ANGINA PECTORIS.
During an acute paroxysm treatment must be prompt and decisive to be of use, and as the sudden nature of the attack and its often brief duration prevents the services of the physician being obtained in'time, the patient must he instructed how to act as soon as he fee's the spasm and pain approaching.
Nitrite of Amyl is the only drug to he relied upon once the paroxysm has occurred. The glass capsules enveloped in cotton-wool surrounded by olsilk, and each containing say 5 mins., afford the most convenient the administration of the remedy, and should he a'ways carfed by the patient in a pocket easily emergencies. By pinching the fragile capsule is readily broken and the highly volatile contents can be inhaled through the nose. Tf inhalation through the open mouth be attempted the effect is not so rapid. as theindrawnair does not become so highly saturated with the vapour of the drug as when a pro longed sniff is taken. As a rule some relief is marked in a few seconds, even in those cases where the arterial tension is not apparently high, Tn severe and prolonged attacks a second or third capsule may be used and the effect may be intensified or prolonged by a full dose of alcohol' which acts also as a powerful vaso-dilator, and at the same time stimulates the over-burdened and weakened left ventricle, or the effect may be pro longed by a hypodermic dose of Morphia combined with Atropine, which is the next best remedy, or Chloroform inhalation for a brief period may be tried, alcohol having been given preferably immediately before. A I-oz. dose of Spirit of Nitrous Ether in hot water has a powerful and prompt vaso-dilating effect. In those constantly recurring attacks where the patient has warning that the seizure is about to take place Trinitrin in tablet form is better than amyl. One B.P. tab'et should be broken up in the mouth and swallowed as soon as the premonitory symptoms are experienced, and by this procedure the threatening attack may often be completely prevented. Mannitol and Tetranitrate of Ervthrol, though
powerful and pro'onged in their action, are too slow in the presence of an impending seizure to be relied upon.
Constable reports a case where all pain was immediately relieved by making the erect patient grasp the rail of his bed with both hands behind his back, bending his body forwards at an angle of 6o° with the head thrown well backwards stretching the arm and thoracic muscles.
During the attack all constriction should be removed from the neck and chest; it is a mistake to insist that the patient should assume the horizontal posture; he must be advised to keep his body at rest, but he may safely be permitted to remain in the position which he feels most comfortable. If the attack has come on after a very heavy meal, and especially when ineffectual attempts at vomiting are present, the fauces may be tickled or an emetic of Zinc Sulphate should be given, but apo morphine had better be avoided. After a severe seizure has entirely passed away the patient should be compelled to rest in bed for r or 2 days, in order to enable the cardiac muscle to regain its normal tonicity.
In attacks of pseudo angina Amyl has often little or no action, but in first seizures, the diagnosis not being established. it should always be employed; its failure, too, is a valuable diagnostic point. A full dose of an active carminative, as 3j. Tincture of Ginger with the same amount of Sal Volatile diluted, or 5 mins. Oil of Peppermint should be given. Where acute gastric distress is present, a promptly acting emetic is beneficial, and the same treatment is indicated in Tobacco angina. Often a large sinapism applied over the heart and pit of the stomach affords speedy relief.
During the intervals between the attacks of true angina pectoris there is great scope for the practical physician's skill in the management of the case. The patient's dietary, habits, temperament, and environment must be carefully investigated.