ample of such degenerative changes found in the arteries which could not be recognized macroscopically, I ask attention to Fig. 1. The patient had stenocardial attacks for years, and died at the Hôpital St. Louis, Paris, of chronic Bright's disease. The presence of aortic lesions is strongly dwelt upon by many authorities as being so often present that their share in the disease must be considered. Aortic lesions, however, are those of adult life, as a rule, and when mitral lesions are also present, they have usually been acquired in early life. While these lesions may have preceded the symptoms of stenocardia by many years, the reverse also holds true, for as the suffering patient grows older, valvular lesions may gradually make themselves manifest, and may be the result, rather than the cause, in some cases. During the life of a patient, if examination reveals cardiac valvular lesions, or thickened or sclerosed arteries, or myocarditis, or cardiac arrhythmia, by which we can infer disturbed functional activity, the pathology is cleared up. In some cases I have found that an ophthalmoscopic examination of the fundus, by revealing degenerative changes of the arteries, or hemorrhages, aided me materially in arriving at a diagnosis when the lesion. was little manifest in the superficial vessels. But in all cases of doubt the physician should apply the sphygmograph and sphygmomanometer, and, if need be, also the arteriometer, before deciding that the vessels and heart are functionally and organically sound. It is not without reason that I say that a single examination decides nothing; several examinations, repeated at the same hour of the day on successive days, at the same digestive period, under wellarranged normal conditions of the patient, and in the same position, preferably that of lying down (sometimes when the pressure is feeble the uncertainty of the results compels the use of the sitting posture) should be made.

Symptoms.It is generally agreed that men are more prone to these attacks than women, though I think the proportion in favor of men has been somewhat exaggerated. The ages between forty and fifty are those in which most men are attacked. Before entering upon the consideration of the symptoms, I must state that it is my firm belief that by far the larger number of cases of pseudo and hysterical angina are cases of true angina. When heart-pain recurs in its characteristic manner, and with some of its usual symptoms, my experience has taught me that sooner or later the signs become sufficiently certain for me to include the case under true stenocardia, and this in a considerable number of cases in which, at first, the usual examination gave no indication of real lesion. For me a patient must have

a clear history of hysteria preceding or accompanying the attack of heart-pain, and have been under observation for some time before I, from a negative standpoint, place the case in the pseudo-angina category.

Again, it has been customary to consider as genuine cases only those in which the symptoms of pain were marked and unmistakable. For me, the mildest symptoms characterize a considerable number, or the early stages of a number, in whom lesions may be recognized with difficulty, or not at all, for a time. Experience has, in a certain number, made the lesion clear, after several years of observation. Next, as to the ultra-severe cases, it has seemed necessary to some authorities (Nothnagel and others) to place in a separate category the cases in which the severe general vasomotor disturbances occur. Such cases have been denominated cases of angina vasomotoria. To me, these are only cases with unusually severe complications, or else severe forms of the disease. While allowing for exceptional cases of pseudo and hysterical stenocardia, I prefer to include all cases, mild or severe, with feebly or fully developed symptoms, and with or without vasomotor disturbances, provided examinations, properly made, give us changes in arterial tension, or other vascular or cardiac functional or organic changes, as true cases of stenocardia.

The first and most marked symptom we must consider is pain. However, this must be differentiated from intercostal, neuralgic, and rheumatic pains, and from pain resulting from various accidental causes. The pain is sometimes simple discomfort; again a sense of oppression or compression, varying in degree and severity; sometimes sharp and lancinating, sometimes like that of a sword pushed through the sternum and back; sometimes there is a feeling of unbearable weight, accompanied at times by a sensation of cold in the same region; sometimes there is a feeling of distension or bursting within the chest, or, again, a sensation of burning. This most pronounced symptom of stenocardia, however, is usually referable to the heart, but not always beginning or ending in the heart, and sometimes, by reason of greater intensity at other points, is not clearly appreciated as a heart pain.

