work, then signs of distress will develop, resulting in incompensation.

The pathology of angina is based on the organic changes that are found in the coronary vessels, myocardium and beginning of the aorta. The first few centimeters of the aorta must be included because this part is supplied by the coronaries through small branches which anastamose with the small vaso-vasorum from the bronchial and pericardial arteries. The cause of angina symptoms is generally believed to be due to various degrees of occlusion of some of the coronary vessels, and this may be developed suddenly by thrombosis or by a slowly developing obstruction or occlusion such as occurs in arteriosclerosis. It is self-evident that partial or complete obstruction to vessels of the coronary system will sooner or later produce grave changes in the myocardium through interference with the nutrition of the muscle.

Le Count of Chicago has recently reported the autopsy findings in sixty cases of sudden death, thirty-four had a fibrous myocarditis with sclerosis of the coronary arteries, and twenty-six more or less acute occlusion. Of the twenty-six with acute obstruction eleven were found to have some traces of syphilis, and the obstruction in the coronary arteries was in the most instances a thrombosis. It may be argued that many of these cases may not have had angina. for unfortunately, the history was not available in many of the cases, but it is clear that a large number may have died in the first attack of angina. The best example are those that died of acute occlusion of the coronary arteries by thrombosis. Herrick and others have reported such cases giving well defined symptoms which would justify a diagnosis of coronary thrombosis, and in most of these death may be expected to occur in a comparatively short time.

The exciting cause of the symptoms in angina may be variable but in the great majority of cases exertion is usually connected with the first attack as well as succeeding ones. In some cases, the first attack will develop all of the classical symptoms with fully developed chest pain radiating over the arms and shoulders, while others merely complain of a feeling of oppression in the chest, this becoming more and more frequent and severe until it is a definite pain. Anger or other intense emotional disturbances in some cases may be the first disturbing factor, but in a large percentage, the first attack is noted after some physical exertion.

Various authorities on cardio-vascular disease have advanced different theories concerning the cause of the chest pain. Mackenzie leans strongly to the supposition that the chest pain is due to muscle exhaustion which distributes the pain over the area reflexly connected with the heart and beginning of the aorta. He claims that when exertion is indulged in sufficient to produce pain, it is the cry of the myocardium for more nutrition and states that even in normal individuals exertion can be indulged in to the point where there is a pain resembling that of angina. Another reason for thinking it is due to the lack of blood supply to the muscles is the results noted in intermittent claudication. In this condition, the arteries of the legs are very much sclerosed and the caliber is greatly reduced. When such individuals walk rapidly, there is noted pain in the calves of the legs, described as a cramping sensation. Almost immediate relief is obtained by resting. Such individuals will usually stop for a moment, or perhaps lean against a building or even sit on the curbstone to rest. I think all agree that in intermittent claudication, the pain is caused by a lack of blood supply to the muscle. The production of the symptoms in angina pectoris and intermittent claudication are both ascribed to exertion and are relieved by rest, so that it is reasonable to consider the conditions parallel as affecting the muscle. Others advance the theory that the pain originates in the blood vessels and is the result of stretching the aortic walls. The same condition may apply to the coronaries. There is no doubt that pathological changes in the beginning of the aorta are frequent, and that pain is evidence of this, as shown in cases of syphilitic aortitis; and we have cases of angina pectoris where the seat of the trouble is more in the aorta than in the myocardium. Arterial spasm is also advanced as a cause, based in part on the fact that the spasm of the blood vessel interferes with the supply of blood to myocardium and because of this interference, pain is produced. This spasm may be produced by toxins circulating in the blood, having a more or less direct effect on the blood vessels or it may possibly be produced through the nervous system.

