participate, undergo convulsive movements, and spasmodically contract into inaction.

En résumé, the predisposing cause of cardiac apnoea consists always in gradual failure of the mechanical force of the circulation: the exciting cause is anything that shall drive that failure on to suspension of the circulation, and deprive the muscles of blood. Cardiac apnoea is virtually, therefore, asphyxia commencing in the circulation.

TREATMENT OF CARDIAC APNEA.

When once cardiac apnoea has proclaimed itself in a definite paroxysm, but little, I fear, can be done to avert a fatal termination during one or other attack. In cases where the paroxysms are slight, or where the warnings only are given, such as have been depicted in the section on "absolute diagnosis," we may, nevertheless, if we are convinced that the change which is progressing consists of degenerative tendency in the structure of the heart, advise the patient very greatly to his advantage, and materially reduce the predisposition. Thus, if he be given to habits of intemperance, by far the most fertile source of cardiac muscular atrophy, we may advise him to reformation, may replace his port wine or brandy by a light Burgundy, and entice him to free himself from that external recklessness, irregularity, and exposure, which, not less than the alcohol itself, lay the foundation of disease. I do not, however, for my own part, in these examples, advise sudden and

complete removal of alcoholics. I believe that to the habitually intemperate alcohol becomes a form of food; and I know that as a food it cannot be instantly replaced by anything else in the way of sustenance, however wisely the new bill of fare may be selected. For this reason, if ever we do attempt rashly to deprive an alcoholic patient of all alcohol, he immediately begins to lose power; his sinking sensations, which no simple food can replace, drive him instinctively from our directions to his old resource; he finds relief in that, and, looking on his Mentor as an impracticable man, returns to alcohol as food, with a more lively appetite for it than ever.

In other cases, where the patient is encumbered with fat, and where it is dreaded that the heart is overburdened externally, or has undergone fatty degeneration, we may render service by recommending such a change in dietary and mode of life as shall tend to reduce the fatty deposit and develope the muscle. In these instances we shall suggest that, as regards food, the patients do reduce the amount of fatty substances, such as butter, or the fat of flesh; next, that they reduce, or remove altogether, substances transformable into fat, especially sugar. I once had under my care a lady, who, encumbered to the last degree with fat deposit, was really in danger. For all articles of diet having a tendency to produce fat, she had a peculiar distaste, except for one, namely sugar; of this she confessed that she would sometimes take half-a-pound, or even a pound a day. I assured her, positively,

that this habit was the cause of her distress, whereupon she had the resolution steadily to give it up; since which time, although she has remained always comely, she has suffered from no serious embarrassment, and has lost all the threatening symptoms of cardiac breathlessness.

Next to reduction of sugar, in these cases, it is well to reduce the amount of beer, and after that of bread; indeed, it is advisable, in most instances, to withdraw the former article altogether, and, if an alcoholic must be taken, to select some of the light French wines, such as claret or Burgundy. In lieu of the fat-forming foods, the patient should be instructed to take the nitrogenous articles of diet in greater quantity, such as eggs, and the lean of meat; while milk, as representing both series of food in perfect proportions, may be used ad libitum. Care should also be taken that the meals be frequent, but each time in small quantity, so that the body may never, on the one hand, become depressed from deficient aliment, nor, on the other hand, overburdened by an excessive supply.

To these regulations in diet, exercise out of doors must always be added: this exercise should never be violent, but, commenced in moderate degree, should be steadily increased until the patient is capable of walking ten or fifteen miles a day without undue fatigue.

Together with these rules, free excretion, renal and alvine, should be maintained; and, occasionally, copious exudation from the skin, by means of the

hot air bath, should be excited, if circumstances prevent a due amount of bodily exertion; but I can conceive no case in which the bath can exclude or take the place of muscular exercise.

Medicinally, tonics, and particularly the tincture of the sesquichloride of iron, if there be anæmia, may be given with the greatest benefit. I often prescribe the iron, together with quinine, when there is failure of appetite, and have found the combination excellent; I have also combined it with solution of peroxide of hydrogen, in doses of five minims of the tincture of the sesquichloride, with from one to two drachms of a solution of peroxide containing ten volumes of oxygen, and have seen great good result from this administration. Connected with the use of iron, however, there is one important point of practice always to be borne in mind; namely, to give repeatedly, during the time, gentle alteratives, so as to keep the secretions from the liver and alimentary canal in full play; unless this be done, the tonic acts as an over-repleting agent, and virtually depresses, instead of giving support to the system.

Certain medicines, again, ought always to be carefully avoided; and, beyond all others, mercury. I do not say that a mercurial purgative is to be rigidly prohibited, but anything like a long, or even short course, of mercury, must certainly be avoided. Antimony, too, must, if possible, be struck off the list; and equally so digitalis. I must dwell a moment on this last-named medicine; it happens often in persons predisposed to cardiac apnoea, that the

heart, in embarrassed moments, palpitates-endeavours, in a word, to make up in rapidity what it has lost in power. It is easy, very easy, to be misled by this symptom, and to conclude that an organ apparently so active, but really so feeble, should be depressed into natural action by so direct a sedative as digitalis. The error may almost be called fatal; and, as I have known it do the utmost mischief, I the more heartily expose its dangers.

In those cases where the tendency to cardiac apnoea is induced by deposition of fibrine in the circulatory system, cases of the acute inflammatory kind attended with increase of fibrine, the preventive treatment consists in endeavouring to retain the fibrine in solution; this is best done by the free administration of alkalies. Nay, if a diagnosis can be formed that a fibrinous deposit is left in the heart and is producing chronic symptoms, it would be rational to sustain for long periods of time the superalkaline condition of blood, care being taken not to carry the alkali to the extent of modifying or destroying the red corpuscles.

In other forms of cardiac disease, where there is bony deposit surrounding the heart, or adhesion, or atheroma, or ossification of the coronary artery, I doubt if anything more can be done than to order a well-regulated hygiene, and to protect the patient as far as possible from those exciting causes by which an acute attack is induced.

We have finally to consider the treatment which is