In the mildest forms, the pain usually begins over the epigastrium, the lower end of the sternum, or the mid-mediastinal space, and from here it passes upward toward the neck and to the left arm, terminating at the left shoulder, elbow, or one, or several, or all of the fingers. At times it radiates into the right chest and right arm also, or, passing downward, radiates toward the abdomen. As the attack> grow in severity, the accompanying symptoms grow

in intensity. The feeling of constriction or fulness of the throat becomes almost a choking one, and the sensation of compression of the chest and epigastrium becomes absolutely unbearable from a sense of superhuman weight to be overcome. The sharp pain appears like that of a sword-blade, with the hilt pushed against the chest, the handle even being twisted about to intensify the suffering. Anxiety and restlessness, a sense of fear even of some impending catastrophe and death, pallor of the face and coolness of the extremities, followed at times by irregular suffusion of the face, and sudden, profuse perspiration, and even loss of consciousness supervenes. The fingers of the left hand, sometimes the entire left upper extremity (less often those of the right hand or extremity) become numb and useless for a time. The attack may become modified, the pain being more bearable for a short time, and then may return in full force, continuing in this way for from one to several days in very rare instances. Usually the attacks last from a few seconds to a few minutes. ·

In persons subject to the attacks, pulmonary congestion, with expectoration of frothy, bloody mucus, lasting from a few hours to days, may occur.

Examination of the heart may reveal no irregularity, but even in such cases I have always felt that the heart seems to be acting against depressing influences; its action is not free as it should be. In characteristic cases, the heart beats irregularly, sometimes tumultuously, with alternate feeble and strong beats, very suggestive of the condition of fibrillar contraction of the cardiac muscle. At times it seems to beat feebly, being almost arrested in its action, then beating irregularly, and gradually returning to its previous condition. Less often there is simple tacchycardia, with feeble beats. The pulse, as already said, may indicate nothing; again, it may be small and thready, or may indicate increased arterial tension, or may be irregular and slower, or even faster. In cases in which the attack goes on to a fatal termination, syncope soon supervenes, the heart gets feebler, edema of the lungs, with cyanosis and coolness of the surface, follows, and, with the usual symptoms of this complication, life quickly ebbs away.

Beyond these usual phenomena, other more marked vasomotor disturbances may occur. Thus the symptoms described under the separate heading of "Angina Vasomotoria of Nothnagel" may be superadded to the ordinary symptoms. As a rule, the symptoms are associated with attacks produced by exposure to cold. We have general spasm of the peripheral vessels, pallor, cyanosis, and subnormal temperature, and a sense of stiffness and inability to use the extremities. At times faintness or uncon

sciousness follows. This condition, supposed to depend upon diffused spasmodic contraction of the peripheral arteries, is found, according to the author, in cases in which the pulse remains regular, and there are no signs of cardiac disease.

There is still another form of vasomotor disturbance which may or may not be associated at times with cases of stenocardia, and that is the form called by Jacob "angiospastic cardiac dilatation," in which any of the internal viscera, the liver, spleen, kidneys, or lungs in most cases, may be the seat of engorgement. The kidneys, if not the principal seat of the lesion, sympathize with the system, and the albumin and casts temporarily eliminated show their passing congestion if nothing worse. There may be signs of pneumonia or pleuritis, which disappear in a few days, and there may be some edema. The temperature is slightly elevated. The condition may last from a few hours to a few days. The heart is usually acutely dilated, even when dilated before. The pulse is, of course, small. This condition may assume all forms, from the mildest to one threatening the life of the patient. In very mild cases, engorgement of the liver or lungs, when slight, is overlooked, and frequently in severe cases the condition is mistaken for acute infection from old ulcerated valves or chronic endocarditis. The life history of these cases is exceedingly variable. Some few patients never have but a few attacks, and die in an attack of moderate severity. A small number after having been subject to a few attacks remain well, and years after upon the first return of an attack of greater severity succumb to the attack. In a fair number of cases, which number is now being increased, the attacks are induced to subside, and the patient enjoys years of freedom. In others the attacks may last for an indefinite number of years; in some, slowly increasing in severity, in others varying to and fro, the patient's life being dependent upon his general cardiac and constitutional condition.

The treatment of the patient may modify the career of the disease, and the occupation of the patient may be such as to intensify it. If the sufferer cannot avoid the mental or other exciting causes of the disease, the symptoms and number of the attacks will be dependent really upon the exciting cause, rather than upon the lesions and underlying causes. And it is this psychical element that is largely responsible for making cases appear so contradictory as concerns symptoms and lesions. Prodromal symptoms exist in quite a number of cases. Frequently a feeling of fulness or slight sensation of pressure or discomfort or sense of uneasiness is felt in the epigastrium, lower or midsternal regions, before the symptoms of stenocardia set in definitely. Many patients recall that

these irregular and uncertain sensations existed for months or years, appearing at long intervals for a few seconds at a time, long before they became the subject of stenocardial attacks. It becomes an open question whether such prodromal symptoms may not really be part of the attack itself. But in many instances, by resting or resorting to medication, or by getting the body warmed if it has been chilled, or getting rid of the exciting cause, whatever it may be, the real symptoms are averted, or if too late to abort the attack, it is made more moderate.