I think there is no doubt in the minds of the profession that any and every case of angina pectoris should be diligently searched for any possible foci of infection that may be a distributing point for toxins, having a profound effect on the body in general. In my experience this has proved of extreme importance

especially in cases where the angina symptoms have been of comparatively short duration. I cannot emphasize too much the importance of careful study of the tonsils, teeth, sinuses and gall-bladder as possible foci of infection as I have had striking results in the removal of infection from all of these points in patients suffering with angina symptoms. Allow me to refer to one case with typical symptoms of angina brought on by exertion so that he was unable to walk more than a block without severe pain. X-ray of the teeth revealed several apical abscesses and removal of these teeth was followed by almost complete relief so that in the course of two weeks, the patient was able to walk three or four miles a day without any discomfort whatever. I have had similar experiences from the removal of diseased tonsils.

The prognosis of angina pectoris is very uncertain. It is impossible for any one to predict with any reasonable degree of certainty the length of life that individuals suffering with angina may expect. In my experience, I have had a number of cases that suffered such intense pain with recurring attacks throughout the day or night that frequent use of nitroglycerine had to be resorted to in order to obtain relief. If the question had been asked, one would have been inclined to say that the individual would be likely to die almost any time, and the prospects of living more than a few months were dubious. One such case was under my care more than four years ago, and improved slowly, so that within several months, he was able to walk about the city without much trouble. A few months ago, I had a letter from him stating that he was greatly improved and rarely had any attacks of angina. On the other hand, I have had cases that apparently suffered much less and died within a short period. Much, of course, depends upon the habits of living and the attitude of the patient toward the disease. If they are alwavs apprehensive as to the outcome, they stand much less chance than those who take it philosophically. The condition of the blood vessels is something of a guide in the prognosis. If the arteries are extensively sclerosed, we must conclude that the prognosis is unfavorable; the danger being acute thrombosis of the coronary arteries.

In the management of cases of angina pectoris, it is necessary to assure the patient that the attacks are not fatal, even if the pain is severe, and they must be made to accept the pain as a warning so that whenever the first symptoms manifest themselves, they will stop

and rest until the pain is relieved. In presenting this feature to the patient, he is likely to be less apprehensive and we thus eliminate the fear and anxiety as factors in causing these attacks. Next, we must see that all possible foci of infection are eliminated, as above referred to, and also emphasize the importance of proper elimination by way of the intestines and the kidneys. These patients should be placed on a laxative diet that is not too bulky, and if necessary, mild artificial remedies used to secure proper elimination. In conjunction with this, the exogenous toxins indulged in by many of these cases in the nature of alcohol, tobacco, tea, coffee, and the excessive use of proteins should be proscribed if possible.. Everything should be done to give the patient the best chance as far as general health is concerned. When this has been done, other treatment may be considered. Many authorities favor a complete rest cure, but in my experience, I have not found this satisfactory. While it is true that these patients during the period of the rest cure experience no pain, as soon as they endeavor to resume activity, even moderately, they are troubled more than ever, which is very discouraging.

For a period of four years, I have observed a number of these cases, and I have advocated the policy of urging them to take all the exercise possible, short of producing discomfort or pain. I instruct them to rest on the slightest evidence of discomfort or chest pain. Furthermore, I always advise them that in walking, they should start out slowly and gradually increase their gait. This prevents the lowering of the muscle tone and if persisted in, gradually increases the efficiency of the heart muscle. If this can be done, the chest pain is less apt to develop with moderate exertion.

In conjunction with the exercise, moderate massage, mild hydrotherapy including Nauheim baths have proved beneficial. In these treatments, however, anything in the nature of a sudden insult to the circulation should be avoided, as this is likely to bring on a paroxysm of pain. In cases with increased blood pressure, high frequency will prove beneficial, and in some cases diathermy has served to relieve the pain. In giving the Nauheim baths, it is important that the temperature be gradually reduced to about 92 degrees during a series of baths, and that immediately after the bath, the patient rest on a couch for at least half an hour.

