mentioned the ammoniated tincture of valerian, the fœtid spirits of ammonia, sal volatile, camphor, chloroform, æther, brandy, opium, belladonna, and henbane. Administered in full doses and at bricf intervals, these remedies will usually cut short a paroxysm which without them might have lasted for many hours, or might even have been protracted, with occasional intermissions for several days; and as, when judiciously administered they are not productive of general disturbance, but rather obviate the mischief which often results from long continued and violent palpitation, there cannot be a doubt as to the propriety of employing them. But it should be clearly understood that diffusible stimulants and anti-spasmodics will not always suffice to get rid of the palpitation. In some instances-especially in gouty persons, and in those who are suffering severely from dyspepsia-the tongue is furred, and the breath offensive, and there are acid eructations, and other evidences of stomach derangement. In such patients the remedies already alluded to will be of little avail until the stomach is emptied, and the disordered secretions corrected or got rid of: the first step to be taken under these circumstances is to evacuate the contents of the stomach by an emetic-nothing answers better than sulphate of zinc or mustard and water-and then to administer a calomel purge, followed by rhubarb and magnesia, and subsequently by bismuth, soda, colchicum, hydrocyanic acid, cajeput oil, or whatever may seem most likely to counteract the acidity of the stomach, allay its irritability, and disperse the flatulence. The first action of an emetic, or the first full bilious evacuation of the bowels will often afford very great relief, and this may then be sustained by the action of the very stimulants and antispasmodics which previously had proved inoperative.

But something more is needed than to mitigate or subdue an existing paroxysm of palpitation. Though the first violence of the attack may be overcome, the patient will still experience the pain, the fluttering, or the discomfort from which he has long suffered, and will be as anxious as ever respecting the sensations over which he has long brooded and despaired. The first step, therefore, which the physician should take when the paroxysm has subsided, is to examine the heart carefully, and then to assure the patient that however great his sufferings, the attack was purely functional and unconnected with organic disease. He should point out how common such attacks are found to be in persons pursuing sedentary occupations or otherwise placed under circumstances unfavourable to their general health, how inevitably they arise in certain states of the blood, and in certain disordered

conditions of the secretions, and how essential it is that the patient should have repose of mind, and lead a life in which cheerful society, change of air, careful dieting, moderate yet sufficient bodily exercise, and due regulation of the secretions will one and all contribute their quota towards the maintenance of the general health. The patient should be made to understand that no medicine can avail, so long as over-fatigue and anxiety of mind, or excessive indulgence of the sexual desires are permitted to exert their baneful influence, and that even under the most favourable circumstances time will be an essential element in his cure. If the stomach is the principal organ at fault, the mineral acids, taraxacum, and the vegetable bitters, or the alkalies in combination with hydrocyanic acid, small doses of colchicum, and warm carminatives will often prove serviceable, and these may be administered either with or without valerian, camphor, chloric æther, and the other anti-spasmodic and stimulating remedies of which mention has been already made. In most instances of functional palpitation, iron proves a remedy of great value, and so does the daily use of the shower bath; and there are few cases in which a belladonna plaster will not be found useful in tranquillising the action of the heart. When the patient passes restless nights, and is irritable and nervous during the day, opium, henbane, or hop, are remedies which cannot be safely neglected. Venereal indulgence, and the use of tobacco, strong tea, and other substances which are apt to induce or aggravate palpitation, must of course be abandoned.

The prognosis in these cases must be regulated by the circumstances under which the patient is placed. In young persons it is almost invariably favourable, but in persons advanced in years the heart itself is often texturally diseased, the excretory organs are sluggish in their action, and the patient, therefore, is in a condition unfavourable to recovery, and although, if he will consent to follow the plan of treatment best calculated to improve his general health, he may shake off the nervous irritability on which the functional palpitation depends, it is scarcely probable that he will be enabled to do so, if his circumstances compel him to keep up the strain on his mind and body which have contributed so largely to the production of his disorder. Hence it often happens that persons advanced in years, who begin to suffer from functional palpitation, are led to regard their malady as hopeless, and, brooding over the pain and discomfort they experience, too frequently become confirmed hypochondriacs.

