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or ith of a grain, caused the characteristic headache and throbbing of the arteries, while one case showed an almost total insusceptibility to its action, the patient taking as much as one minim of the pure substance eight times a day with hardly any inconvenience. In seven days he took the enormous quantity of over a drachm of the pure drug.
On the whole, Dr. Murrell's cases seem to show that when Nitro-glycerine does good in angina pectoris, its beneficial effects are most marked when the drug is administered in such small doses that none or very moderate symptoms of its characteristic physiological effects are observed.
Dr. Murrell says that the pure Nitro-glycerine may be handled with perfect safety. That is his experience. Our own is not so favourable to its innocuousness. On one occasion we had a phial containing about two ounces of Nitro-glycerine, and on essaying to remove the cork the whole exploded with a loud detonation, shivering the bottle to atoms. The whole force of the explosion fortunately took place downwards, and our hands escaped without injury, but the same good luck might not attend a repetition of the experiment, and we would not advise anyone to keep a stronger preparation than a 5 per-cent. solution, which is quite strong enough for all medical purposes.
As a specimen of the power of Nitro-glycerine over angina, we transcribe Dr. Murrell's first case:
William A—, set. 64, first came under observation in December, 1877, complaining of intense pain in the chest, excited by the slightest exertion. It was distinctly paroxysmal, patient being perfectly well in the intervals. The first attack was experienced in September, 1876. Patient was at that time in his usual health, and was, in fact, out for a day's pleasure in the country. The pain seized him quite suddenly when walking. It was a most severe attack—as severe a one as ever he experienced in his life. It caused both him and his friends great alarm, and they were most anxious that he should return home at once. He cannot tell at all what brought it on; he had been enjoying himself very quietly; it was not by any means a cold day, and he had not been running, or even walking faster than usual. He remained perfectly well until the following April, when he experienced another similar attack; and since then he has been suffering from them with increasing frequency. From September, 1877, they had been a cause of constant anxiety, and it was only by a determined effort that he could continue to follow his occupation.
The attacks usually commence with a feeling of warmth, then of heat, and then of burning heat in the chest, immediately followed by a heavy pressure, from the midst of which proceeds an acute pain, so that in a moment the whole chest seems as if it were one mass of pain. It is almost impossible, he says, to describe it, for he never felt anything like it before. The pain is first experienced at a small spot on either side of the sternum, corresponding to its junction with the fourth costal cartilages. From the chest the pain flies to the inner side of the arm, at a point midway between the shoulder and the elbow. It runs down as far as the elbow, but never to the fingers. It is not more severe on one side than the other. During the seizure the patient suffers most acutely and feels convinced that some day he will die in an attack. He usually experiences some shortness of breath at the time, but there is no feeling of constriction about the chest. He can speak during the seizure, though with some difficulty. The attacks are not accompanied by any sensation of warmth or chilliness, but patient is under the impression that he grows pale at the time. These attacks are induced only by exertion in some form or other, most commonly by walking, and especially by walking fast. Walking up hill is sure to bring on a seizure. Stooping down has a similar effect, and the act of pulling on boots will excite a paroxysm almost to a certainty. He is almost afraid to stoop down, and when he wants to pick anything up from the floor he goes down on his hands and knees. He has a slight cough, but although it shakes him at times it never brings on the pain. The attacks are not excited by food, but exercise taken after meals is more likely to induce them than when taken on an empty stomach. Patient has noticed that they are far more readily excited immediately after breakfast than at any other period of the day. They are more readily induced, too, after an indigestible meal than at other times, but patient is quite clear that no amount of indigestible food per se will bring on an attack. The paroxysms, as a rule, last only three or four minutes, but occasionally from twenty minutes to half an hour. If they come while he is walking they always continue till he stops. Patients finds that stimulants afford no relief. In the intervals between the attacks, patient is perfectly well, and he feels that if he could only remain absolutely quiet the whole day, he would be quite free from pain. Practically as he is obliged to be out and about, he has several attacks, on an average six or eight every day. At the time of coming under observation the seizures were rapidly increasing both in frequency and severity. His family history was fairly good. His father died at the age of eighty-three, and hardly had a day's illness in his life. His mother died of phthisis, but only, patient says, through catching cold, hers not being a consumptive family. He lost two brothers, one at the age of eighteen from consumption, and the other in the tropics, cause unknown. He has two brothers and one sister living, all well. There is no family history of gout, asthma, fits, heart disease, or sudden death. He has four children, one of whom (a boy) is consumptive, and the other (a girl) subject to facial neuralgia. Patient is a bailliff by occupation, and is a remarkably intelligent man. He is a cool, clear-headed fellow, but little prone to talk of his sufferings although they are at times very severe. He has travelled much, and has lived in Egypt, Turkey, Italy, and Greece. For the last thirty years he has been accustomed to lead an active out-door life, seldom walking less than fifteen miles a day, often very fast. He has, he says, done a great deal of hard work in the way of pleasure. He usually smokes about two ounces of bird's-eye in the week, and has done so for years. His health has always been remarkably good with the exception of rheumatism ten or twelve years ago, and pleurisy seven years ago; he has never suffered from gout. On a physical examination, it is noticed that there is some fibroid degeneration of the arteries, and there is slight hypertrophy of the left ventricle. There are no signs of valvular disease, and there is nothing to indicate the existence of aneurism. The urine was free from albumen. There could be no possibility of doubt respecting the diagnosis. It was a typical uncomplicated case of angina pectoris.
