good result. When the case was in my hands, the first thing I did was to prohibit the "nightcap," and otherwise to reduce the hydrocarbon supplies. Medicinally, Fowler's solution was prescribed, in three minim doses three times a day. After one month, during which the medicine was well tolerated, the nail underwent rapid progress towards renovation; and three weeks later it, together with the finger, had recovered the natural appearances.

The evidence in respect to the treatment of this disease of the nails is thus strongly in favour of arsenic as the remedy. This view in some measure removes the hypothesis of the invariably syphilitic origin of the disorder, and shows, at all events, that there may, as in lepra, be two sources, one of which is not directly of venereal growth.

In any doubtful case, where arsenic alone did not cure, it would be good practice to move from Fowler's to Donovan's solution (the compound of hydriodate of arsenic and mercury), a solution which, notwithstanding Hebra's opinion upon it, is admirable in obstinate cases of mixed syphilitic and squamous disease.

ESSAY III.

ON REDUPLICATION OF THE SECOND SOUND OF THE ᎻᎬᎪᎡᎢ.

THERE is perhaps no phenomenon more curious to the practising physician, when he first meets it, than that known as reduplication of the sounds of the heart. It is so rare that its novelty strikes forcibly; it is so well marked as a peculiarity when it does occur, that its existence can admit of no dispute.

Those who have not heard what is called reduplication, may learn it by hearing what it is. In lieu of two heart-sounds to each action, there are three; in lieu of the familiar "lub-dup" and pause, there is distinctly caught "lub-dup-dup"; that is to say, a third and unexpected short sound takes in great part or altogether the place of the pause. Therefore, in strict definition, reduplication applies to but one of the sounds of the heart.

OBSERVED FACTS AND ANALYSES.

In the beginning of this year (1860), a young man, 23 years of age, came before me at the Royal Infirmary for Diseases of the Chest, with the following complainings. He was subject, and had been subject for

three weeks past, to almost constant palpitation of the heart. He believed that his first symptoms were due to a "cold on his lungs". The palpitation kept him sleepless, and in subdued suffering; he could feel a tilt of his heart against the chest-wall, not in the anterior point, where the beat is ordinarily felt, but laterally towards the left side. At times this palpitation became unusually violent; there was a sensation of choking in the throat, a struggle for breath, and afterwards great exhaustion. In addition to these signs, there were flatulency and anæmia: but the tongue was clean, the bowels acted daily, and the skin was cool. There was desire for food, but a dread of taking it, inasmuch as anything like a meal oppressed the chest; but the urgent symptoms of which the man complained, and of which he came to be relieved, were the palpitation and oppression. “If I could lie down and sleep", he said, "I should be well; but, as I try to sleep, this terrible weight and palpitation come on increasingly, and I start up at last as if I were being strangled, or crushed between two heavy doors."

The symptoms described by the man might have passed current in the run of practice for those of hysteria and anæmia. Fortunately-if that is fortunate which becomes a habit-I examined the chest of this man. I could find in the lungs no trace of tubercle, bronchial dilatation, nor other organic lesion yet this was peculiar, and I pointed it out at the moment to Mr. Louis Parnell, who was attending my clinique, that there was everywhere a deficient

respiratory murmur. Turning to the heart, I found it unusually active, and giving a sharp quick thoracic impulse against the chest-wall on the left side, between the fifth and sixth ribs, and rather bearing upon the sixth rib itself. This impulse could be seen as well as the normal anterior impulse, but much more evidently. Each impulse was marked at least eighty times per minute, and without apparent intermittence: yet the action was irregular; for, if the number of beats were counted one minute, and then again for a second minute, there would be eighty in the first minute, and eighty-five in the second; but if each beat were taken singly, there was no apparent irregularity between them, the disparity in the whole number of beats per minute being distributed with an equal gradation, extending over some measurable period of time, whether towards increase or diminution.

On taking the sounds with the stethoscope, there was to be heard, with unceasing regularity and clearness, the reduplication which I have already briefly noticed-lub-dup-dŭp, lub-dup-dup.

I ordered for this man tincture of the sesquichloride of iron in ten minim doses, in bitter infusion, twice a day. The symptoms, it will be seen from this treatment, were supposed to be mainly dependent on anæmia and dyspepsia: we shall find in the end how far that suggestion was right.

Three days after this treatment had been carried on, the man came to me again. He was irritably nervous; and, as I thought, gave to every symptom

I

an exaggerated colouring of the sombre tint. The medicine did him harm, was his argument; it did not confine his bowels, but it made him worse every dose of that he was sure. Not believing much of this report, I nevertheless changed the individual remedy, but not the direction of the treatment. ordered him a combination, which I have found most efficient in many cases of dyspeptic anæmia; namely, trisnitrate of bismuth in ten grain doses, with five grains of the ammonio-citrate of iron and an ounce of water. This medicine was persisted in twice daily for a week without change. The oppression was complained of as before; and the reduplication was as clear as ever. I now added to the mixture a little sulphuric ether, in fifteen minim doses, and ordered a five grain galbanum pill at bedtime. The next week my man did not come; nor the next. I feared he was lost as a history, and regretted it much. But, five weeks after he had left me, he reappeared, very comfortable in health, rather triumphant in manner, and entirely relieved of reduplication and palpitation. His relief occurred thus.

On the second night after his last visit to me, he went to bed very oppressed; he was restless all night, often getting up and going to the window for air. He lay down more composedly towards the morning, and, worn out, fell asleep. Soon he awoke; and his wife and friends were truly and naturally alarmed at his appearance. The oppression at his chest prevented respiration; his lips were blue; his limbs. convulsed. He was with difficulty half-dressed, put