greatest caution in handling an aneurismal tumour,* but otherwise, the effects produced by plugging of the arteries, are regulated by the amount and seat of obstruction, and not by the source whence the fibrinous plug is derived. Pathologically, it is right to recognise the possibility of its occurrence, in order that if the fibrinous plug does not appear to have been formed at the spot where it is found, nor to have been detached from coagula within the heart, a diligent search may be instituted for an aneurismal pouch, or some other source of fibrinous deposits.

CHAPTER XIV.

FUNCTIONAL DERANGEMENT OF THE HEART.

HAVING discussed the various forms of cardiac disease, it now only remains to notice those derangements of the heart and arteries which although they result from mere functional disturbance, and are unconnected with organic mischief, are yet productive of great uneasiness and distress to the patient, and are liable to be mistaken for the result of disease in the heart or great vessels.

Briefly, then, it may be stated, that there are many forms of functional disturbance of the heart which may simulate organic cardiac disease. These are characterised by palpitation or fluttering of the heart, with or without valvular murmur, and by irregularity, feebleness, or otherwise altered rhythm of the pulse. They are of common occurrence, and depend upon a variety of causes, which operate at different periods of life, but especially during adolescence and middle adult life. Intimately connected with perverted innervation, and often induced, therefore, by excessive mental exercise and sedentary occupation, great anxiety, and strong mental emotions, they are, nevertheless, very generally found associated with local or general derangements confessedly productive of nervous irritation or nervous exhaustion. Amongst these, may be specified the uterine and ovarian excitement which so generally attends the commencement and cessation of the

* In Virchow's Arch. für Path., Anat., und Phys.,' vol. xii, p. 410, 1857, quoted under the head of "Treatment of Aneurism by Manipulation," in vol. iii of Holmes' 'System of Surgery,' a case is recorded in which embolism was produced in this way.

catamenial discharge in women, and often results in spinal irritation and aggravated hysteria; excessive venery, and the vicious indulgence of masturbation by the youth of both sexes; the influence of certain poisons in the blood, such as strong green tea and tobacco, an excess of spirituous liquors, and the materies morbi of gout and rheumatism; spanæmic and anæmic conditions of the blood, and certain derangements of the stomach and liver, characterised by the existence of flatulence and acidity. In adult life, especially, the last-named cause is a fertile cause of functional palpitation. Wearied and exhausted by a long day's work and anxiety, during which, perhaps, they have taken nothing to eat, men sit down to dinner, with their minds still upon the stretch, and not only partake too heartily of the food, but swallow it quickly, without proper mastication. If their minds were at rest, and their bodies in vigorous exercise, they might possibly digest it, but leading, as they do, a sedentary life, it is impossible that the digestion should be otherwise than deranged. At first mere weakness of the stomach and slight irregularity of the bowels, are complained of; but, after a time, the most careful dieting will not suffice to rectify the chronic derangement which has taken place, and which has issued in flatulence, acidity, habitual disorder of the bowels, turbidity of the urine, palpitation, and other symptoms of general derangement.

Of all the causes of palpitation of the heart, none demand more serious attention, or call for more remark in a practical work, than the functional disturbances now under consideration. Those persons only who have suffered severely from functional palpitation, or, who have had examples of it brought before them in the course of their professional ministrations, can have an idea of the painful character of its symptoms, or of the degree to which it often simulates organic disease of the heart. The palpitation itself is often greater than that which accompanies diseases of the heart, except, perhaps, in its later stages; the cardiac action is excessive both in force and frequency, often irregular, and sometimes intermittent, and the carotids and other large arteries pulsate with a force apparently exceeding that of the heart itself. The pulse also may be unequal and irregular in the highest degree; at one moment slow, at another extremely rapid; at one moment full and forcible; at the next so weak as to be almost imperceptible; at one moment regular, at the next irregular, or even intermittent. The apex of the heart beats in its normal position; but, never

theless, the cardiac impulse can be seen and felt over an unnaturally large surface. If the heart be healthy, the impulse will be simply more forcible, and more widely felt than natural, or, possibly, will have somewhat of a knocking character. If it be hypertrophied, the impulse will be more distinctly heaving; whilst, if the heart be thin and weak, the impulse, though still felt over an extended area, will be more feeble, and of a flapping character. The area of dulness on percussion varies with the pre-existent condition of the heart, and is seldom modified to any sensible degree by an attack of functional palpitation; but, in some instance, in which the paroxysms of palpitation have been severe and prolonged, the dulness has been said to extend to the right of the sternum, in consequence of the long continued distension of the right cavities of the heart.* Theoretically, this is, perhaps, conceivable, but I have never been able to verify the observation in cases in which the heart was healthy; and knowing, as I do, the practical difficulties which beset the attempt to determine the exact limits of the heart, I cannot but feel that the possible extension of præcordial dulness in these cases is a sign which at least cannot be relied on. The sounds of the heart, unless modified by preexisting disease, are simply louder, clearer, and more abrupt, than natural; but, not unfrequently, the first sound attains a metallic quality at the apex,† and may even be reduplicated, or the second may be reduplicated at the base. Sometimes, again, systolic murmur is heard both at the base and apex of the heart, and this holds good as well when the patient is apparently healthy as when he is anæmic or spanæmic. This has been repeatedly forced upon my notice during the examination of persons about to insure their lives, in about one eighth of whom the nervous excitement produced by the ordeal through which they have to pass, and the forcible effort of blowing the spirometer, induces temporary systolic murmur at the base, and in a certain, though far smaller proportion at the left apex. In some cases the murmur is extremely loud, and a systolic thrill may be felt in the carotids and larger arteries. These instances, however, are rare.