To

Medication should be instituted, first for the immediate relief of pain and next, for the improvement of the efficiency of the myocardium. For the first, nitroglycerine is probably the most valuable, and this can be given in doses of 1/200 to 1/100 of a grain. The patient should be instructed to place the tablet on the tongue, and not to attempt to swallow it with water. In this way, almost immediate relief is obtained. If necessary, the dose of nitroglycerine may be repeated without any danger whatever. Occasionally, we find a patient in whom amyl nitrite gives better results than nitroglycerine. improve the efficiency of the myocardium, and in this way decrease the muscle exhaustion, digitalis is of the greatest value. This is particularly true in cases where there is dyspnea or evidence of myocardial insufficiency. It is my habit in all cases of angina with the least evidence of cardiac embarrassment to give a rather vigorous course of digitalis therapy. This particularly applies to cases where the pulse rate is above normal, and where there is the least evidence of shortness of breath or edema, and the results have been decidedly gratifying. When the above efforts fail to give relief, the use of diuretin may be tried as first advanced by Von Noorden. I usually give 5 to 72 grains in a capsule three times a day, occasionally securing very satisfactory results.

In cases of emergency, where nitroglycerine does not afford relief and there is danger of death, morphin should be used hypodermically for the relief of pain, and in the average case 1% morphin with 1/150 atropine will give relief.

SUMMARY.

1. Angina pectoris is a disease of the coronary vessels, beginning of the aorta and myocardium.

2. The disease is evidenced by subjective symptoms of chest pain beginning in the region of the precordium and radiating to the left shoulder, arm, neck and back, and sometimes to the right arm.

3. The symptoms are probably the result of muscle exhaustion due to an insufficient supply of blood to the myocardium or stretching of the aortic ring.

4. These symptoms may be greatly aggravated by focal infections such as teeth, tonsils, sinuses, gallbladder or toxins from faulty elimination by way of the bowels or kidneys.

5. Exciting causes of the symptoms are exertion, anxiety and emotion.

6. Treatment: General conditions affecting the health of the body should be carefully adjusted, foci of infection and sources of toxemia removed as completely as possible. Digitalis should be used to improve the myocardial tone.

7. In cases of emergency, immediate relief of pain should be obtained by nitroglycerine, or morphin with atropine..

DISCUSSION.

DR. W. M. DONALD, Detroit: I am very glad indeed to respond and am glad of the opportunity of talking on Dr. Mortensen's very excellent paper on the subject of angina pectoris.

I don't know as there is a great deal I can say on this matter. It seems to me in an academic way, Dr. Mortensen has covered the ground completely. There are a few points on which there is a slight divergence of opinion. Before going

to these, I would like to mention a point, and that is this: In all cases of sudden death, we should absolutely refuse to sign a death certificate until we know the exact cause of death and thereby would we enhance our own knowledge and the knowledge of others in the profession as to angina pectoris, one of the various causes of sudden death. In our laziness, in our effort at obtaining the good will of our pa tients, we are too lax; and, consequently, fail to add to the world's knowledge.

The information Dr. Mortensen has given us is interesting and especially valuable. Now, I must confess the thought comes to me, there may be cases of neuro-muscular diseasethere may be cases of sudden disturbance, mental disturbance of the individual. And whatever they are, I don't care; they seem to form a symptom complex. And Dr. Mortensen to the contrary notwithstanding, I feel almost, in justice to myself. like adhering to the old nomenclature. I apply the term "angina pectoris" to a certain group of cases. Where the patient is low, and there are so many factors to disturb their mental faculties. I call these pseudo-angina pectoris. We can do more good than in ordinary cases of angina pectoris.

So far as the cause of the disease is concerned, it always occurred to me as being a case of cardiac anemia. Whether that be due to stretching of the muscle fibers, due to dilatstion of the heart-I have seen any number of cases due to this particular cause or whether due to an aortic disease or whether due to a coronary disease or whether it be due to a spasm of the conaries-it could not be characterized as a disease but simply as a functional disturbance. Whether. I say. any of these factors be present or whether they all be present, the pathology of the disease is anemia of the cardiac mus culature. Because of the coronary sclerosis, of course we have a gradual increase of anemia. In cardiac spasm again we have myocardium anemia. In diseases of the aortic group. we of course again have a sclerosis of the apertures of the coronary vessels and consequently subsequent anemia of the myocardium. So that, in my judgment, the cases are all practically cases of anemia of the myocardium.

