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appetite good, his sleep sound, and his bowels regular. After taking food he has no pain, he has no flatulency, and, according to his own often repeated expression," he does not know that he has a stomach." On the other hand, we constantly see dyspepsia in all its varied and severe forms without the sign of intermittency.

In publishing for the first time on this subject I held, as above, that dyspepsia has no necessary relation to the prime cause of intermittency, and although Dr. Leared and some other learned friends, for whose opinion I have the greatest regard, have disputed the position, I am forced to re-affirm it. I admit that many persons who are dyspeptic have intermittency of the pulse, and I believe there are cases in which dyspepsia itself is due to some similar cause as that which is at work to induce intermittent action ; so that the two symptoms running together, the one, unless the analysis be searching, may seem to stand in relation either of cause or of effect to the other, whereas they are simply co-incident symptoms. Further, I am quite willing to allow that in persons who have what may be correctly called

recurring intermittency,” the recurrence may, and indeed often does, present itself with symptoms of dyspepsia. Further still, it is I think possible that in those who are disposed to intermittent pulse, an attack of dyspepsia may, by the irritation and deprivation of general power which it induces, aggravate the symptom of intermittency. But this is the position I accept, nature leading me to it,—that amongst the large number of persons who have intermittent pulse none owe it simply to dyspepsia ; that its cause lies beyond dyspepsia even in the dyspeptic, and that it may be present in its most aggravated form when dyspepsia does not exist at all.

I know of no diseased condition of the blood with which the phenomenon of intermittency is connected. Neither have I been able, after careful research, to trace it, in the light of

effect from cause, to any affection of the lung, the liver, the kidney, or other secreting or excreting organ.

Thus we are driven at last to one sole system of the body in which to seek for the origin of the phenomenon of intermittency of the heart; and that is the nervous system. Followed to this seat, all the evidence is too unequivocal to be doubted. The frequent sudden development of the phenomenon, its purely functional character, in so far as the heart is concerned, and the other symptoms by which it is attended, leave no room to question the correctness of the view that the momentary cessation of the ventricular systole occurs from deprivation of or opposition to the nervous force by which the ventricles are enabled, under the stimulus of the blood thrown into them by the auricles, to contract upon and regulate the blood currents in their

course.

All the evidences, again, point to the fact that, in every case of true intermittency, one particular point or centre of the nervous system is the primary seat of the derangement. The phenomenon is too uniform to admit of any explanation less definite; it speaks to us and says that either there is deficiency of force in the centre of the nervous system which provides for ventricular contraction, or there is some centre which balances or controls that supplying centre, and which, rendered overactive from irritation, is interfering with contraction.

The derangement might be in the ganglionic centres of the heart itself; but if it were, the nutrition of the organ would surely be more decidedly influenced, and the cardiac symptoms would not be intermittent, but persistent. The derangement might be from irritation in the periphery or in the branches of the pneumogastric ; but if it were, it would hardly be continuous for years, with no other sign of muscular disturbance. Where then is the primary mischief? I believe it to be in some mental centre of the nervous system. The clinical history of every case I have seen points to that truth. In the aged, intermittency 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.

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 lifethis 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

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