Patient was placed for a week on infusion of quassia in order that he might be observed, and also to eliminate the effects of expectation. It need hardly be said that he derived no benefit from this treatment. He was then ordered drop doses of one per-cent. Nitro-glycerine solution in half an ounce of water three times a day. At the expiration of a week he reported that there had been a very great improvement. The attacks had been considerably reduced in frequency, and for two or three days he had had only one attack—in the morning after breakfast. The attacks when they did occur were much less severe. He found too that a dose of medicine taken during an attack would cut it short. He had tried it several times, and it had always succeeded. It would not act instantly, but still very quickly; so that the attacks were considerably shortened. He was thoroughly convinced that the medicine had done him good, and said he was better than he had been since first he had the attacks. It was found that the Nitro-glycerine, even in this small dose, had produced its physiological action. Patient complained that for two or three days he had experienced a strange fulness in his head with a sense of pulsation. The pulsation was felt chiefly in the temples, but also across the forehead. It caused him no positive inconvenience, and he evidently had no suspicion that it was due to the medicine. The dose was then increased to three minims, and patient found that this gave him more speedy relief. On two days during the week he had no seizure at all, a most unusual circumstance. Patient had adopted the plan of carrying his medicine with him in a phial and taking a dose if an attack seized him in the street. It never failed to afford him relief. The beating had increased considerably in intensity, and was described as being a "kind of pulse." Patient had discovered the fact that it was produced by the medicine. It came on immediately after each dose and lasted about a quarter of an hour. It was now experienced chiefly across the forehead. Patient continued steadily to improve and the dose was gradually and cautiously increased. With the increase in dose the pulsation became more severe, lasting from twenty minutes to half an hour. When twelve minims were given every three hours it became a positive inconvenience. On January 14th the dose of Nitro-glycerine solution was increased to fifteen minims every three hours. A few days later he had a "kind of fit" immediately after having his medicine. The pulsation came on as usual, but was quickly followed by headache and pain at the back of the neck. His speech " began to go off," and he felt that he would have lost his senses had they not given him tea and brandy. Patient took the fifteen minim dose every three hours from the 14th to the 28th of January, but on the latter date had two "bad shocks." He took a dose of medicine in the morning as usual and had the customary pulsation, which passed off after about half an hour. An hour and a half later he experienced a sensation as if he would lose his senses. He did not fall, but had to catch hold of something to prevent himself from so doing. It did not last more than half a minute, and there was no pulsation with it. The other seizure occurred later in the day and was of the same nature. Patient attributed these attacks to the medicine, and was in no way alarmed by them. He thought it advisable, however, to reduce the dose by a third, and henceforth had no return of the fits. At this time his anginal attacks were so thoroughly kept in check by the Nitro-glycerine that they gave him comparatively little inconvenience. He always carried his bottle of medicine with him, and immediately on experiencing the slightest threatening of an attack he took a sip. Relief was certain, for even when it did not at once cut short the attack, it eased the pain so considerably that he was able to go on walking. For two months longer he continued the ten minim dose, sometimes taking a little more and sometimes less. The attacks became gradually less severe and less frequent, the dose was reduced to one minim, and in April he was so much better that he was able to do without the Nitro-glycerine entirely. He continued to attend from time to time until the following September, taking nothing but cod-liver oil and a little tonic, and during the whole of that time he had not a single attack. In July, 1879, he was seen again, and said he was well and strong. He had a good deal of trouble and anxiety, but his health was excellent. He had had no return of the attacks. He could walk six miles at a stretch at a good pace, and found no difficulty in going up-hill. He had gained weight and ailed nothing. I still hear from him occasionally, and he is now (January, 1882) well and strong, and has had no return of his old attacks. In this case the cure has been complete, and it appears to be permanent.
In the June number of the Practitioner, Dr. Matthew Hay has an article on the chemical nature and physiological action of Nitro-glycerine, which adds little or nothing to our knowledge in the latter respect. He gives sphygmographic tracings to show the effect of Nitro-glycerine on
VOL. XL J, NO. CLXV. JULY, 1883. R