There is just one other point I want to bring up in this connection. These cases are exceedingly dubious and uncertain. Those we expect to get better, die; and those we expect to die fortunately for them and unfortunately for our reputation-get better. But the cases are undoubtedly of exceed ing doubtful prognostic individuality.

I make a practice of telling my patients frankly, lying cheerfully, that they are going to get better, and minimize as much as I dare, trying to square my statements with my own conUnfortunately science, minimizing the gravity of the disease.

for my own peace of mind, deep down in my heart I am watching the death notices in the papers to see that so-and-so died suddenly the day before, knowing the true character of the lesion and the true character of the disease. Fortunately for those cases, I rarely have an opportunity to exploit my pet scheme; and somebody else is called in to sign the death certificate and the patient hurried away without an examina. tion of the heart, which should be done in such cases.

There is one other point and that is in regard to the point about focal infections. I don't think in these cases the foei should be removed. Infected tonsils, of course, are a source of danger. This comes deep from my heart. If there ever

was anything that has been exploited to the detriment of the profession-or shall I say to the detriment of the public-so damaging (except to depart, that holocaust upon the ovary perpetrated by our profession about twenty-five years ago), it has been the useless sacrifice of teeth where a little point of infection has been found up in some root; and the physician, for lack of anything better, has had the whole orificial cavity denuded of teeth. Might as well die almost of angina pectoris, might as well die suddenly and peacefully as die by inches as so many of these people do. In such case, I have said remove a tooth or two; but for little persistent neurotic pains, little persistent myalgic pains, to simply send the patient to an X-ray man and then ruthlessly eliminate from his mouth all the teeth in order to cover his own ignorance, then I absolutely protest.

DR. E. W. HAASS, Detroit: I think that we can be quite justified in regarding angina pectoris as a symptom rather than a disease. Of course, it is so closely associated with certain factors that we may, in some cases, of course, regard a coronary sclerosis and the symptoms of angina pectoris as one and the same thing. However, I think our pain of arthritis is of an entirely different prognostic value and subjected to entirely different treatment. I don't mean to say we can't have some arthritic pain that depends upon a condition in the mouth.

Vaso motor angina pectoris. These are the ones that can be benefited by removal of focal infections. When a patient has once developed a sclerosis, it is foolish to imagine the condition can be eradicated by the removal of some focus.

Two patients I had developed, six years ago-one was a tea taster who had typical attacks of angina pectoris. The blood pressure would go up with a typical attack. The other one was an excessive tobacco chewer. Typical angina pectoris without any demonstrable at least sclerotic process. Those are very different cases. But where the blood carries some toxemia, the result possibly of tooth abscess or a tonsilar affair, those patients, of course, can be benefited by the removal of the focus; but the removal of the focus will not have any effect upon a 'well established neurotic process.

DR. H. A. FREUND, Detroit: Mr. Chairman, the paper of Dr. Mortensen brings up the time honored discussion of what angina pectoris really is. I think at the present time if we are satisfied to accept angina pectoris as a syndrome rather than as a disease, we have gone as far as we can with the subject. I am in hearty accord with what Dr. Mortensen says in regard to pseudo angina.

One point Dr. Mortensen did not mention in particular in connection with that is the fact, I think the older text books mention to a large extent, the rarity of angina pectoris in women. That is not my experience. Angina pectoris occurs in women and occurs not infrequently with just the same intense symptoms we see in men. True, that is not as common, perhaps, because of the difference in the mode of life of women. They are relatively not as prone to the strain. Syphilis and aneurism do not occur as frequently. Among them we do not see the marked symptoms of myocardial disease the way we do in the male. However, angina pectoris does occur in females, and the use of the term pseudo angina is a very dangerous one.

