Connected with the subject of intermittent action is that of palpitation of the heart. I believe that all persons who suffer from intermittent pulse have attacks of palpitation, but some persons have palpitation who are not liable to intermittent motion. The symptom of palpitation is not always well defined, nor is it at all times defined in the same terms. One calls it a fluttering of the heart; another, a fluttering within the chest ; a third, palpitation or throbbing. The symptom, moreover, is not uniform in character. At first it is noticed as if proceeding from the stomach and ascending to the throat, giving a singularly unpleasant tickling sensation in the back of the throat, with fulness. Exertion after meals is a common apparent cause of this palpitation, which, though comparatively devoid of danger, is still often a disagreeable and even alarming condition to those who have to endure it. After a time other symptoms occur, and are embarrassing. On lying down to sleep there is disturbed action or movement in the chest, with overaction of the heart, so that the action can be heard loudly through the pillow; and this is followed by frequent twitching of the muscles of the limbs, of the lower limbs especially. In most instances of this character the limbs actually move as if under the influence of a galvanic shock, and with the movement, or immediately preceding it, is a painless movement in the chest, as if from a jerking act of the heart itself. During this condition the motion of the heart may be actually intermittent, but the jerk I speak of is distinct from intermittent action. All the time through there is no pain, and I may add that all the

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time through there is no spasm. In this point of view the paroxysm of palpitation differs from a paroxysm of cardiac apnoea. Physiologically, the motor tracts only of the nervous organism are deranged. After a longer or shorter period sleep comes on, at first perhaps starting and disturbed sleep, but anon quiet; with the quiet, and with placid sleep, all the signs of irregular muscular motion disappear.

In persons strongly disposed to the form of palpitation now described, it is remarkable how small a matter will excite a paroxysm in the latter part of the day; late hours, indulgence in strong tea, indulgence in tobacco, too hearty a supper, these all tend to bring on the irregular action and the sleepless disquiet. But that which induces the nervous symptoms most readily is emotion or continued mental exertion; either of these, especially at the hour of rest, are peculiarly provocative of the mischief of which I now speak. Some amusements of the evening, even, lead to this disturbance. Chess is a game very bad for a late hour; played earnestly and intelligently, it calls special faculties into undue action at the expense of other faculties; it leaves active faculties at work; it leaves, that is to say, some of the cerebral centres still thinking, and these, like troublesome, noisy companions, are fatal to repose. In a lesser degree, and with irritable persons in as great a degree, late whist is bad. Nay, I know of nothing worse than quarrelsome whist with the stake high. A game of this kind may be ended, but hours will pass before the dissatisfied and quarrelling mental organs within the player will arrange terms and settle down. Reading late in the night and reading aloud are especially mischievous.

The worst mischief of all is the practice of carrying to bed the anxieties and annoyances of the labours of the day. I believe that more than half the cases of palpitation of the heart occur from this one mistaken and foolish practice. It is a practice from which success can never follow, for the organ

that must work must rest, and if it do not rest diurnally its proper time, it will rest annually in time to come-i.e., it will die while the rest of the organism lives, and then there will be physical anarchy, disease of the mind's kingdom, one of the great estates defunct, and the balance lost.

The condition of the heart when it palpitates is not greatly different from what occurs during intermittent action: that is to say, if the palpitating organ be submitted to auscultation there will be heard a quick repetition of second sounds with an occasional first sound. The sounds may run sharply thus:Lū dúp 0. Dip đẹp 0. Dip dip 0. Dúp Lub dip 0. Dúp 0 đúp. Lũb đúp dúp. Lūb 0 dip. Dip dip 0. Lúc đúp 0. The motion of the heart is at first extremely rapid, and the first indication of recovery from the disturbance of balance is slowing of the heart.

The influence at work in producing cardiac palpitation 'is akin to that which produces intermittent movement, but the change is functional and temporary. It consists of sudden excitement or irritation of the organic nervous ganglia which supply the heart. When the vapour of nitrite of anyl is inhaled for a few seconds it has the effect, even in strong persons, of exciting the organic ganglia; and quick, vehement, and palpitating action of the heart is the immediate result.

There is another kind of tremulous action, felt as if within the chest, which is commonly called palpitation of the heart, but which is not seated in the heart at all; some of the older writers named this epigastric palpitation, and as it deserves to be well known I refer to it specially. I had read of the symptom, but had not been forcibly impressed with the lesson, until I met with a direct observation, from nature, which made me curious to know more.

One of the most eminent of living men in physical science first pointed out to me the fact that even severe palpitation may not be cardiac, "because he knew he himself constantly ·

had palpitation when his pulse was quite steady and slow." As I doubted the correctness of his observation-for he was the subject of intermittent pulse-he one day rode up to me at my house, "Now," said he, "I have unbearable palpitation; you can see it through my clothes, and it makes me feel faint, but it is distinct from the intermittent action of my heart, and from the actions of my heart or pulse at the wrist, as you will find." His observation was accurate: his heart beat seventyfour times a minute, with intermittent action every twentysixth stroke, but the motion of the heart, nevertheless, was tranquil and entirely distinct from the rapid vehement palpitation. The palpitation was from some pulsating action immediately below the heart; it was epigastric, and had no relation to motion of the heart.

I have, since this case, very often examined the chest in other persons during palpitation, and found the same factviz., tumultuous action or fluttering felt as if within the chest, without any actual disturbance in the motion of the heart. This palpitation is usually accompanied with a sense of fulness in the throat, and is relieved by the eructation of flatus, or by the passage of gas along the small intestines into the colon. The pulsation can be felt by the observer very distinctly, and it can also be heard through the stethoscope, but not always in exactly the same place. It is usually most distinctly heard in the epigastric region, centrally, a little below the lower point of the sternum; it consists of a series of quick throbs, very full and bounding, sometimes with faint murmur. In my first communication on this symptom I thought it was due to a tremulous rapid movement in some of the fibres of the diaphragm, but further experience has proved to me that the pulsation is really vascular, and that it is due to motion in some of the large vessels which proceed from the aorta to feed the abdominal viscera, such as the coeliac axis. It is as if the nervous supply to the vessel were rendered in an irregular or dis

turbed manner, and that the vessel underwent a rapid series of contractile movements, independently of the cardiac movements. Epigastric palpitation is rarely prolonged, and, although it is painfully disagreeable, it is not alone of serious moment. It is less commonly connected with intermittent action of the heart than is the true cardiac palpitation.

The treatment of that form of palpitation in which the motion of the heart itself is involved, is the same as that which holds good for intermittent action. The palpitation which may be called epigastric, is also properly treated on similar principles; but when it is present, it is more important to attend to the digestive functions, to administer an alterative aperient, or an alkaline bitter, if there be acidity, or a mineral acidnitro-hydrochloric-if there be inactivity of hepatic function. When the symptom is connected with anæmia, with want of muscular tone, and with deficient action of the bowels from feebleness of muscular power, the Syrup of the Superphosphate of Iron, Quinine, and Strychnine, is, with an occasional alterative, the best of all medicinal aids to cure.