lesion may be temporary in its character and entirely disconnected with actual disease of the valve affected.

I shall not stop here to speak of the differentiation between murmurs of exocardiac and endocardiac origin, but only mention the great importance of making such distinction. It is well, however, in this connection to emphasize the importance of the fact that many murmurs, apparently due to incurable lesions, may depend upon those which are curable, and, therefore, that the murmurs may not only disappear, but the heart itself become perfectly rehabilitated. Failure to bear this fact in mind has led to some deplorable results. When patients are informed of the presence of a heart lesion, they connect same with sudden death, have been led to lead a life miserably unnecessary in its restrictions and results, hence the great care a physician should exercise in informing any patient as to the presence of a heart lesion, basing his diagnosis upon physical signs alone. I call to mind in this connection a case which recently came under my observation. A young man, about five or six years ago, had a loud heart murmur, and in fact was apparently the subject of an incurable lesion. Examination a few days ago revealed the fact, not only of the entire disappearance of the murmur, but of all evidence of any cardiac disease whatever.

The subjective symptoms to which I wish to direct attention on this occasion are as follows: Precordial anxiety, palpitation, irregularity and intermission, tremor cordis, tachycardia, bradycardia, delirium cordis, breathlessness, cough, hæmoptysis, pain, dropsy and symptoms of digestive disturbance, renal symptoms, menorrhagia and cerebral symptoms.

As regards precordial anxiety, we understand by this term a feeling of emptiness and uneasiness in the cardiac area, rendering the presence of a heart conscious to the individual. In normal conditions this organ works with such ease and comfort that the person hardly knows he has a heart. In the presence of precordial anxiety, however, the apex beat will be found to be weak, hardly perceptible; the heart sounds enfeebled; indications of weakness of the myocardium; the heart, being weak, is irritable and its action likely to

be excited or deranged by mental or physical exertion or causes of disturbed inervation. Accompanying precordial anxiety we are apt to have palpitation and irregular heart action in relation to its force and rhythm.

The term palpitation is applied to all forms of abnormal cardiac pulsation, which make themselves unpleasantly sensible to the sufferer, and include intermission as well as irregular action. The distinctive peculiarities of this symptom consists in the regular, rapid and violent pulsation of the heart, oftentimes shaking the entire chest and making itself disagreeably sensible to the sufferer, accompanied by throbbing in the larger arteries, but not extending to the smaller vessels. It usually comes on suddenly, and may last for a few moments to several hours; it is distressing and alarming to the sufferer, but not ordinarily a dangerous symptom; it is apparently due to reflex inhibition of the pneumogastric nerve with reflex paralysis of the inhibitory center, removing the controlling influence of the vagus and allowing the augmentor to temporarily run off with the heart. It occurs in hysterical, anæmic and dyspeptic persons, and may be entirely disconnected with any organic cardiac disease. On the contrary, it may be symptomatic of almost any form of heart disease, involving the valves or cardiac muscle itself. The determination of the diagnostic importance has to be reached by further study of this case and the presence of other symptoms or physical signs.

Intermission and irregularity are also due to reflex inhibition of the heart through the vagus, and, while they may be of little importance in youth on account of the large margin of reserve strength, become of much more serious import after middle life, because the conditions, if present, are accentuated and the tendency of persistent intermissions to induce dilatation and its consequent disturbance of the circulation. This inhibitory influence may be of almost any character and comes from divers sources; it may be of physical or emotional origin, a diseased organ, depraved nutrition, or mental shock; violent emotion, if even of a pleasant nature, may be sufficient to fatally injure the heart's action. Railroad accidents are

not infrequent causes inhibiting even a strong heart and causing it to intermit, but in persons the subject of heart disease, compensation may be ruptured by such a shock, causing the individual to become a permanent invalid, and finally causing death.

The intermission and irregularity, due to stomach irritation, arising from flatulence, undigested food or other disturbance, also those intermissions due to the abuse of alcohol, tobacco or similar poisons, fortunately may easily be removed; but to a person in advanced life. they require careful attention and recurrence prevented if possible. Another common cause of irregular and intermittent heart action is due to anæmia. Here we have the effect of the impoverished blood producing its deleterious influence by the imperfect nutrition of the cardiac muscle itself, resulting in either very rapid action, in which the heart attempts to increase its nutritive supply by this method, or resulting in some form of irregular action.

