8 THE TONEE LECTURES. 



excursion when he was out of condition, he became extremely 

 ■ fatigued, and was ill and sleepless the following night, and 

 some days later was attacked by severe prsecordial distress, 

 with sensation of impending death, which luxrassed him for a 

 considerable time. Now, if in cases of the kind the violent 

 exertion is maintained for a longer period, we have the typical 

 irritable heart developed. 



But we may have it also coming on suddenly under circum- 

 stances of particular excitement, and then persisting. Of 

 this I encountered an instance some years since in a man who 

 had served in the armj^ to the end of the war without the least 

 evidence of cardiac distress, and joined in 18G6 the marine corps, 

 being at the time in excellent health. He was sent to Alaska, and 

 on the return voyage a heavy storm occurred that necessitated 

 his remaining on duty for forty-eight hours, all of which time he 

 was greatly excited and alarmed. Palpitation developed itself, 

 and annoyed him so much that, three weeks after the storm which 

 so upset him, he applied to a physician for relief from the 

 severe cardiac beating. I saw him in 1869, and his case was a 

 typical one of irritable heart ; the action was excessively fre- 

 quent ; the beats of the pulse not even ; the respirations were 

 only twenty-four, and he was not much troubled with difficulty 

 in breathing excepting in going up stairs. There was a soft 

 S3"stolie murmur near the apex. Rest, digitalis, and bella- 

 donna improved his condition very much, and the cardiac 

 murmur disappeared ; but though he was under treatment for 

 six months, the frequent and irregular action of the heart did 

 not entirely leave him. 



Yiolejit excitement may thus give rise to an irritable heart, 

 which may become a very obstinate condition. But such cases 

 bear no proportion to those in which the exciting cause acts 

 more gradually and over a long space of time. 



Of causes that are very commonly the starting point of irritable 

 heart, and with which I know observation has made you familiar, 



