the intermittency itself became intensified, despite all our efforts, until death came to bring the only possible relief.

A case such as is here related is, truly, extreme and rare, and I do not adduce it as suggesting undue alarm respecting intermittent action. I would give to the symptom its just Whenever it is persistently present in

value, and no more. any person, the actual value of life as compared, cæterus paribus, with the life of another person who has no such symptom is reduced; the power for work is less, the power to meet extremes of heat and cold is less, and the power to meet the anxieties and calamities of life is unquestionably much less. The man or woman with a hesitating heart is thereby unfitted for sudden tasks, demands, resolves, which, when the heart is firm, are considered as of comparatively little moment; for when the heart hesitates, the brain, which reposes for its power on the blood the heart supplies to it, falters with the heart, just as the gas flickers when the steady pressure is taken off the main. From these circumstances some persons who once were known as resolute and determined, lose those qualities when they are subjected to intermittent action of the heart, becoming, as their friends say, uncertain and doubtful in character, becoming, as they themselves feel and know, less the masters of themselves, and less secure in their own work, and skill, and power.

Another point is worthy of note. Persons in whom there is permanent intermittent action of the heart pass through all acute diseases with less chance of recovery than others of similar age and like constitution who have no cardiac failure. They sink more readily from surgical operations, from falls and injuries, from influenza, from acute congestion of the lungs, from inflammatory attacks, and peculiarly from typhus and typhoid fever. I would look upon a man's chance of recovery from typhoid if he were fifty years of age, and had a steady heart, as preferable to that of another man at forty, in whom

F 2

intermittent action of the heart was developed before the occurrence of the disease, or in whom the symptom came on, as it sometimes does come on, in the course of the disease.

Such are the principal facts conveyed to the mind when the phenomenon of intermittency of the pulse is before the practitioner. The phenomenon is truly to be reckoned only as one symptom, and I would in no sense exaggerate its importance. At the same time, in severe justice, it is correct to say of it that the person who presents it, though he may live long, is of infirm body, that his cardiac mechanism is out of tune, that if ever his heart should be called upon for a great effort, it will not be prepared for the effort; and that if ever, from mental strain or pressure, his heart is weakened, it will succumb more easily than it ought naturally to succumb to the resistance put upon it.

Thus the phenomenon, symptom though it be, is of moment; it is of such moment that if two men, of equal age, build, education, and power, were put into any contest, mental or physical, and the one had, and the other had not, intermittent pulse, the chance of success would be altogether in favour of the man whose heart was not intermittent. In like manner, if two men of equal apparent build had to contend with a surgical operation, a disease, or a given equal amount of anxiety, the values of resistance are beyond measure in favour of the man whose heart was not intermittent.

The phenomenon has therefore its general meaning, both for the physician and the surgeon. It has also its particular meaning, since it may be raised into fatal consequence by disorders which need not, in its absence, prove fatal.

The Persistency of the Symptom.

In children the symptom of intermittency of the pulse may pass away with growth and increase of strength: in adults,

when the symptom is once established, it never, I believe, goes away entirely. It may be absent for long periods when the general health is good, but it returns on every occasion of depression of power, and is very easily induced by agencies which act deleteriously on the nervous system. Excessive venereal gratification, excessive smoking, deficiency of sleep, and dissipation, act powerfully in increasing the evil. In persons at or past middle age, the symptom, if it once be fully developed, continues persistently, and often to extreme old age. One of my patients, who died at eighty-six years of age, told me he had been discovered to have an intermittent pulse when he was forty-two, and that he had never failed to exhibit the phenomenon since that time.

CHAPTER VI.

TREATMENT-POINTS OF PRACTICE.

There is no known specific treatment for intermittent heart, but, whenever the symptom of intermittency is present, there are certain general lines of treatment which should always be enforced by the physician.

(1) In the case of young children, when the intermittency is clear, however infrequent it may be, the utmost care should be taken to avoid every source of mental emotional excitement. A ⚫child having intermittent pulse should not, under any pretence, be oppressed with study. He should not be subjected to any amusements which powerfully excite the mind; he should not at any time be exhausted by physical fatigue; he should be well fed, warmly clothed from head to foot, and, above all things, should be allowed to have abundant sleep. Ten to twelve hours' sleep is not a moment too much. Moreover, such a child should never be put to sleep with stories which excite dreams or cause alarm.

(2) In adults equal care should be taken, and, above all things, attempts should be made to remove impressions derived from any untoward event. Change of scene should be recommended, while a carefully regulated diet, abstinence from exhausting pleasures and abstinence from exhausting labour, especially mental labour of any one particular kind, should be encouraged. Good sleep is here again the most valuable of remedies. Eight hours of sleep out of the twenty-four are essential, nine hours are still better. Two other special points

of advice are of moment. It not unfrequently happens that, by accident or by direct information, patients learn the fact that their pulse intermits. Then they begin to feel their own pulse, and become charged with dread of sudden death. As the disorder is of itself mental, this watchfulness and fear will increase the frequency of the intermittency. With these patients, a word from the physician timely and firmly spoken is often the best prescription. He assures them on the results of experience that their malady is not of necessity fatal; he commends them not to enquire after the symptom, and if he can succeed in persuading them to his views, which he may honestly try to do with all his influence, he will effect the most marked improvement in their condition. Again, it sometimes happens that patients conscious of the failure of the heart resort to alcoholic stimulants as a means of relief. For a moment, by its exalting the activity of the heart, alcohol affords relief, but the depression that follows calls the more rapidly for a return to the supposed remedy, and a fictitious benefit leads to a habit which excites structural changes and hastens death.

(3) In cases of sudden intermittency, with symptoms of cerebral congestion, depletive measures are sound. A purgative is essential, and blistering at the back of the neck is always useful. I have seen also great advantage in these cases from abstraction of a moderate quantity of blood by the cupping glasses.

(4) In chronic extreme forms of cardiac intermittency, while all the general rules laid down in Nos. 1 and 2 hold good, it becomes often imperatively necessary to subdue nervous excitement, and to induce rest. For this latter purpose, opium is the sheet anchor. It must be given freely when it is given, and not too frequently. Small and repeated doses of opium excite, depress, and give no rest. A full dose, equivalent to a grain or even two grains, produces, on the contrary, no excitement, but gives sound sleep and that quietude of circulation