bartholow, and others seem to share this view, although Hare in his recent brochure, 11 Epilepsy, Its Pathology and Treatment," does not mention it. Bar- tholow says " it (angina) is, as Trousseau first pointed out, sometimes a masked epilepsy, and angina pectoris may alternate with epileptic attacks. ' ' A great part of the fascination which the study of the pathology of nervous diseases presents to the inquiring mind seems to be its inherent obscurity. A dark, diffi- cult, and winding road lies before the neurologist, and no doubt its very difficulties and uncertainties, its pitfalls and false beacon-lights only incite the searcher after truth to more earnest effort and more careful study. As to Trousseau's allegation, it is exceedingly hard to affirm or deny it until the true nature of the disorders mentioned has been ascertained. If similar things only are susceptible of comparison, it would seem that the principal characteristic which angina and epilepsy have in common is the uncertainty by which they are surrounded. Their real cause not being known, it is begging the ques- tion to declare that they are different manifestations of the same constitutional state. Dr. Hare frankly ac- knowledges, in the work already spoken of, that the ulti- mate nature of epilepsy is entirely unknown, and Striimp- 11 fel says the same thing of angina. This, of course, is not to say that certain conditions may not produce these phenomena, for we know that they do. It is, however, idle to dogmatize upon this subject, as Potain and other writers have done, and such a method of studying pathol- ogy is, fortunately, becoming obsolete. In nervous dis- eases especially, the clinician and the pathologist must join hands, and faithfully, carefully, and with minds free from bias, work out the difficult and intricate problems which present themselves, some of which I have alluded to to-night. The careful study and accurate record of the symptoms of a large number of cases seem nearly if not quite as necessary to the establishment of a knowledge of the pathology of nervous diseases as are post mortem exami- nations and laboratory and microscopical investigations.