peutic action of different character than aimed at by the prescriber. It needs no argument to prove that any of these four results would, under certain conditions, be likely to be disastrous to the patient.

The pharmacist is the responsible and trusted dispenser of the physician's order, and when he acts differently than ordered by the doctor, he snips at the threads of fate, possibly without the slightest idea of what will result from the snipping. Then he is no better than a man who fires a bullet among a crowd of people. The result in either case may be manslaughter. Let us take a less extreme view of the crime from the patient's standpoint. The latter fails to get benefit from his medicine, and, as a result, loses time and money. He was cheated when he bought the preparation. Now, indirectly, he has lost the fee he paid the physician, and last, but not least, he has lost confidence in his doctor.

From the standpoint of the physician the evils of substitution have a wider range in their effect than on the individual patient. Medicine has been said to be an inexact science. The reason of this is because it is very difficult to ascribe a given effect to a certain cause. In other words, so many causes operate to produce a given effect in the human economy that it is difficult to ascertain and fix upon a definite cause. Modern therapeutics is the outcome of the physician's observations and experience of the effect of drugs upon the human system. It is a science to which every physician contributes his mite or his much, according to his ability and his opportunity.

The pharmacist who substitutes, leads physicians astray. By presenting false premises to the latter, the former causes him to make erroneous deductions. The entire medical profession may thus feel the result of a single instance of substitution, and numerous other invalids suffer on account of the errors following faulty experience in the case of the physician treating a single patient who is the victim of the fraud in question.

I have already spoken of the loss of confidence in his physician, on the part of the victimized patient. This has not only a direct effect upon the invalid, because confidence in his doctor's efforts are, to a great extent, essential to the latter's success in the treatment of the case, but it may also cause the dismissal of the physician and his

loss of what perhaps would have been a lucrative practice. In this country physicians have the reputation of being practical. They are the best practioners in the world. In other countries, medical men are deeper students and better theorists, but here, we pride ourselves on the results we obtain in curing disease. The reason for this is because we strive less for honor and glory than we do for the almighty dollar. We must give our patients the worth of their money, and we know that we will not be tolerated unless we do. Our patients are quick to discover mistakes, and they are laid at the door of the physician rather than at that of the pharmacist. If this was not the case, the subject of substitution would not be worth consideration, for it would be a rarely committed crime.

The question of injury to the manufacturer is a very important phase of the matter, for, rather singularly, the remedy for the great evil must spring mainly from this source. This is not so strange after all, when we come to think of it, for here we find the effects of the evils of substitution so direct and so distinctly felt that interest is natural. Nothing causes men more concern than pecuniary loss. Cause and effect are here so closely associated that a hue and cry at once follows. The manufacturer invests large sums in producing a reliable preparation; he spends more in bringing it before the medical profession. The latter find it worthy of use and patronize it until the weeds of substitution check its growth. The way these weeds act after what I have said is obvious. For example, some pharmacist substitutes an inferior mixture or drug in the preparation of the physician's prescription; the effect of the medicine on his patient is is nil. The disappointed doctor heralds the fact to his brethren. Such news travels faster than any favorable comments, and undoes in a short time that which the manufacturer has taken months or perhaps years to accomplish. Great injury is in consequence done to a deserving business.

Then again, the evil is a widespread one, and the same substitution in a good preparation is very large and directly affects its sale. I know of no other crime that tends so much to destroy one's faith in man's goodness as substitution. For the sake of insignificant profit the dishonest pharmacist deliberately cheats and perhaps destroys his fellow man. I can only account for the practice by assum

ing that the perpetrator in some way persuades himself that he is doing no harm, that he is selling something "just as good," that he holds the judgment and knowledge of the physician in small repute, and that he feels perfectly competent to act in the premises. It is a curious psychological fact that it is the easiest thing in the world for a man engaged in a nefarious trade to persuade himself that he is doing no harm so long as he is making money by his acts.