I think the main query on that subject will simply be a matter of prognosis. We simply convey to our own minds, we hypnotize ourselves to the belief that it is not a serious disease and we put it in the discard in the matter of being dangerous to the individual. I think we should regard all precordial pains radiating around the left arm and neck as being under a group which may be due to certain cardiac conditions.

Dr. Mortensen has summed it up in saying, due to myocardial anemia. I think rather it is ischemia, that is the failure of blood supply to some part of the myocardium.

Whether due to endarteritis, whether due to myocarditis from infection, sclerosis, really makes little difference in our conception of what the disease is doing in a patient. It is really ischemia, and whether it might exist in such a case as Dr. Haas has mentioned is also important. Still, we must not lose sight of the fact that there are many cases of generalized sclerosis in which we have angina symptoms. Where, in post mortem, the heart shows a marked thickening of the coronary vessel, such individual never possesses any of the symptoms of the real angina pectoris. That brings us to the fact there must be something else that occurs besides the sclerosis or ischemia. I think in a great many cases, the mental state plays a large part.

I think when Dr. Mortensen encourages his patients to walk, beginning slowly and increasing their walk, he does one great thing outside of exercise. He really brings to their mind the possibility that they can walk. He makes them believe that,

although suffering from a disease from which they can not walk, by carefully increasing the exercise, they will overcome the disease. The psychic factor is enormous and should be considered.

In the therapeutics of this disease, the importance lies not in the general measures, but in the elimination or rather in the estimation of what are the things that are most likely to cause angina in the individual. I think there is where the main thing lies in the treatment of our case. 1

If we must treat our case symptomatically, first of all nitroglycerine should be used. The most useful way I have ever found is taking one per cent. of spirits of glonoin and putting it on the back of the tongue. In that way, the patient gets about one-one-hundredth of a grain. The tablets are varying, whereas the fresh solution is always to be had; can be freshly made up and can be used by the patient and by the attendant of the case. If nitro-glycerine or any of the nitrite series are of no avail, I believe the patient should be allowed to use morphia. It does more to relieve these patients than any other single thing.

In myocardial disease, we frequently see signs of cardiac failure increased in the right border of the heart, slight dyspnea and some cyanosis on exertion and may be other symptoms referable to the beginning of cardiac failure. In such a case, the use of digitalis is indicated. The use of digitalis in a neurotic heart, where there is no failure in decompensation, might do harm. I have seen such patients suffer more severe attacks by the use of digitalis where there are signs of contra-indication.

I may add one thing more in the therapy of the case of angina associated with syphilitic disease, that is, in the antisyphilitic treatment. I have seen great harm and danger come from too radical and too severe treatment of cases of angina by the use of large doses Salvarsan. I know that is done at times, especially with aortic lesions. I have seen in two instances, giving large doses of Salvarsan, and in one case resulting, in twenty-four hours, in death. I believe our time honored use of mercury and iodides is the essential thing until such a time as we feel safe in giving more stringent therapy.

THE CHAIRMAN: Personally, I don't like the division into angina and pseudo-angina. I think we ought to use some specific terms. When I talk to medical students, I say, "Either they have angina or they have not." I have discarded this term of pseudo-angina.

There was not the stress laid on syphilis that is very often laid. I don't believe that every case is due to syphilis. That is a contention that some men make, and men whose opinions I value, too. I sometimes see doctors with angina pectoris, and I don't want to think that all my doctor friends that have angina pectoris have syphilis. It may be that is true. I really don't think that obtains in every case. I personally do not believe it is so.

I am glad Dr. Mortensen brought out the fact of focal infection and the possibility of other infections. It can't be simply that angina is poor nutrition of the heart muscle, because in any number of cases of heart disease of long standing, they must have had the condition, and yet don't have the angina. I have always had the idea there must be some pathological change around the root of the aorta, as well as some pain in the heart muscle itself. That is the opinion which I at the present time hold.

