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

rule he was not conscious of the intermittency unless he took an observation on his own pulse as though he were apart from himself, but occasionally, after severe fatigue, he would be subjectively conscious of it, and was then much distressed and depressed. "I am broken-hearted," he would say, "physically broken hearted." And so he was; but the knowledge of his broken heart tempered marvellously his passion, and saved him many years of a really useful life. He died ultimately from an acute epidemic disorder.

Intermittent Pulse from Excessive combined Mental and Physical Fatigue.

After excessive mental and bodily fatigue, intermittency of the heart is a frequent symptom. Indeed, when such double fatigue is long continued, few persons escape. For this reason the symptom is exceedingly common in members of the medical profession who are exposed to night work, and who, in the presence of serious care, secure little rest. I have seen a large

number of cases of this character.

A medical man in a large general practice, who was in the habit of attending from three to three hundred and fifty cases of midwifery in the year, and who rarely had two consecutive nights of unbroken rest, was suddenly exposed to mental depression, incident upon the death of his wife. His first acute symptom was a sharp pain running down the right side and right arm, and this was soon succeeded by a sense of internal feebleness. The sense of exhaustion was referred chiefly to the lower part of the chest anteriorly, and to the region of the heart, but the sufferer himself was not subjectively conscious of intermittent cardiac action. On examination I found that the cessation of the ventricular systole occurred from six to seven times in the minute, and extended not unfrequently over a full period of two seconds. I learned also, after a short time, that the sense of

exhaustion was always co-incident with the periods of extreme intermittency. After a few nights of rest and some mental quietude, this patient made a fair recovery, and became able to carry out a considerable share of his professional work. But a little over-fatigue, a return of broken sleep, or even a slight over-taxation of the stomach, are sufficiently potent causes to reproduce the cardiac irregularity, with the sense of central exhaustion described above. Emotional excitement of any kind, if at all prolonged, is equally the exciting cause of a relapse.

This is a good typical case, selected from many of a similar class. In all I have observed the character of the work to be the same it has been work not simply muscular, not simply mental in the purest sense of the term, but work in which great prostration from broken rest has been accompanied with equally great mental anxiety respecting results. From my observations I infer, on very safe grounds, that a man or woman may undergo any possible amount of pure muscular work without showing the least sign of intermittent action of the heart. The heart may wear out under muscular fatigue, and present various forms of organic changes, but it need not necessarily intermit with or from these changes. I infer again, also on very safe grounds, that actual hard work of brain, if the work be of a kind which does not excite the worker, or call into action the emotions, or lead from rest of sleep, may be carried on, even to apparent excess, without causing intermittent action of the heart. But whenever in conjunction with broken rest there is excess of labour, irregular mode of life, and, added to both, anxiety, then the conditions are present for the development of the phenomenon of intermittent action.

Intermittent Pulse following upon Adverse Fortune.

There is no more common cause of intermittent pulse than extreme reverse of fortune. A man poor at all times, having

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never felt the pride and power of wealth, may live to the fullest length of days free from any irregularity of circulation: but a rich man, and especially a rich man who has once been a poor man, brought suddenly low by adversity, rarely escapes that physical change, the outward manifestation of which is intermittent stroke of the heart. I could fill many pages in illustration of this fact, and could account, on physical principles, for some painful catastrophes which the world at large would probably trace to moral or rather immoral or immaterial agencies. Thus the physical basis of suicide lies in such close proximity with the basis of intermittent heart-stroke, that I doubt if any man or woman having a perfectly acting heart did ever commit self-destruction. Suicide is in fact a disease pres enting certain well-defined physical symptoms, a disease admitting of diagnosis, a disease in which the act of suicide is but one part, a part holding the same relation to the disorder as the natural act of death holds to other disorders. Intermittent action of the heart as a sign of failure is therefore, when blended with other physical signs of the disease suicide,-on which I will one day try to speak at greater length,—an important sign, not of any value of itself absolutely, but of extreme value as part of a series of symptoms, which taken altogether are strictly diagnostic.

I could give the history of many cases in which reverse of fortune has led to intermittent action of the heart, but one illustration will serve.

A person, aged fifty, living in easy circumstances, and having little occasion to think of to-morrow, received news that a banking firm in which all belonging to him was embarked had suddenly collapsed. The shock at first produced faintness and coldness of the surface, followed by what was called "fever." In this stage of anxiety he was subjected also to some overexertion, and to what seemed a chill from coldness of the air. He went to bed restless, and in sleep continued to dream of his