Diagnosis.-The seat and character of the pain and remaining symptoms, especially if arterio-sclerosis, with or without cardiac valvular disease, exist, makes the diagnosis certain. If cardiac disease is not present and there is increased arterial tension, the diagnosis is not difficult. In gouty subjects, even if the heart is not apparently involved and the arteries are thickened or pressure increased; and even if there be no apparent change in the arteries, gout with characteristic symptoms is very suspicious of stenocardia.

In all forms of myocarditis, whether primary or even secondary to renal disease, the symptoms should be considered as strongly indicative. Hypertrophy with or without dilatation of the heart, and especially cardiac dilatation, makes the diagnosis fairly certain.

The occurrence of the symptoms in men over forty years of age, more especially with aortic disease and arterio-sclerosis, is a combination of conditions that makes such symptoms especially significant and unquestionable. In cases in which the symptoms are as yet few, and the finger and ear cannot detect changes in the arteries and heart, the diagnosis should be kept in abeyance until the sphygmomanometer, arteriometer, and sphygmograph have been brought into requisition. It is a question I have not yet decided as to how far the capillary pulse instrument will be useful, but it appears to me that in time with perfection of the apparatus, it should have great value.

The differential diagnosis from that rare form of stenocardia due to the use of tobacco must be based upon the history of the patient and the peculiar cardiac condition accompanying chronic tobacco-poisoning. In a case of cardiac valvular disease, the differential diagnosis would be difficult. If, however, such a patient smoked so much as to make himself liable to stenocardia, the probability is that the symptoms would be indicative of true stenocardia; however, he might coincidently suffer from tobacco-poisoning.

The differential diagnosis which Huchard makes between true and pseudo-stenocardia, is for the most part untenable, and I feel certain that in following tradition he has adhered to the arbitrary division so long made by other equally great authorities. To maintain that "spontaneity," being "often periodical

"sensation of

or nocturnal," "pain less severe,' distension,' "duration one or two hours," are essential features belonging to the pseudo types, is by no means in accordance with fact, for true stenocardia may be characterized by the same symptoms. The occurrence of attacks in a young woman of an hysterical temperament, free from cardiac disease, taken in connection with a lack of the usual succession of symptoms but with the existence of dyspnea, favors the diagnosis of pseudo or hysterical stenocardia.

Prognosis. The prognosis depends upon the nature of the cardiac lesion and condition of the blood-vessels, and upon the severity of the attacks. Patients may go on having fairly severe attacks for years even with extreme lesions, while in other cases moderate attacks prove fatal. Balfour relates a sin

gular case, but it was in the person of an old man who, having had an attack, was free for ten years and succumbed to the next. In seeking to fix the future of such cases it is wisest first to determine how far the patient's condition and attacks are amenable to treatment, for much depends upon the vascular and cardiac condition, and the ability to moderate the attacks. But even in desperate attacks with edema of the lungs, we must seek to keep up the heart's action until the edema has subsided, for the spasm may have passed off and the patient's only danger be from the effects of the edema.

The patient's environments and the extent of his means to purchase comforts and save himself from the injurious effects of work, temperature and surroundings are additional factors that tend to regulate the probable length of life. Considering the large number of persons so afflicted, the prognosis while earnest should never be made too grave.

Treatment.-The treatment should be regarded under three headings, (1) prophylaxis, (2) general treatment, and (3) of the attack itself.

Prophylaxis.—A great many attacks are excited by the influence of cold. The avoidance of cold water, and even of tepid water to any large surface of the body on account of the succeeding chill, must be advised. Such patients must wash their bodies one part at a time, and have that part well dried and covered before proceeding to the next. Even the keeping of the hands well gloved, maintaining warm feet, protecting the mouth and nose from the sweeping cold wind or air are precautions that will save the patient from many an attack. The regulation of the patient's life and habits come under this category. Avoidance of mental worry and emotion, of over-exertion, and even needless exertion at times, is imperative. The patient must walk with deliberation, and the combination of talking and walking may be too great a

strain for the heart until it is improved by general treatment. Tobacco should be absolutely interdicted, and all spirituous liquors as well. In persons who have always taken wine, a small quantity of a light Moselle or claret, preferably Moselle, may be taken diluted at dinner or, exceptionally, if the patient feels weak and in need of it. Over-indulgence in food must be guarded against. If the patient has the prodromal symptoms of an attack, the seeking of shelter, of a warm room, of warmth to the surface, or resting or lying down, may ward off an attack.

