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termittency is an almost invariable follower of failing power; in the very young, it presents itself with other indications of mental derangement or feebleness. But that which impresses me most in favour of this origin of intermittent pulse is the mode in which it appears in the prime of life. I have never met with a case in which it has not been traceable to some form of mental excitement with succeeding depression. Grief imposed by the deaths of relatives and friends, shock from failures of enterprises in business; disappointments, violent outbursts of passion, remorse, degradation, and, most fruitful cause of all in this madly striving age, over-work and worry, these are the outside influences leading to the systemic change on which the phenomenon of intermittency of the pulse depends.

In my original essay I expressed these same views, and my experience during the last three years, an experience quite exceptional, has strengthened them in every particular. In no case, except where the symptom has belonged merely to old age, have I failed to trace the disease back to what may be called mental shock, and in many instances the patients have themselves described to me the first occurrence of the symptom as derived from their own immediate knowledge. In the next chapter I have given a few illustrations of mode of origen of intermittent action.

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CHAPTER III.

ILLUSTRATIONS OF ORIGIN OF INTERMITTENT PULSE.

Intermittent Pulse Induced by Terror of Sudden Death during Shipwreck.

A gentleman of middle age was returning home from a long voyage in the most perfect health and spirits, when the vessel in which he was sailing was struck by a larger one, and, hopelessly injured, began to sink. With the sensation of the sinking of the ship and the obvious imminence of death-five minutes was the longest expected period of remaining life— this gentleman felt his heart, previously acting vehemently, stop in its beat. He remembered then a confused period of noise and cries and rush, and a return to comparative quiet, when he discovered himself being conveyed almost unconsciously out of the sinking vessel, and on to the deck of another vessel that had rendered assistance. When he had gained sufficient calmness he found that the periods of intermittent action of his heart could be counted. They occurred four or five times in the minute for several days, and interfered with his going to sleep for many nights. On landing the intermittency decreased, and when the patient soon afterwards came to me there were not more than two intermittent strokes in the minute, all the intervening strokes being entirely natural, and the action of the heart and the sounds of it being simply perfect. In this gentleman the intermittent pulse became a fixed condition, but so modified in character that it was

endurable. At his last visit to me he was not conscious of the symptom except he took it objectively from himself, by feeling his own pulse or listening to his own heart.

Intermittent Pulse from Anxiety.

One of the extremest cases of intermittency of pulse I have yet seen was in the person of a member of one of the learned professions, who, by an innocent, but in his case imprudent act, brought himself under ecclesiastical censure. The result was his removal from his position, and indeed from his profession, and during the anxiety, and as he felt unmerited disgrace which followed, the intermittent motion of his heart was developed. In this instance the mischief continued until at length it was an ever conscious fact to the sufferer, and for months prevented anything like natural sleep. He could not lie down, lest the heart should stop altogether, and though I and two medical friends did all in our power to give rest, we could never restore the balance of natural action. In this instance the persistent intermittency, and the silent but terrible and sleepless suffering it produced, caused gradual failure of power and death.

Intermittent Pulse from Grief.

Grief, especially when it is combined with exhaustion of the body, is a very common cause of intermittent pulse.

(1) A young woman, an out-patient at a public hospital to which I was formerly attached as physician, came before me with an intermittency of the heart which could be counted twenty-three times in a minute. It was in plain truth a painful duty to feel her pulse, and it was matter of wonder to me how life could be sustained with so broken a current of arterial blood pervading the system. The cause of the disorder was here manifest enough, and was clearly traceable to its

origin. The poor woman had lost, from epidemic disease, three of her children-all she had-at one stroke. In the midst. of her grief she miscarried, and suffered from severe hæmorrhage. At the time she came to me she was still suffering from menorrhagia. Under tonic treatment and good food, coupled with soothing and encouraging words and hopes, this patient recovered beyond my first expectations. At the last visit she paid to me the intermittency was reduced to a single failure in one hundred and sixty pulsations.

(2) In another case, one I have now had under observation for five years, the patient, a gentleman about sixty years of age, told me that he became first conscious of intermittency in the action of his heart upon the anxiety he felt from the loss of one of his brothers, to whom he was deeply attached, and for whose superior talents he had, as indeed many others had, a profound admiration. The attacks at first were so severe that they created in his mind some alarm, but in the course of time he became accustomed to them, and the sense of fear passed away. The intermittency in this case alternates with periods in which there is very slight interruption of natural cardiac action. During these more natural periods there is, however, an occasional absence of systolic stroke once in two or three hundred beats, but the fact is not evident to the subject himself. When the extreme attacks are present the intermittency of pulse occurs six or even seven times in the minute, and the fact, which is subjectively felt, is very painful. The stomach at the same time is uneasy, there is flatulency, and a sensation of sinking and exhaustion in the region of the stomach. In the worst attacks there is also some difficulty in respiration, and a desire for more capacity for air, but unattended by spasms or acute pain. A severe attack is induced readily by any cause of disturbance, such as broken rest or any mental excitement; on the other hand, rest and freedom from care seem definitely curative for the time.

In this case another symptom was presented for one or two years, which is somewhat novel, and exceedingly striking in a pathological point of view. The symptom was this. When the intermittent action of the heart was at its worst there came on in the fingers of one or other hand a sensation of coldness and numbness, followed instantly by quick blanching of the skin, and precisely the same appearance as is produced when the surface of the body is frozen with ether spray. The numbness and temporary death of the parts would often remain even for an hour, during which time the superficial sensibility was altogether lost. When recovery recommenced in the fingers it was very rapid, and after recovery no secondary bad effects were ever noticeable.

Intermittent Pulse from Passion.

In some cases outbursts of passion are the prime source of intermittency of the pulse. One striking example of this nature was afforded me in the case of a member of my own profession. He admitted to me that original irritability of temper was permitted, by want of due control, to pass into a disposition of almost persistent or chronic anger, so that every trifle in his way was a cause of unwarrantable irritation. Sometimes his anger was so vehement that all about him were alarmed for him even more than for themselves, and when the attack was over there were hours of sorrow and regret, in private, which were as exhausting as the previous rage. In the midst of one of these outbreaks of short madness this gentleman suddenly felt as if I use his own expression-as if his "heart were lost." He reeled under the impression, felt nauseated and faint; then recovering, put his hand to his wrist, and discovered the intermittent action of his heart as the cause of his faintness. He never recovered from that shock, and for ten years, to the day of his death, he was never free from intermittency. As a

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