The main medication, it seems to me, is iodides, persisted in for long periods. Digitalis I have found useful. Of course, there are signs of decompensation. Another drug which I believe is helpful, one which I use in a great many of the cases, is theobromine and sodium salicylate. I think it is beneficial in producing a better blood supply to the heart itself. When it comes to the use of the nitrites for my use I generally use perles of amyl nitrite. I generally have the patients get a box of the perles and have them on hand. The method Dr. Freund uses is valuable, but when people have to use the nitrites over a long period of time, why, the use of the spirits is not so easy as the use of sodium nitrite. I find that I can generally control the blood pressure pretty well in these cases. I found the use of the tablets, half grain doses, four times a day, will generally give me what results I need, by means of such agents.

One drug which you should not use-and Dr. Haass has given us a clue as to why-in these cases is caffein. Any of the caffein group seem to be productive of harm in these cases, They increase the angina.

As far as local measures are concerned, I find that the use of the electric pad is about the most comforting thing. There is weight with the hot water bottle. With light things, such as an electric pad, which brings a degree of heat to the precordium, it will give great relief.

In that connection, I want to say that really the best thing for the patient is not to stay in a cold climate. I have one patient who goes to Florida. I used to get fifty or one hundred a month during the winter. He goes south and does not need a doctor down there. Once in a while, he calls in to see how his blood pressure is getting along. I know a physician who went down to Florida and now contemplates changing his place of practice to Florida, because he found he got so much relief from going there during the winter. The cold climate seems to have a bad effect on him. By getting in a warm climate, they have dilatation and lowering of the blood pressure. However that may be clinically, we do find that these patients practically all do much better in warm climates.

DR. M. A. MORTENSEN, Battle Creek: I thank the gentlemen very much for the discussion they have brought out. 't is a subject that has interested me very much for a number of years, and it is gratifying to me to know that other people who are interested in it are on the fence on some things just as I am. It is on occasions like this we some times can get help in crystallizing our ideas.

I heartily agree with what Dr. Donald said in regard to the question of autopsies. I think we, as a profession, in all classes of cases, are probably very lax in trying to get autopsies, and in that way lose a definite conclusion as to the condition or the findings in the patient that we have been treating. I think this applies very definitely to the cases such as Dr. Donald referred to, and also cases of renal diseases in connection with arterial hypertension. It is a condition that interests us very much in conjunction with cardiac pathology. There is a great deal in this subject that is still not unfolded to us. By a careful study of the autopsy findings in many of these cases, we might get more light than we have.

The question of pseudo angina is one that is troubling me. My experience has been in cases of where the question is whether that patient had pseudo angina or not-after a very careful study of the patient from all angles, I have not been able to come to a conclusion that the patient had the definite pathology that we ordinarily associate with angina and consequently I do not feel justified in diagnosing pseudo-angina.

With reference to the removal of foci of infection, I deplore very much the experience of many people of the promiscuous removal of teeth and tonsils. This, I think, is a very unfortunate thing that is practiced by some. We should not depend alone on the fact that there is a little infection, but if there is extensive infection in either teeth or tonsils and the condition of the patient will permit, then I think we should advise the removal of the foci of infection; but not necessarily promise the patient that removal of the foci of infection is going to relieve any symptom of which they specifically complain. I feel this way: in such cases where there is definite infection the patient will be better off without it than if we let them go on with it.

Dr. Haass' remarks on the vaso motor conditions is another very interesting phase of cardiac pathology from the symptomatic standpoint at least. It is here again that the foci of Infection may play a part, that the toxines from some foci may be the cause of vaso motor disturbance. We all know this, that it is not unusual to have a patient with an increased blood pressure, where you remove the foci of infection, the blood pressure will subside and various other toxines eliminated will have the same effect.

