When an otherwise apparently well person begins to complain of
weariness, or perhaps drowsiness in the daytime and sleeplessness at
night, or his sleep is disturbed, or be has feelings of mental
depression, or he says that he "senses" his heart, perhaps for the
first time in his life, with or without edema of the feet and legs,
or pains referred to the heart or heart region, we should presuppose
that there is weakening of the heart muscle until, by perfect
examination, we have excluded the heart as being the cause of such
disturbance.

Although constantly repeated by all books on the heart and by many
articles on cardiac pain, it still is often forgotten that pain due
to cardiac disturbance may be referred to the shoulders, to the
upper part of the chest, to the axillae, to the arms, and even to
the wrists, to the neck, into the head, and into the upper abdomen.
It is perhaps generally auricular disturbance that causes pain to
ascend, but disturbances of the ventricles can cause pain in the
arms and in the region of the stomach. Not infrequently disturbances
of the aorta cause pain over the right side of the chest as well as
tip into the neck. Real heart pains frequently occur without any
valvular lesion, and also when necropsies have shown that there has
been no sclerosis of the coronary vessels.

While angina pectoris is a distinct, well recognized condition,
pains in the regions mentioned, especially if they occur after
exertion or after mental excitement or even after eating (provided a
real gastric excuse has been eliminated), are due to a disturbance
of the heart, generally to an overstrained heart muscle or to a
slight dilatation. Too much or too little blood in the cavity of the
heart may cause distress and pain; or an imperfect circulation