General Treatment.—This must have two objects, first, the improvement of the heart and bloodvessels, and second, the relief of engorgement in the internal viscera and capillaries.

For the improvement of the heart and bloodvessels, the use of potassium or sodium iodid in from 3- to 5-grain doses kept up for months is an old remedial agent of a certain, though not always satisfactory, value. The treatment by saline baths and by the Schott method of exercises, has a most potent effect in improving the condition of the cardiac muscle and vessels, and appears to have a direct effect in making the attacks less numerous and severe, and even in causing them to cease during a period of months or years.

The exercises with resistance or Schott movements should be carried out in the way indicated by me in a previous paper before the general meeting of this Academy. The movements are made in such a manner that the attendant can easily resist or hinder the movement, and the patient in seeking to complete the movement must overcome the resistance of the attendant. The movements must be made with especial care and caution in these cases, and the resistance at the outset must be at a minimum.

The artificial saline baths should contain from one to three per cent. of salt, and from one-fourth to one per cent. of chlorid of calcium, and should gradually be strengthened by the addition of carbonic acid. By a process now in the last stages of completion, it will be possible to prepare the saline effervescent and saline effervescent flowing baths by means of a simple apparatus, so that the carbonic acid will be intimately mixed with the water. Details of the manner of administering the baths and exercises for this and other cardiac conditions will appear later.

For the relief of visceral and capillary engorgement we may resort to medicinal agents. Although the baths and exercises do this to a marked extent the administration of a half-grain of calomel (well triturated) thrice weekly at bedtime, succeeded the next morning by a dose of Carlsbad sprudel salts, adds materially to the effect.

After the visceral engorgement has been much re

lieved, we can now use our nitrites, and, in some cases, nitroglycerin; for until visceral congestion is relieved it is only playing hide and seek to try and relieve the capillaries which are immediately clogged again by the nearest congested viscus. Having accomplished this, we will now find the cardiac tonics, spartein, strophanthus, strychnin, valerian, and, in suitable cases, digitalis, of the greatest utility.

The general tendency to anemia and defective. oxygenation must never be lost sight of, and general tonics, including the use of oxygen gas, as recommended by A. H. Smith, will be of excellent service.

The Attack.-The treatment of the attack, includes the use of nitrite of amyl in from 3- to 5-drop doses, poured upon a handkerchief, or taken from a glass pearl in similar manner, and inhaled.

The use of nitroglycerin in 1-100 grain doses is of less rapid efficacy. It may be repeated once in three or four hours, or at even longer intervals. In a severe attack it may be given at half-hour intervals, but should be given guardedly. In some patients the effect of nitroglycerin is immediate,

in others very slow.

in others very slow. Hypodermatic injections of morphin, with or without atropin, is often of great service.

The use of ether or chloroform, with or without valerian internally, relieves moderate spasm, and is somewhat stimulating. Local counter-irritation-by issue, sinapism or blister over the precordium, or the actual cautery over the precordium, or applied over the hepatic region in some cases, and the application of electricity, may be resorted to. Sometimes the local application of the hot water bag is of service. Exercises given with extreme caution has in my own hands sometimes given some relief to the acute symptoms.

To recapitulate, I wish to emphasize that the treatment should not be haphazard, but systematic, if we would accomplish anything; and considering the suffering entailed by this disease and the danger involved, such attention upon our part is essential and called for.

First we must remove exciting causes of every kind, and next relieve the visceral engorgement that has long existed because the heart was too weak and the vessels not elastic enough to keep up proper venous circulation, and, having gotten rid of the vis-a-tergo, we relieve the capillaries by appropriate remedies and coincidently stimulate the heart, which can now act better because its capillary embargo has been raised. The success of the treatment depends upon the following out of the sequence just suggested. The comfort to be guaranteed to the patient, and the prolongation of life, are sufficient rewards for patient toil and scientific interest. I add a few cases taken at random from a

large number, illustrative of the manner and results of treatment.

CASE I.-A. S., aged fifty years, a Russian, came to Nauheim in the summer of 1895. Family history negative. Had syphilis. In 1875 had severe rheumatism and marsh fever. Lived in Sardinia. In August, 1893, had his first attack of angina. Diagnosis of stenocardia by Professor Müller of Budapest, by whom he was put upon iodid. In October, 1893, iodid was stopped, and patient ordered a coldwater cure at Budapest. He grew worse, and the treatment was discontinued. He went to Professor Oser, in Vienna, who said he had gastric trouble. In November, 1894, was seen in Vienna by Abeles and Nothnagel. Nothnagel recognized his cardiac disorder, diagnosticating gallop-rhythmus with myocarditis. Next saw Professor Muri of Bologna, who renewed the iodid treatment.

