_Diagnosis._--The diagnosis of angina pectoris, in those severe forms with which the popular idea of the disease is chiefly connected, can hardly be a matter of much difficulty. When we see an elderly man lying in a state of deathly collapse, which has suddenly come on, with cold sweats and nearly extinguished pulse, gasping for breath, and complaining of intolerable pain in the chest and arm, and a sense of oppression more dreadful, even, than the pain, we can hardly doubt that the case is angina in its worst form. On the other hand, when a young person, especially a young female, complains even of very severe pain in the cardiac region, together with breathlessness, especially if the heart be palpitating and the face flushed, the diagnosis, though not immediately certain, already very strongly indicates the probability that the case is not one of primary cardiac neuralgia at all. These are extreme instances, however. In more doubtful cases, the following are the principal materials for decision:
3. Nervous temperament (personal 3. Temperament either not nervous and family) without marked at all, or markedly hysterical hysteria or hypochondriasis. or hypochondriacal.
4. Existence of arterial 4. No signs of arterial degeneration. degeneration.
5. Existence of valvular disease 5. No discernible valvular of the heart. disease.
6. Extension of the pain to 6. Heart sounds clear and strong. one or both arms.
7. Vivid sense of approaching 7. Pain fixed to one spot and dissolution. increased or relieved by muscular movements of the painful parts.
8. Pain running round one side, but not extending to shoulder or arm.
It is scarcely necessary to say that no single one of the above signs is individually of positive worth for the decision, which must be made after a careful review of the comparative arguments, _pro_ and _con_. The disorders with which angina is most likely to be confused are (1) Myalgia of the intercostal or pectoral muscles; (2) intercostal neuralgia; (3) acute commencing pleurisy. Either of these may very perfectly simulate the more formidable disease, as regards the two elements of acute pain and catching of the breath; but the condition of the circulation, taken together with the consideration of the above named points, will generally decide the question. Especially important is the deep persuasion of impending dissolution, when present, as a positively affirmative symptom.