ventricle near the apex. Aneurysm of the auricles or of the right ventricle is rare. The aneurysm may vary in size from that of a nut to that of the heart itself. Its sac is composed of pericardium, myocardium (the muscular fibres of which are often replaced by fibrous tissue), and endocardium. The cavity of the aneurysm is frequently occupied by laminated fibrin. Rupture of the aneurysm has occurred in but 7 out of 90 cases.

The symptoms are not distinctive, and a diagnosis is rarely made. There may be near the apex some localized bulging, which may give an expansile pulsation. If the aneurysm be large, there may be marked disproportion between its pulsation and the feeble pulsation in the peripheral arteries.

The prognosis is exceedingly grave. Death may result. from syncope or rupture, but more usually it occurs gradually from heart exhaustion due to the primary disease.

The treatment is that of fatty heart. Nothing can be done directly for the aneurysm.

RUPTURE OF THE HEART.

Etiology. A degenerated condition of the myocardium. must in all cases precede rupture of the heart. Fatty degeneration, especially of localized areas, is the most frequent cause, occurring in 77 per cent. of all cases, but anæmic necrosis following thrombosis of the coronary arteries, fatty infiltration, circumscribed myocarditis, broken-down tumors and gummata, and deep endocardial ulcerations and cardiac aneurysms may also lead to rupture. Two-thirds of all subjects of rupture of the heart are over sixty years of age. The rupture usually occurs after exertion, but it may occur while the patient is at rest.

Pathology. The usual situation of the rupture is in the anterior wall of the left ventricle, near the apex; more rarely

the rupture may be situated in the posterior wall of the left ventricle, in the septum, or in the wall of the right ventricle. The rupture is usually small, and it may be either direct or indirect.

Symptoms. If the rupture be direct, the patient experiences agonizing cardiac pain, suffocation, and great apprehension. The pulse becomes rapid and feeble; the skin is cold and clammy. Death may occur in syncope in a few minutes (in 71 per cent. of cases), or it may be deferred for several hours. In the more protracted cases vomiting and purging may be noticed.

The prognosis is always fatal.

The treatment is entirely prophylactic. Persons known to have degeneration of the myocardium should lead tranquil lives free from every mental or bodily strain.

4. NEUROSES OF THE HEART.

PALPITATION.

The term "palpitation" is applied to all forms of abnormal cardiac sensations which are unpleasantly sensible to the patient. The destructive features are violent pulsations of an unpleasant nature, usually with throbbing of the larger arteries. The pulse may be rapid and over-forcible, but it may be normal or even weak. The attack appears suddenly, lasts a few minutes or hours, and, while not serious, occasions considerable alarm. Various neurotic symptomsflushing of the face, sweating, eructation of gas, and the abundant passage of limpid urine-often accompany or follow the attack.

Palpitation is a pure neurosis, which may, of course, occur in a healthy or a diseased heart. It is to be distin

guished from the over-action of organic disease in that it is not produced by exertion-in fact, is often dispelled by exercise-appears often at night while at rest, and is not accompanied by dyspnoea or other symptoms of cardiac distress.

Pathology. There is no lesion, but in long-continued cases hypertrophy or dilatation may result.

Etiology. The cause of palpitation of the heart is a reflex inhibition of the vagus action that enables the accelerators to run away with the heart. The affection is common in women and in young adults, and is rarer in advanced age. It occurs in weak and nervous conditions, after sickness, in hysteria and neurasthenia, in excitable subjects, and at the climacteric. It is produced by unhealthy occupations and by vicious modes of life. It is common with over-use of tea, tobacco, or coffee. Flatulent dyspepsia is a prolific cause of palpitation, and it may occur as a reflex phenomenon from gastric, intestinal, or ovarian irritation. The effect of emotions is well known. Palpitation of the heart is a symptom of exophthalmic goitre.

The "irritable heart of soldiers" (DaCosta) is a form of palpitation caused by excitement and over-exertion, especially if the thorax be compressed with shoulder-straps; this condition is accompanied with some dyspnoea on exertion.

TREMOR CORDIS.

This condition, which is the opposite of palpitation, occurs occasionally in youth and more commonly in advanced life. It may occur in healthy hearts or in those enfeebled by myocardial degeneration. The attack comes without warning; the heart “trembles" or "flutters," while the pulse sinks to a tremulous thread. The attack lasts for a few seconds and terminates by a forcible cardiac beat.

Tremor cordis is almost always due to flatulence or car

diac distress, and is not produced by emotions. There is no accompanying faintness, although the attack occasions serious alarm.

The prognosis is perfectly good.

INTERMITTENT ACTION.

Intermittent action occurs whenever the heart misses a beat from time to time. Intermittency may be regular or irregular, habitual and constant or only occasional. It usually occurs after meals, as an evidence of flatulent dyspepsia; it occurs after over-use of tea, coffee, or tobacco; it is common in gout, in uric-acid diathesis, in nervous and hypochondriacal conditions, and after bodily and mental shocks. A constantly intermittent action of the heart is common to many old people, and is of no serious sig nificance.

Intermittency often occurs with fatty degeneration of the heart, and is to be distinguished from reflex intermittency by getting the patient to exercise briskly. By such exercise the really weak heart goes to pieces, while the healthy but neurotic heart clears up.

Intermittency associated with organic disease of the heart is often of serious omen, indicating that the contraction of the auricles is not sufficient to fill the ventricles, hence the ventricles wait until they are properly filled.

TACHYCARDIA.

A rapid pulse accompanies many morbid conditions, such as fevers, exhaustion, collapse, emotional conditions producing palpitation, pain, maniacal conditions, and the ingestion of certain poisons, as alcohol, atropine, nitroglycerin, and over-doses of digitalis. A rapid pulse is physiological after exertion and in the newly-born, whose normal pulse ranges between 120 and 135.

The term "tachycardia," or "heart-hurry," is more properly applied to a rapid heart-action, often reaching 200 or more in the minute, the action being, moreover, usually feeble. Its distinguishing feature is the very little disturbance it gives, in contradistinction to the rapid pulse of exoph

thalmic goitre, of palpitation, of exertion, and of cardiac failure. Tachycardia may be due to tumors pressing on the vagus trunk or to mitral stenosis. In later life it is an important sign of senile degeneration, and is an added source of danger, as the attack may terminate in syncope or in asystole.

Reflex tachycardia, a pure neurosis, may occur from any source of irritation, especially from gastric distress, and in reflex tachycardia the pulse may be fairly forcible.

Intermittent tachycardia is a rare disorder in which hearthurry comes in attacks at varying intervals, each attack lasting a few hours. The pulse is rapid and weak, frequently over 200 to the minute, but usually the distress to the patient is but slight. The cause for such attacks is not definitely known. A permanent cure is rare, and the disease may terminate fatally at any time.

BRACHYCARDIA; BRADYCARDIA.

Two forms of slow heart are recognized-the false and the true.

False brachycardia, in which the pulse is slow but the