The prolonged

iodid treatment and his illness had made him profoundly anemic. He now suffered from constant attacks of angina most of the day. The attacks came on after every meal and every movement. Even while asleep he would not be entirely free from them. The simplest food-even milk-caused an attack. Finally they became so intense that the patient often became hysterical and cried with agony. During this time he was in bed for months. He noticed that if he yawned severely he got relief. Pain usually began in the epigastrium, then went upward and across the chest into the left arm and hand and over the left shoulder slightly; it rarely went into the right side, and if so, was not so severe. In February. 1895, he consulted Dr. Secchi and others in San Remo, For two months previously he had been again in bed and taking iodid. Secchi now stopped the iodid and ordered strophanthus during April and May, 1895. Nothnagel came to San Remo in May, 1895, and advised him to go to Bad Nauheim as a last resort, and in July he came there.

From July 4th to 14th he was given nine saline baths at a temperature of 32° to 31° C.; duration eight to eighteen minutes. From July 16th to 30th. there were administered twelve effervescent saline baths at a temperature of 31° C.; duration eight to twenty minutes. August 1st to 12th he took nine effervescent flowing baths at a temperature of 29° and 30° C.; duration twelve to twenty minutes. To the saline baths from one to two liters of mutterlauge had been added.

After the first week daily exercises with resistance were given. He made a complete recovery to the extent that all the angina attacks disappeared.

In August, 1896, he returned to Nauheim and reported to Dr. Schott that he had remained free from attacks, barring a slight suggestion of an attack in the shape of mild prodromal symptoms. He had taken no treatment of any kind meanwhile.

He repeated his treatment in the summer of 1896, and in the fall reported himself, in a letter to me, as being free from every symptom.

CASE II.-X., aged forty-three, American, came to Nauheim in the summer of 1896. Family history: Father died of cerebral apoplexy. Mother

Patient never had had rheumatism or syphilis, and was well up to three years ago when he began to complain of dyspnea on exertion, had precordial discomfort, and was anemic.

Six months ago began to complain of attacks of angina, which came on by day and by night. Attacks occurred at times without apparent cause, and always under the influence of cold. Diagnosis of aortic stenosis had been made in 1893. After two weeks of saline baths with mutterlauge (1 to 3 liters), temperature varying from 33° to 312° C., the attacks ceased, and up to November, 1896, had not returned.

CASE III.-X., aged sixty-one years, native of Batavia, came to Nauheim in 1895. No history of Excessive smoker. rheumatism or syphilis. For years patient had worked under pressure in a hot climate. He maintained good health until he suffered severe shocks from family bereavement. He then began to complain of vertigo and headache, and of malaise, weakness, loss of appetite, and marked dysHe suffered from attacks of carpeptic symptoms. diac arrhythmia, which were followed by a sensation of faintness and slight syncope. He had more or less sharp and lancinating pain in the precordium, going into left shoulder and passing down to left elbow. This pain was brought on by any exertion or slight excitement. The noises of his beating heart awoke him at night. Examination revealed aortic disease (stenosis and insufficiency), and although he discontinued smoking upon his doctor's advice, he did not improve. He left Java and came to Holland in the winter, and rested in Holland for four months, where he was treated without result. After this treatment, in the summer of 1895, he came to Nauheim suffering as before. Examination revealed an intermittent arrhythmical heart, myocarditis, and general atheroma, aortic stenosis and insufficiency. Patient complained of angina, dyspnea, and symptoms as above, and was unable to walk without distress.

After six weeks' treatment by baths alone his symptoms disappeared. It was noted that whereas before the individual bath his pulse was 80 to 82, afterward it was 66 to 68. He remarked to me: "I am wonderfully better." He was able to go about without pain, and his heart had become reduced from 15 cm. to 121⁄2 cm. in its greatest transverse diameter. The improvement was maintained throughout the winter of 1895-1896, and in the summer of 1896 he returned to Nauheim and repeated the treatment. left in most excellent spirits and with no symptom of discomfort.

He

CASE IV. ---Miss X., aged thirty-six, school teacher, German. Mother subject to chronic gout. At seven years of age patient had had pleurisy and periostitis. of left chest. Fairly well till her sixteenth year; became anemic, and for two years had epileptic attacks. Then suffered from chronic bronchitis for two years, with a slight return of epilepsy. Was profoundly anemic all this time, and suffered from chronic malarial poisoning. Menses appeared (but scanty) at nineteen