tolic 130; diastolic, 80; pulse pressure, 50. Since September 8, 1923, the patient has taken 16 grains of thyroxin including what he will take up to March 8. On March 9 he is to take 10 gr. Thyroxin t. d.

April 10, 1924. The patient is better. He is thinking of returning to work on the 14th. Weight 231 pounds. Heart rate 80; Pulse 76: regular; full strong; arteries not palpable. Dulness third interspace; sixth rib; 2 cm. right; 13.5 cm. left. Oblique diameter of cardiac dulness 20 cm. No murmurs. P2 equals A2. Muscular quality of the systolic sound fair. P.M.I. not obtainable. Blood pressure: recumbent. (Riva Rocci) systolic, 122: diastolic, 70; pulse pressure, 52. Pulse recumbent, 60.

Dréyer's Method: Sitting height, 36 inches; normal weight, 149 pounds, 8 ounces. Cir

cumference of chest, 42 inches; weight 256 pounds 7 ounces. Normal weight, 202 pounds 15 ounces. Overweight 14.35 per

cent.

May 19, 1924. Feels pretty well; has lost 8 pounds since last note. Weight 2231 pounds. Overweight (Dreyer and Hanson) 8.87 per cent. Went to work on April 14 and has worked ever since. Has some soreness in the feet. Chest measures 102 cm. in expiration; 109.5 cm. in inspiration; mean chest 106 cm. Transverse diameter 30 cm. anteroposterior diameter 24.5 cm. Heart rate 76; pulse rate 76. Blood pressure: Recumbent (Riva Rocci) systolic, 126; diastolic, 75; pulse pressure, 51.

Urine examinations throughout were negative.

T

HOSE of us who live in a large center of population have to do with all types of people and in New York there are many different

races.

In dealing with heart disease it is fair to generalize and say that those races that are of a buoyant nature are much more resistant to cardiac disease than those whose temperament is different. In particular it may be said that any individual person with heart disease who has a definitely developed anxiety neurosis or who has a tendency in that direction is much harder to help than he whose disease is not complicated in this way.

It is particularly hard to deal with cardiac disease in the face of a depression of spirits that leads to fear of the outcome. And here we come to an interesting point in differential diagnosis. When we meet a person with an anxiety neurosis he is apt to project his psychical depression into some bodily complaint. As everyone knows who has had a large experience with this type of mental disease it is very common for this projected pain to be located in the front and upper part of the chest.

The heart has always been the accepted seat of the emotions and it is almost natural to speak of a sinking of the heart as an expression of fear or despair. So it comes about that

an elderly patient suffering from an anxiety neurosis and whose age and condition correspond to those usually found in angina pectoris and who suffers from pain described as oppression in the front of the chest sometimes presents a difficult diagnostic problem. The pain may be of cardiac origin and the outward expression of cardiac disease in a person suffering from anxiety neurosis, or the pain and oppressions may come from the neurosis itself. The electrocardiogram may show coronary disease, or a study of the relation of the pain to physical exertion may give us the key, or the response to nitroglycerine, relieving for the moment the intracardiac pressure, may show that the pain does come from the heart.

I recently had a very curious experience: An old gentleman suffered from the intractable type of angina pectoris which was relieved only by the continuous use of large quantities of nitroglycerine. He did fairly well in general, being of a cheerful disposition. His younger brother, possibly on account of business reverses, developed an anxiety neurosis and at the same time complained of terrific pains across the chest which came in frequent attacks. The technical examination of the heart was negative. The attacks were accompanied by tremor and began in the hands and

spread to the chest. A diagnosis of an anxiety neurosis with pseudoanginal attacks was made, which were possibly traceable to suggestion from seeing the brother's condition. This diagnosis was concurred in by an eminent neurologist who reviewed the case. Electrocardiograms of the men are given (figs. 1 and 2).

This question of the proper appraisal of anterior chest pain has long been divided between the cardiologist and the gastro-enterologist.

Duodenal ulcer and many other conditions may have a pain referred to the chest and conversely, myocardial disease may produce pain below the diaphragm.

Soul pain, as my great teacher, the late Prof. E. C. Seguin, used to call the melancholia of his time (the anxiety neurosis of the present day) is often described as severe pain in the front

of the chest so we must admit the neurologist as a third party in the interpretation of pain in the front of the chest.

Anxiety neurosis in a mild or severe form is a constant companion of many sick people and every true physician gives it its appropriate place in every medical problem.

The test of a physician's real ability is the fineness with which he differentiates the psychical element and physical element in disease. But if modern medicine has taught any one thing it is that we must first survey all the physical manifestations of disease discovered by ourselves and by the laboratory before we attempt an appraisal of the psychical element. In this way we will escape the blunder of calling coronary disease psychical pain or a diseased gall bladder angina pectoris.

IT

BY J. L. ABRAMSON,

T MAY perhaps be best at the very outset to give definitely the conception and the criteria to be used in this paper for those free thrombi of the heart which will be considered as "ball thrombi." This becomes a matter of necessity, if one is to avoid confusion and useless discussion as to the actual number of cases of true ball-thrombi reported, especially as collected and compiled by Hewitt (14), whose admirable paper will undoubtedly be the foundation-stone for all future writers upon this subject.

In general, one divides cardiac coagula into two classes-antemortem and postmortem clots. Of these, the latter have no clinical significance, only, as Smithies (33) so aptly puts it, "many of the observations on the socalled heart thrombi are really records of postmortem clots entangled in, but not organically attached to, the muscle columns and trabeculae." We agree with him that the term "cardiac thrombus" must be reserved for a solid or partly solid structure, primarily formed from blood elements, which develops in one or more chambers of the heart during life. When cardiac thrombi are measured by this standard they are relatively uncommon postmortem findings. Of the free cardiac

From the Pathological Laboratory of the University of Michigan, Ann Arbor, Michigan..

Ann Arbor, Michigan

thrombi Hewitt declares that "it has heretofore been the custom of authors to consider these loose thrombi found in the heart in a general way, and to class them all under the heading of "ball-thrombi." A careful consideration of the original report of many, in fact, the majority of these cases, shows that, as far as could be made out from the description and the accompanying illustrations, the thrombi were not 'balls,' but more or less irregular antemortem blood clots. Accordingly, this second class of loose bodies in the heart may be considered under two subheadings: (a) those loose thrombi of irregular shape, size, and situation, associated with a constant pathological change in the heart, or in other words, free thrombi, and (b) ball-thrombi."

For the purpose of the final compilation it is obviously important to differentiate between these subclasses. Yet, while it will often be a matter of hair-splitting to decide whether a given free cardiac thrombus is to be considered a true ball thrombus, this will in no way alter the presentation of both classes of cases, since this paper has for its particular aim the correla tion of those facts in the history, the physical examination, and the autopsy findings, in an attempt to formulate, if possible, a syndrome, or to enumerate those features which have occurred more constantly than others.

ANNALS OF CLINICAL MEDICINE, VOL. III, NO. 4