The general symptoms are indicative of great distress. The patient complains not only of palpitation, but of a fluttering and thumping, as

* Walshe, loc. cit., p. 570.

+ This metallic ringing quality of the first sound is characteristic of excessive cardiac excitement, and is doubtless attributable to the energy of the muscular contraction, and the consequently increased tension of the auriculo-ventricular valves.

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if the "heart were about to jump into the mouth" of fulness and of deep oppression in the præcordial region, with pain, breathlessness, and tendency to faintness-the pain being usually of a dull aching character, but sometimes sharp and stabbing. Not unfrequently the pain is relieved by pressure, but the patient is unable to lie on the left side, because that position induces increase of palpitation, or aggravates the existing soreness at the heart." He suffers from frequent giddiness, with pain and heat in the head, singing in the ears, flushing of the face, and coldness of the extremities, and from time to time, when the paroxysms are severe, and faintness or actual syncope supervenes, the skin is bedewed with a clammy perspiration. Add to these symptoms dyspepsia, with excessive flatulence, acid eructations, restlessness at night, depression of spirits and pertinacious nervous solicitude as to the nature and issue of his malady, and it will be readily concluded that the sufferings induced by serious functional palpitation are scarcely exceeded by any form of cardiac disease.

The question then arises as to how these cases of functional palpitation are to be distinguished from cases in which palpitation is due to organic mischief? It may seem strange, but it is nevertheless true, that one of the evidences least likely to deceive is the constant complaint which the patient makes of palpitation, and the morbid anxiety which he manifests respecting it. The sufferer from organic disease of the heart seldom complains of his cardiac disorder, but calls attention to the shortness of breath or to some other symptom resulting from it, whereas the sufferer from functional palpitation is ready at all times with a detail of his sufferings, of which palpitation is always the most prominent. Another fact of some importance is, that functional disturbance of the heart is often relieved by active exercise, and aggravated by the patients remaining long in one posture, and as this is the reverse of what is usually observed in cases of organic disease, it is of value in a diagnostic point of view. Unfortunately, however, when the patient is either anæmic or spanæmic he is unable to take exercise, however sound his heart may be, and thus in some instances the diagnostic value of this sign is materially lessened. In short, the diagnosis of functional palpitation is by no means easy, and in difficult cases can only be determined by repeated physical examinations. The impulse of a palpitating heart may be violent, its rhythm irregular or intermittent, its systolic sounds accompanied by murmur, and nevertheless the heart may be sound, and these symptoms may all disappear as soon as the palpitation subsides.

On the other hand the temporary disappearance of the local and general symptoms of cardiac disturbance will not alone suffice to indicate with certainty the functional character of the disorder; for in many forms of organic cardiac mischief the symptoms may be temporarily subdued, and the heart may for a time regain its regularity both in force and rhythm.

The most difficult point to be determined in doubtful cases is as to whether the palpitation is due to hypertrophy of the heart, or simply to functional disorder. The question, of course, is complicated in many instances by the coexistence of hypertrophy and functional palpitation, but even in uncomplicated cases it is not always easy of solution. Indeed it is often impossible to arrive at a conclusion from the result of a single interview; and no careful practitioner would venture to express a positive opinion until he had made repeated examinations. The principal points to which we have to look for guidance in our diagnosis, are the results of percussion, the position of the apex beat, and the relative force of the heart's action, and of the radial pulse. A healthy heart under the influence of palpitation may be felt pulsating violently over an extended surface of the chest; and although in such cases the impulse is usually quicker or more abrupt than in cases of hypertrophy, yet it may be difficult, if not impossible, to distinguish its force and extent from those of an hypertrophied heart. In the one case, however, the area of percussion dulness will not be increased, or, if temporarily extended, will resume its proper limits when the palpitation has subsided; the position of the apex beat will remain unchanged, and the radial pulse will be weak in comparison with the apparent force of the cardiac action; whereas, when hypertrophy exists, the area of percussion dulness is permanently enlarged, the apex beats lower than usual, and far to the left of its normal situation, and the radial pulse is permanently full and forcible.

The treatment applicable to functional palpitation varies according to the circumstances of each case, whereas the principles on which it is founded are always the same. Our first aim must be to tranquillise the excitement of the circulation; our next to guard against the recurrence of the malady by getting rid of its exciting cause, or removing the patient from its influence, by regulating his mode of life, and giving tone to the various organs. With a view to alleviate the violence of a paroxysm and shorten its duration, a mixture of anti-spasmodics, stimulants, and sedatives is especially useful, and amongst these may be