The Heart. 143. 



paths, utilized in the transmission of pain to the arm in 

 angina pectoris, may be : From the cardiac plexus to the 

 cervical cardiac branches of the middle and inferior cer- 

 vical ganglia of the sympathetic, then through the com- 

 municating branches from the middle ganglia to the fifth 

 and sixth cervical nerves, or through the branches from 

 the inferior ganglia to the seventh and eighth nerves, and, 

 lastly, through these trunks to the brachial plexus and 

 thus down the arm. Another path may be : Through the 

 few filaments connecting the cardiac plexus with the first 

 dorsal sympathetic ganglion, and, then, through the rami 

 communicantes which unite this first dorsal ganglion to 

 the first dorsal nerve and thus into the brachial plexus. 

 When the pain is felt in the neck, it may be due to a re- 

 flex act passing up from the cardiac plexus to the superior 

 cervical ganglion of the sympathetic, and then, by means 

 of the external branches of this ganglion, to the four up- 

 per cervical nerves, from which nerves branches are dis- 

 tributed to the superficial structures of the neck. Lastly, 

 when the face is affected, the paths are the same as in the 

 case of the neck, excepting that the branches from the 

 superior cervical ganglion communicate with the cranial 

 nerves instead of with the cervical. In neurasthenia, 

 pain and tenderness are very often present in the precor- 

 dial region, and are occasionally found in the neighbor- 

 hood of the second left costal cartilage, about one inch 

 from the sternum. One explanation of the above precor- 

 dial symptoms is, that they are due to a localized disturb- 

 ance of the cardiac plexuses, but, while this may account 

 for the pain, it would hardly explain the presence of the 

 tenderness. Tenderness must be associated with irrita- 

 tion of the intercostal nerves themselves. The possible 

 path, in this case, may be : From the cardiac plexus to the 

 inferior cervical ganglion 'of the sympathetic, thence 



