Anginal attacks before the age of 40, presumed, from a possible narrowing of the aortic valve, to be due to coronary sclerosis, are frequently due to a long previous attack of syphilis. In these cases, active treatment of the supposed cause should be inaugurated, including perhaps an injection of the arsenic specific, and certainly a course of mercury and iodid, with all the general measures for managing and treating general arteriosclerosis, as previously described. SYMPTOMS The pain of true angina pectoris generally starts in the region of the heart, radiates up around the left chest, into the shoulders, and often down the left arm. This is typical. It may not follow this course, however, but may be referred to the right chest, up into the neck, down toward the stomach, or toward the liver. The attack may be coincident with acute abdominal pain, almost simulating a gastric crisis of locomotor ataxia. There may also be coincident pains down the legs. It has been shown, as mentioned in another part of this book, that disturbances in different parts of the aorta may cause pain and the pain be referred to different regions, depending on the part affected. Instances occasionally occur in which a patient had an anginal attack, as denoted by facial anxiety, paleness, holding of the breath, and a slow, weak pulse, without real pain. This has been called angina sine dolore. The patient has an appearanece of anxious expectation, as though he feared something terrible was about to happen. The position of the patient with true angina pectoris is characteristic. He stops still wherever he is, stands perfectly erect or bends his body backward, raises his chin, supports himself with one hand, leans against anything that is near him, and places his other hand over his heart, although he exercises very little pressure with this hand. The position assumed is that which will give the left chest the greatest unhampered expansion, as though he would relieve all pressure on the heart.