Tremor cordis is another remarkable form of irregular heart action, the very opposite of palpitation, the emotions having nothing to do with the causation; the heart, instead of throbbing, trembles like a leaf. It is a most alarming symptom, not only from its peculiar character, but on account of the sudden way in which it seizes its victims, the heart having previously been beating quietly and steadily, suddenly becomes rapid and tumultuous; life itself seems slipping away when the heart trembles. These attacks come on without warning, usually passing off shortly without any serious detriment. These cases are spoken of as "fluttering of the heart." The pulse does not die away, but suddenly drops from the ordinary full pulse to a mere tremulous thread. In these cases there are generally a series of imperfect systoles, during which time the ventricle is becoming overfilled; then an augmental wave is called into play, the ventricle forcibly expelling its centents, the heart then settling into its ordinary rhythm. These cases of tremor cordis can usually be associated with flatulence or some other stomach disturbance; emotional influences have no share in its causation.

Coming now to speak of tachycardia, or heart hurry, this is a physiological phenomenon in the new-born, where the heart beats at

the rate of about 120 per minute; in pathological tachycardia the heart rate is said to have reached a rate of 200 or 300 per minute. The peculiarity of pathological tachycardia is the little disturbance it causes to the sufferer; with a heart beating more rapidly than that of an infant the patient may go about his duties as if nothing was the matter. This is an important distinction between tachycardia and palpitation, with which it is apt to be confounded. Tachycardia is observed occasionally in women during the menstrual period or during the puerperium, and is occasionally observed in convalescence after acute diseases; the last cases are morbid in their causation and usually disappear when the cause is removed.

In regard to those cases of tachycardia where this appears to be the only detectable symptom, on careful inquiry you generally discover some previous heart strain sufficient to originate an endocarditis or myocarditis, or some co-existent chronic disease or history of some overwhelming emotion, or abuse of some kind of the cardiac organ, any one of which might be sufficient to account for this symptom.

Of all valvular lesions tachycardia appears most frequently to be connected with mitral stenosis, and in every such case evidence of this lesion should be carefully sought. On the other hand, when the heart is found to be enlarged and dilated with persistent tachycardia, suspicion should be directed to impairment of the coronary circulation or of some condition involving imperfect metabolism of the myocardium; in the latter half of life tachycardia is symptomatic of various forms of mild degeneration, and, if not at first dependent upon cardiac disease, is always associated with dilatation.

Among the poisons producing this symptom the most important is alcohol, which probably acts by producing neuritis of the vagus, ultimately inducing a fibro-fatty degeneration of the myocardium; excessive use of tea and coffee and tobacco should also be taken into consideration in the production of this symptom. In fact, there is nothing of a neurotic or organic origin which may not act as an excitant to tachycardia. All kinds of emotional and psychycal

impressions, all sorts of neuroses, hysteria, epilepsy, neurasthenia in its various forms, dyspepsia, disturbances of the liver, floating kidneys, prostatic disease, abdominal tumors, intestinal worms, various forms of neuralgia, may at all times prove exciting causes of paroxysms of accelerated heart action of shorter or longer duration. In women these attacks are most prone to occur at the menopause or disturbance of the function of menstruation; then again, as an exciting cause there is no doubt that in breaking down of the general health or any anæmia that may be present acts as a powerful predisposing cause, especially if combined with a disposition to gout and if present after middle life. In conclusion in regard to those symptoms, I should mention that tumors, often of small size, pressing upon or involving the pneumogastric nerve, are well-known causes of this symptom, which is not simply paroxysmal, but continuous, and in the end fatal.

Bradycardia and Delirium Cordis.-Bradycardia, the opposite condition from tachycardia, means an excessive slowness of the heart's action. It is important to distinguish between the true and the false bradycardia; the latter condition may be called "delirium cordis," depends upon feeble ventricular contractions, resulting in a failure of the blood wave to reach the periphery. In a certain proportion of cardiac pulsations occasionally every alternate beat is dropped and at other times two or more, thus the heart may be beating at the rate of 60 a minute, the radial pulse may only be 20 or 30. This condition can very easily be determined by a comparison of cardiac pulsations with the radial pulse; the abnormality depending in many instances upon some remote cause; has a very different prognostic signification from true bradycardia, the latter belonging to another and much more serious condition.

In determining the presence of a genuine bradycardia, it is important to remember that in some persons the normal pulse is unusually slow; occasionally it never rises above 60, and in a very few it may even be as slow as 48; consistent with perfect health. Cases reported of 20 to 30 beats a minute, in the absence of any pathological condition, should be regarded with suspicion, as most,