To correct the practice of substitution does not seem to me a difficult matter. A few years ago the adulteration of food products was a very serious fraud. Confectionery, for example, was greatly adulterated at that time. The exposure of the practice by the Health Department of New York City so injured the confectionery business that the reputable manufacturers banded together in an Anti-Adulteration League. Not only did the Health Department cause the formation of the League in the way I have described, but the unfair competition engendered by adulteration also had its effect in forcing honest manufacturers to protect themselves. This league made it its business to run down and punish all persons who adulterated their wares. The result was that in a short time adulteration ceased, and today it is impossible to find any adulterated candy offered for sale. Another instance of manufacturers banding together for mutual protection is offered by the Jewelers' Protective Association. This body pursues like an avenging Nemesis any one who robs or cheats its members. Let the manufacturers of pharmaceutical preparations who suffer from the evils of substitution form a like union and charge its agents with the duty of bringing to justice the perpetrators of the fraud of substitution. The Penal Code and the Pharmacy Act both afford excellent laws for the punishment of these criminals. The Board of Pharmacy is not sufficiently equipped to enforce the provisions of the law to this end, and the Health Department is too busily engaged in fighting disease to cope with the evil. The formation of such a union as I have indicated, however, and the punishment of a few offenders would soon stop the practice. The mere publication of a few instances of fraud, giving the names and addresses of the dishonest pharmacists, would go far towards suppressing substitution, for the public is quick to discover and shun the druggist who is considered unreliable and unscrupulous.

PALPITATION OF THE HEART.

BY JAMES T. WHITTAKER, M. D..

Professor of the Theory and Practice of Medicine and Clinical Medicine in the Medical College of Ohio, etc.

Palpitation of the heart, though considered as a separate affection, is a symptom and not a disease. It is the symptom of many diseases and conditions, and is, though very simple in its manifestations, very complex in its cause.

Mere beating of the heart does not constitute palpitation. As everybody knows, the heart never ceases to beat. Sleeping and waking the heart continues to pulsate. It takes its rest between pulsations. The first beat is long, the second short, and there is a pause between. During the pause the heart rests. Nor does violent beating of the heart constitute what is known as palpitation. The heart beats violently under effort. Sometimes the heart beats violently and the patient is unconscious of it. Palpitation is such an action of the heart as shakes the wall of the chest so that the patient feels it. That increased action, palpitation, which occurs under effort, running, climbing, etc., is physiological. Palpitation is pathological when it occurs without any effort at all.

It is impossible to understand anything about palpitation without a knowledge of the innervation of the heart. The modern anatomical idea of the nerves of the heart is this: The branches of the vagus and sympathetic, which form the heart plexus, each develop, after their entrance into the thoracic cavity, a plexus in front of and behind the ascending aorta. Both unite to form the plexus coronarii about the coronary arteries. Ganglia are found in the wall of the auricle, especially in its septum, and at the borders of the arteries. The ventricles have no ganglia at all. The motor fibres originate, according to the studies of His last year, in that part of the central nervous system which becomes later the ganglia of the anterior horns. The sensitive nerve-fibres originate from cells in the spinal cord.

The development of the sympathetic cord has been until recently in doubt. Kolliker, as long ago as 1850, showed the resemblance of the spinal and sympathetic ganglia of the communicating branches and of the posterior roots, intimating that the sympathetic ganglia

very probably originated from the spinal ganglia. But it was only recently that Onodi was able to demonstrate that the sympathetic ganglia are, in fact, offsprings of the spinal ganglia. The sympathetic ganglia belong, according to the evidence of development, to the domain of the posterior roots. All the nerve-fibres of the posterior roots, all the ganglion-cells, and all the end organs are according to general acceptance, sensitive and not motor. So that the ganglia of the sympathetic nervous system belong to the sensitive system.

This fact has an important bearing on the function of the heart ganglia. Both the vagus and the left recurrent-i. e., the spinal accessory-send, united with sympathetic fibres, branches to the heart. All heart nerves carry at the same time cerebro-spinal and sympathetic fibres, but the heart ganglia belong only to the sympathetic system. These ganglia are only in the auricles, i. e., in the receiving chambers. They feel at once the effect of poison in the blood.

Until a better explanation is found, we must believe that the motor impulse of the circulation originates in the heart muscle itself. The muscle makes rhythmical contractions without being excited by nervous elements. The heart muscle is the automatic motor of the circulation. If its power is reduced by pathological change or its capacity diminished, there occurs much more immediate damage to the circulation than from changes in the heart ganglia. Anomalies. connected with the heart itself, arising from general diseases, find explanation in accurate study of the muscles of the heart. The nervecentres do not originate the motion. The nerves merely inhibit and regulate the rhythm. Hence all the factors may be concerned in palpitation.

Gley corroborates previous investigations on the conduct of the heart under electrical irritation. It had been shown by previous studies by Ludwig, Hoffa, Kulian, and Einbrodt, that the heart under electrical irritation is put into delirium and finally stands still. The finest examples of palpitation of the heart are found in Basedow's disease. In this condition palpitation usually prefaces for months or years the exophthalmos and the goitre. There is at the same time. general tremor and neurasthenia. So that Basedow's disease is sup