losses. At one o'clock in the morning he awoke with a sensation of being engaged in a struggle, and soon became conscious of what is called "palpitation of the heart." It was not, however, a common palpitation, for it was attended with frequent cessation of action. In a few minutes the paroxysm subsided, but from thenceforward the pulse has continued to intermit, and vehement paroxysmal seizures of severe intermittent action, extending to embarrassment of the respiration, have many times been experienced. At the last visit paid me by this patient, the anxiety on which the symptoms depended having lessened, the acute-paroxysms had passed away, and the intermittent action, which the sufferer could always detect, had become "endurable."

Intermittent Pulse preceding Acute Mania.

Cases of acute mania not uncommonly, during their preliminary stages, afford typical illustration of intermittency of pulse.

(1) I was called once by a medical friend in the country to meet him in consultation in the case of a lady who was suffering from phthisis pulmonalis. When our consultation was over he asked me if I would see a working man, a mechanic, who was suffering from some peculiar condition of depression and occasional excitability, with a singular irregularity of the circulation. I found soon before me a fine, healthy-looking man, restless and miserable, and on listening to his heart I discovered an intermittency of action occurring after every ten or twelve strokes of the heart. At this time I knew nothing accurate as to the cause of intermittency, and therefore assumed that the heart itself was the seat of the malady. With this in my mind I suggested the administration of some tonic remedy, and expected to hear of a slow recovery, never dreaming of the advent of any acute disorder. But a few days later I was re

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qeusted to visit the same patient in a public metropolitan asylum. Then I learned that a day or so after my first visit to this man he had suddenly manifested acute mania, had attempted to injure some of his friends, and had made a serious and nearly successful attack on his own life. At my second visit on this patient the maniacal attack had passed away, and the pulse was now as regular and tranquil as could be. He made ultimately a good recovery.

(2) In a second case, which was long under my care, the case of a lady who had passed the middle period of her life, and who had been under restraint for temporary insanity early in her career, intermittency of the pulse was an invariable preceding symptom of attacks of semi-acute mania. In this case the maniacal symptoms were always emotional. However severe they were, however violent they were, there was some reasoning faculty intact, which as a rule, enabled her to control herself. So certainly premonitory of an attack was the intermittent pulse in this lady, that she herself was conscious of the premonition, and often sent for me simply because she had detected in it the first sign of an outbreak. She lived on in this way many years, and died at last from simple organic failure of the alimentary organs, her intellect remaining clear nearly to the last.

Intermittent Pulse from Hereditary Predisposition.

In two cases I have been consulted by patients suffering from intermittent pulse, who assigned hereditary predisposition as the cause of the irregularity. An analysis of the evidence presented in these cases seemed to me to establish the truth of the position assumed. Both patients were young, both had been free of any great and sufficient exciting mental cause, and both stated that their parents on the male side had suffered severely from the symptom, and that they in turn considered

the symptom to have come, by descent, from their parents. It is fair, however, to notice that one of these two patients was subjected to considerable fatigue, involving disturbance of rest at the time he became aware of the intermittence, that the action of his heart was feeble, and that there was a constant sense of weariness, although his body was well formed and nourished, and his general appearance healthy. In this case

the intermittent action was sharp and abrupt, and there was no double second sound, the interruption giving rise to a modification of heart sounds like this;-from the natural Lub dúp O, to 0 dúp 0, followed by the natural Lub dúp 0. Under rest there was great improvement in both these cases, and I believe the patients are still living and pursuing their ordinary occupations, with little inconvenience; excess of exertion requires, however, to be strictly avoided by them.

Congenital Intermittent Pulse.

In one instance I noticed an intermittent pulse in an infant on the day of his birth, and it continued in him in the most marked degree for five years. It then gradually passed away. A medical friend once also brought me one of his children, a boy five years old, who had the symptom in an intense form, so that the parent was seriously alarmed; but the boy himself was quite unconscious of any suffering or ailment. In this case the symptom has disappeared, and the boy, now nearly fourteen years old, is in good health.

Intermittent Pulse from Old Age.

In old age intermittent action of the heart is exceedingly common. It is very rare indeed to find a person above seventy who does not present the symptom. At the same time it is not necessarily connected with length of days, for I once had the opportunity of examining the pulse and the heart of a

woman, in the workhouse at Birmingham, who had attained the remarkable age of one hundred and three years, and in her case the sounds of the heart were as perfect as they could be in respect both to tune and time. The action of the heart was feeble, the strokes fifty-eight in the minute, but there was perfect natural action and natural accord between the respiratory sounds and those of the heart. This woman could always eat, drink, and sleep well, and it is singular that she was a devotee to tobacco. She smoked from the time she was a young woman, and no greater punishment could be inflicted on her than the depriving her of her pipe. In the old, when intermittent action of the heart comes on, it appears only to indicate a natural failure of power, and especially of power in the digestive apparatus and the other systems of simple organic or vegetative life. When aged people thus affected are dying from prolonged senile sleep, it is often to be observed that the intermission of the action of the heart extends over periods of several seconds, so that the observer wonders how life can be sustained with such loss of motion.

General Note on cases of Intermittent Pulse.

In the illustrative cases given above I have, I think, briefly but fairly indicated the great classes of cases in which the phenomenon is developed. From what I have learned it does not occur to me that intermittent pulse is peculiar to either sex, neither does it occur to me that any period of life is exempted from it; but it must be admitted, at the same time, that the symptom is most frequently seen in persons of advanced life, and that in very aged people the absence of it is the exception rather than the rule. It is by no means unfrequent in persons of middle age, and it is as common in those who are prematurely as in those who are veritably old. It is least frequent between the ages of ten and thirty years.

Intermittent Pulse in Inferior Animals.

I noticed in my original essay on intermittent pulse that the symptom was sometimes met with in dogs. A neighbour of mine had an old Italian greyhound that presented the phenomenon in the most singularly distinct form. I also had a dog that presented the symptom; this animal was not young, but hearty, and disposed to fat and somnolency. I have since met with several cases in dogs, but not in any other animal. It would be a very interesting and at the same time useful inquiry, in comparative pathology, to determine if the symptom be present in other animals, in horses specially, and I should be obliged if any medical man or veterinary surgeon who might observe the symptom in the lower animals would either favour me with the facts for publication or publish them independ ently.