A few remarks should, perhaps, be added respecting the alterations

in the rhythm of the heart, which are often referred to functional causes. There cannot be a doubt that many perversions of the cardiac rhythm are observed in persons in whom the stethoscope fails to reveal any evidence of disease, beyond that furnished by the altered rhythm itself; nay, more, experience has shown that every variety of perverted rhythm may long exist in persons whose heart's action is tranquil, who are not conscious of cardiac disturbance, and who, moreover, go through life and attain to mature age, without the occurrence of any disagreeable symptoms referable to the condition of the heart. Irregularity and intermission of the heart's action is the most common of these varieties of perverted rhythm, extreme feebleness of action is another, and extreme infrequency of action is, perhaps, the least common variety. The first variety is seldom productive of much inconvenience; but the last two are often accompanied by fits of giddiness, faintness, or actual syncope, which are always alarming, and, if unattended to, may even prove fatal. My own experience does not enable me to state positively that these different varieties of altered cardiac rhythm do not result from mere functional disturbance; but I confess to feeling extremely sceptical as to their being really attributable to the cause assigned. I do not wish to imply that the rhythm of the heart may not be temporarily affected by stomach derangement, nervous excitement, and other functional causes; but without microscopic investigation of the structure of the heart in each particular instance, I should rather be inclined to regard these perversions of rhythm, unless of temporary duration, as resulting from organic or textural cardiac mischief; for they are one and all met with in cases in which the heart is structurally diseased, and are never observed in children in whom the heart is presumably sound. Further, in every instance of so-called functionally altered rhythm in which I have had the opportunity of examining the heart after death, traces of textural disease have been discovered by the microscope; and it seems inconsistent with the history attaching to many cases in point, that there should exist any permanent functional derangement. True that irregularity and intermission of the pulse, which have been noticed for months, or possibly for years, may gradually subside as the patient's health and strength improve; but this surely affords no proof of mere functional disorder, but is equally, if not more intelligible on the supposition that the blood has become healthier and more stimulating in character, and the heart more vigorous and more susceptible of stimulation. And knowing as we do how long persons whose

hearts are structurally diseased may go on in the apparent enjoyment of health, how readily disease of the heart's texture is overlooked if the aid of the microscope is not resorted to, and how seldom, until of late years, the microscope has been employed to ascertain the existence of cardiac disease, presumption, I think, is in favour of the belief that in those cases which have been recorded of persistently perverted cardiac action unconnected with structural disease of the heart, the non-discovery of organic disease has been attributable to the imperfection of the means employed to verify the fact, and not to the non-existence of disease. Practically, however, it must be borne in mind that every form of altered cardiac rhythm may exist in cases in which our present means of diagnosis fail during life to afford any proof of organic disease, and in which, even after death, the aid of the microscope must be invoked, if structural disease is to be discovered.

CHAPTER XV.

DISEASES OF THE AORTA.

Aortitis.

INFLAMMATION of the aorta is a singularly rare disease, so rare, indeed, as to possess little practical interest. I have never met with an instance of it myself, and can find records of only a very few cases; and from the anatomical description given of some of these, there seems reason to doubt whether the disease was indeed what it is represented to be. Its origin is involved in much obscurity. Strange as it may appear, the few cases on record prove that it is seldom associated with endocarditis, and point rather to some peculiar alteration in the condition of the blood, as the starting point of the arterial mischief. Stranger still is the inference deducible from the particulars of certain cases which have been placed on record, that in some instance at least no obvious effect is produced by aortitis, except irritability, restlessness, and general uneasiness!

Thus, then, as there are no reliable physical signs of aortitis, as its general symptoms are so variable and uncertain that it is impossible to diagnose its existence during life, and as its anatomical characters, also,

are so obscure, even after death, that it is difficult in all cases to determine its existence, it is obviously useless to attempt a description of the disease, or to lay down rules for its treatment. Its history has yet to be written, its symptoms and physical signs investigated and described, and the best method of treating it ascertained.

Dilatation of the Aorta.

The aorta is subject to changes of structure analogous to those already described as affecting the valves of the heart-changes which, whether induced by inflammation or resulting from slow degeneration of the tissues, impair its natural elasticity and contractility, destroy the smoothness of its internal surface, and render its coats brittle. Pathological research has shown that these changes are connected with the deposit of various abnormal matters in the coats of the artery, more especially in its inner coat. It is probable, however, that all these deposits originate in an exudation of an albuminoid character, which subsequently undergoes fatty, atheromatous, cartilaginous, or calcareous degeneration, and thus assumes the variety of forms which are met with on dissection after death. Sometimes the deposits are seen as small, isolated, opaque, yellowish specks, slightly elevated above the inner coat of the artery; sometimes several of these isolated specks coalesce, and present themselves as hard, opaque masses projecting considerably above the surface of the inner coat of the artery; and sometimes, again, the aggregation of these morbid deposits is such as to destroy the inner coat of the vessel, so that its surface is rendered rough or even ragged.

The seat and extent of these deposits vary greatly. They usually exist in largest quantity, and, in some instances, are almost wholly confined to the ascending and transverse portions of the arch of the aorta, but it is not uncommon to find them to a greater or less degree throughout the whole arterial system. In some instances they are only dotted here and there over the surface of the vessel; in others they are thickly spread over a large area, and greatly thicken the coats of the vessel, and occasionally they are set so closely, and are of such a calcareous nature that they render the coats of the vessel hard, inelastic, and brittle.

These changes are of very frequent occurrence in advanced life, and this has led some pathologists to regard them as essentially connected with