difficulty in breathing.  When the attack comes on, as it often does, in the course of some bodily exertion, the sufferer is at once brought to rest, and during the continuance of the paroxysm experiences the most intense agony.  The countenance becomes pale, the surface of the body cold, the pulse feeble, and death appears to be imminent, when suddenly the attack subsides and complete relief is obtained.  The duration of a paroxysm rarely exceeds two or three minutes, but it may last for a longer period.  The attacks are apt to recur on slight exertion, and even in aggravated cases without any such exciting cause.  Occasionally the first seizure proves fatal; but more commonly death takes place as the result of repeated attacks.  Angina pectoris is extremely rare under middle life, and is much more common in males than in females.  It must always be regarded as a disorder of a very serious nature.  In the treatment of the paroxysm, nitrite of amyl has now replaced all other remedies.  It can be carried by the patient in the form of nitrite of amyl pearls, each pearl containing the dose prescribed by the physician.  Kept in this way the drug does not lose strength.  As soon as the pain begins the patient crushes a pearl in his handkerchief and holds it to his mouth and nose.  The relief given in this way is marvellous and usually takes place within a very few seconds.  In the rare cases where this drug does not relieve, hypodermic injections of morphia are used.  But on account of the well-known dangers of this drug, it should only be administered by a medical man.  To prevent recurrence of the attacks something may be done by scrupulous attention to the general health, and by the avoidance of mental and physical strain.  But the most important preventive of all is “bed,” of which fourteen days must be enforced on the least premonition of anginal pain.

Pseudo-angina.—­In connexion with angina pectoris, a far more common condition must be mentioned that has now universally received the name of pseudo-angina.  This includes the praecordial pains which very closely resemble those of true angina.  The essential difference lies in the fact that pseudo-angina is independent of structural disease of the heart and coronary arteries.  In true angina there is some condition within the heart which starts the stimulus sent to the nerve centres.  In pseudo-angina the starting-point is not the heart but some peripheral or visceral nerve.  The impulse passes thence to the medulla, and so reaching the sensory centres starts a feeling of pain that radiates into the chest or down the arm.  There are three main varieties:—­(1) the reflex, (2) the vaso-motor, (3) the toxic.  The reflex is by far the most common, and is generally due to irritation from one of the abdominal organs.  An attack of pseudo-angina may be agonizing, the pain radiating through the chest and into the left arm, but the patient does not usually assume the motionless attitude of true angina, and the duration of the seizure is usually much longer.  The treatment is that of the underlying neurosis and the prognosis is a good one, sudden death not occurring.