Angina pectoris is due, not to an in crease, but to a further reduction, of the muscular energy of a heart already en feebled: the Stokes-Parry theory. The associated pathological processes are sclerosis of the coronary vessels, altera tions of the aortic valves, and ectasic aortitis, which latter has a special stenotic effect upon the origin of the coronary vessels. These conditions, together with the resistance of the contracted arterial system, induce weakening of the heart. A moderate distension of the heart may lead to a temporary occlusion of the coronary vessels at the point of an al ready existing constriction, and so bring on an attack of angina pectoris. In other cases a thrombus or embolus may be the cause of the block. T. Schott (Lancet, Sept. 8, 1900).
Prognosis.—The underlying condition is apt to prove fatal eventually, and it may end life in the first paroxysm; but a careful regimen may prolong existence for years; and Flint, Bendel, and Labol bary have each reported cases of recovery.
The signs of danger during any par ticular attack are the subjective sense of impending death and the feebleness and irregularity of the pulse. The general prognosis is, of course, influenced by the stage which the organic circulatory changes have already reached.
The pseudo-attacks are apt to be re peated oftener than are the genuine, but the prognosis is good both as to life and to the final disappearance of the trouble.
True angina, when it occurs in dila tation of the heart, admits of a prognosis more favorable than when it occurs with other mural conditions, as myocarditis or hypertrophy, without dilatation.
Grave cases of dilatation of the heart, conversely to the above, may be looked upon as amenable to successful treat ment if the patient should have par oxysms of true angina pectoris. J. H. Musser (Amer. Jour, of Med. Sciences, Sept., '97).
The majority of writers hold that true angina pectoris (that is, combined with anatomical lesion of the heart, fatty de generation sclerosis of the coronary arteries, etc.), generally ends sooner or later in sudden death, and that recovery is a rare exception. Personal experience in seventy-three cases has shown that this statement holds good only of pa. tients in whom angina is combined with aortic insufficiency. Among the other cases there was only a single patient who died suddenly after the disease had lasted three years. Most of them after treatment recovered sufficiently to under take laborious work; a few were com pletely cured, and in only three cases did no improvement take place. Of these
one was a drinker and a great smoker, another suffered from pleurisy, while in the third arteriosclerosis went on de veloping, aortic insufficiency was pro duced, and the patient died suddenly. Fr. Somberger (Sbornik Klinieky, vol. i, Fase. 1. '99).
Treatment. — During a paroxysm the first remedies to employ are such as will dilate the arterioles. Nitrite of amyl is the best because it acts with the greatest rapidity. A "pearl" of this drug may be crushed in a handkerchief or in cotton placed in the bottom of a glass tumbler, and inhaled. Nitroglycerin may be injected subcutaneously to grain), or a tablet of this substance may be masticated. It is readily absorbed from the mouth and acts almost as quickly as when given hypodermically.
For treatment of attack itself, rest, the inhalation of 5 or 6 drops of nitrite of amyl and an hypodermic injection of grain of nitroglycerin are to be resorted to. To overcome the syncope ether, caf feine, or camphorated oil, the latter in 10-per-cent. strength, are to be employed. Friction should also be applied to the limbs and, should there be evidences of pulmonary involvement, venesection must be practiced, while, if respiration fails, rhythmical tractions of the tongue must be performed. Fifteen- to 45-grain doses of antipyrine may be given by the stom ach or by rectal injection, or smaller amounts of phenacetin may be used; to the point of pain chloride-of-ethyl spray may be applied. Lyon (Revue de Thar. Med.-chin; Ther. Gaz., Oct. 15, '98).
In angina pectoris pearls of amyl-nitrite recommended, especially in the beginning of the attack. The dose is from 5 to 10 drops. Should the attack last for any length of time injections of nitroglycerin advised. A good formula is as follows :— Spirit of nitroglycerin, 10 minims.
Cherry-laurel water, 3 drachms.
M. Twenty minims to be injected sub cutaneously.
Small blisters to the prsecordium are often useful. Between attacks the diet should be very limited and the use of alcohol and tobacco be forbidden. Iodides should be given for at least from two to four years following an attack, and it is well to alternate the sodium and potas sium salts and combine them with digi talis or caffeine. Huguenin (Allgcmeine med. Central-zeit., No. ]4, '9S).