Dr. Freund's remarks with reference to angina in women are interesting. I have observed the same thing in the literature, but I find that the angina complex or syndrome occurs very frequently in women. Yesterday morning I saw a woman 54 years old with a blood pressure of something like 230 that had had, during the night, typical angina symptoms of a very severe degree. Those are not at all uncommon at present. It is likely that a change in the habits of life that occurred in the last 15 or 20 years has brought some causes to act in women that are acting in the male sex as to strenuous life.

With reference to medication and the us of nitro-glycerine: I have had some experience that Dr. Freund refers to in cases where nitro-glycerine is necessary. If it has to be taken frearently because of frequent attacks of pain, then the spirits of glonoin probably will act better than the tablets. But the tablets are more convenient. as a rule. If the patient carries them for a month, they will degenerate and they only rse those occasionally. The same thing is true, of course, of the spirits of glonoin. They must go and have it refilled or made fresh at frequent intervals.

Digitalis therapy should be used cautiously. as indicated by Dr. Freund. And we must not give a patient a large amount of digitalis and tell them to go and take it, and not expect to see that patient in the course of a few days again. When I give a patient with angina pectoris digitalis, I never pre

And then I expect

scribe more than half an ounce at a time. to see that patient every two or three days, and see what the effect of the digitalis is, and in that way little or no harm will be done; but if we are careless and forget that the patient is taking digitalis and give them-some prescribe one or two ounces of digitalis-they may keep it up until they reach the danger point. In cases where there is suspicion of syphills, the Salvarsan must be used cautiously.

I have had a similar experience this winter. A patient had a marked aortic regurgitation with history of, as well as serological evidence of, syphilis. I ordered three-tenths of a gram of Salvarsan. Unfortunately, the man I spoke to about this failed to get the patient's name, and he was given six-tenths of a gram with very unpleasant results. That is, the patient had marked signs of cardiac distress, which lasted about 24 hours, but, fortunately, nothing serious resulted. Syphilis, I think, should always be considered in these cases, as Dr. Wilson suggests, but we should not condemn a person as having syphilis because they have angina. We must have good reasons besides angina to conclude they have syphilis.

My experience with the iodides has been rather unsatisfactory, except in the cases where I found definite evidence of syphilis. A few years ago I used to give it not only to patients with angina, but also patients with arteriosclerosis, but I have fallen away from it entirely because the results did not justify the methods used.

Climate, I think, is important, especially in individuals that have the means to change their abode of living every year for the winter, because warm weather does have a beneficial effect on these cases of angina pectoris.

THE CHAIRMAN: Personally, about this Salvarsan, I believe it is all right to use in a syphilitic heart and aortic diseases. I never start in with a dose of more than 15 centigrams. Fifteen is the first dose. As I say, I have not had any unfortunate results so far. In some cases, I have found some little acceleration.

THE MODERN CLINICAL CONCEPTION OF PULMONARY TUBERCULOSIS.* HERBERT M. RICH, M.D.

DETROIT, MICH.

It is not my intention to inflict upon you a long dissertation on more or less familiar subjects or to repeat the old admonitions. These are old stories to the members of this section. On the other hand it is a pleasure to realize that progress is being made in our study of the world's most dangerous plague, and it may not be uninteresting to consider our changing attitude toward this disease.

Within the last ten years the study of early pulmonary tuberculosis as found in infancy and childhood, and the development of X-ray study of the contents of the thorax during life, have gradually changed our conception of the clinical pathology of this disease.

ROENTGENOLOGIC DIAGNOSIS.

We frequently hear the remark that the roentgenologist finds tuberculosis in nearly every chest we ask him to examine. I often hear it seriously stated as a criticism of the X-ray diagnostician. As a matter of fact the remark reveals that the real relations are not understood. It is, as a matter of fact, true that the Roentgenologist finds tuberculosis in

*Read before the Medical Section M. S. M. S., Detroit, May 22. 1919.