ging power. The question therefore arises-To what extent is alcohol useful as a remedy for intermittent heart? This is a very delicate and difficult question to answer; for unfortunately the remedy itself, if carried too far, increases, after a time, the primitive evil, and as it is a remedy always at hand and viciously pleasant, its bad rather than its good influence is the most probable event. The advice I have to offer on the matter is nevertheless simple, simple because it has been learned by repeated experiences in many cases, and because the results from it are very uniform. I recommend all who suffer from intermittent pulse to abstain from alcohol in every shape as far as is possible, and resolutely to abstain from every alcoholic fluid respecting the character of which there is the merest doubt. There are some fluids, such as champagnes, sweet ports, and even light acid wines,-clarets, burgundies, hocks, —which, so soon as the short stimulating action they produce has passed away, induce great prostration, with marked increase of intermittent action, if they have been taken in any free quantity. All these must be avoided. Objections may also be taken to rum and gin. A person with intermittent pulse is in short brought to the use of three ordinary alcoholic drinks-sound light ale, sound light sherry, and sound brandy the strength of which is known. As a rule, I do not find that any harm follows a moderate use of sound light ale, provided the quantity taken do not exceed three half-pint glasses a day; or, if sherry be preferred to ale, I do not, as a rule, find harm resulting from three wine-glasses of it in the day: but beyond these measures all is hurtful. As to brandy, although I have mentioned it as allowable, it must be considered only as a reserve force, to be called in when there is real and urgent necessity for it, and then in a moderate degree. If after great fatigue or excitement or anxiety, there is sleeplessness, restlessness, and painful knowledge, on the part of the patient, of the hesitation of the circulation, half an ounce or an ounce of

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brandy will act, generally, in the most effective manner. will bring rest at once, and, often when a narcotic fails, sleep: but it must be repeated only after an interval of seven or eight hours; if it be carried to the extent of producing the third, paralysing or narcotic, degree of alcoholic stimulation it will have conferred evil instead of good.

I have suggested the above method of administering alcohol, because it is practical and is most likely to fall in with the ordinary mode of life of the majority of patients. But persons who object to alcohol, and these are daily increasing, need not have the agent pressed on them, except in extreme circumstances where the dose is needed in the true medicinal sense. In the medicinal sense it is best to prescribe absolute alcohol, ordering it in half the proportion of the best brandy. Half a fluid ounce to six fluid drachms will be sufficient in four ounces of water, to which may be added ten grains of bicarbonate of potash or twenty minims of sal volatile if there be acidity of stomach or eructation.

In some instances, instead of prescribing common or ethylic alcohol, I substitute pure methylic alcohol. This is a much lighter spirit, and is eliminated more quickly from the body. The dose is the same as for common alcohol, and may be prescribed in precisely the same way, with the advantage that it may be more frequently repeated than the same dose of ethylic alcohol.

I think I have now said all that needs be said respecting the use of alcohol in intermittent heart. I have expressed a fact, a practice, and a caution. The fact, that alcohol by its stimulant action on the nervous mechanism of the heart will temporarily remove intermittent action. The practice, that in extreme cases and at extreme crises, alcohol may be advantageously prescribed to relieve the symptom. The caution, that in prescribing alcohol it is never necessary to let the occasional glide into the habitual practice of taking it, the tendency of

the remedy being, when it is often and systematically repeated, to increase the primitive disorder.

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It is better that a patient who suffers from intermittent pulse should not smoke tobacco. It has been assumed by some that tobacco may even induce intermittent action, and I have seen one or two cases which would engender a suspicion that both smoking and snuff-taking might be set down as causes. But longer observation tells me the suspicion is not correct. If the practices named were true and independent causes of the phenomenon, we should find, frequently, cases in the male sex where the cause stood alone, and we should also find the phenomenon much more common in men than in women. truth, however, I have never seen a pure case of intermittency from tobacco; neither have I been able to discover that the male sex is specially liable to the affection. At the same time, it is unquestionably true, that when the symptom is developed smoking and snuffing intensify it, not, I think, from any special influence, but from the general debility induced, the steady indigestion which the narcotic sustains, and the restless muscular action-tremor—which it favours and supports. Tobacco, in a word, acts like other depressing agencies, such as loss of blood, or want of sleep, or deficient food, or bad assimilation of food; it injures as a secondary cause; it does not produce from the first.

In men who chew tobacco, and in men and animals under the direct poisonous influence of nicotine, I have watched for the symptom of intermittency of the cardiac motion without result. The action of the heart may be feeble and irregular, the muscles in a state of restless tremor, and the body cold. But there is no pure intermittent action. The symptoms from nicotine are those of cardiac apnoea, of failure of the right rather than of the left side of the heart, with difficult respiration; and, in man, spasmodic pain passing through the thorax, from the sternum to the crura of the diaphragm. A marked

case of this kind is recorded in the essay on cardiac apncea my "Asclepiad."

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The remarks made in reference to tobacco apply equally to tea. Tea does not produce intermittent heart, but when the symptom is present it very seriously increases it; tea, in short, is an article of diet, which in all cases of irregular action of the heart should be scrupulously avoided. Coffee is less objectionable.

In respect to the diet of persons suffering from intermittent pulse, little in the way of special rule can be said, because in each case there is commonly some other functional organic disorder which calls for special attention, the intermittency remaining as a systemic failure rather than as a distinct malady. But one general remark applies to the general condition-viz., that food should be taken by sufferers from intermittent action in moderate quantities and frequently. Long fasting is unspeakably prejudicial, and makes itself speedily felt by the patient, who writhes, while fasting too long, under an indescribable exhaustion, which is not hunger, and not faintness in the natural sense of those terms, but a strange mixture of both sensations with a frequently recurring impression that if food do not immediately come death must. The nervous supply of the heart in these cases is sensitive of the least failure of power, and requires renewal every three or four hours during the working day. At the same time, the system rebels against a large, hardly digested, and oppressive meal.

One note more occurs to me respecting meals. There is a common feeling against late meals, late dinners or suppers, and I have no intention of opposing that which is not only a common, but as a rule, a natural and correct objection. Experience, however, tells me that to retire to rest with the body fasting is as bad a practice as to retire to rest with the stomach busily digesting. A light meal taken an hour or two before sleep is, I think, good for everyone, and it is essential for those

who suffer from intermittent action of the heart. The last meal should certainly not be large, and should consist of some very simple easily digested food, such as milk, or cocoa, with bread and butter, or some similar food, tea being specially excluded. In extreme cases of intermittent action it is also good practice to let the patient have a glass of milk, or of milk diluted with water, at the bedside during the night. The period of the approach of the early morning, the hours between two o'clock and the dawn of day, is a period when the strongest are at their weakest, and the weakest at their worst; and so it commonly happens that the very weak die in the hours named. In the same hours persons who suffer from feeble and intermittent cardiac action commonly become restless, wake with sensation of exhaustion, and, if they are not sustained, sleep afterwards indifferently. At this period the reserve of food I have suggested is the best remedy; it relieves the exhaustion and restlessness, and ensures return to a sleep undisturbed by dreaming melancholy, and from which waking is the taste of the refreshment of sleep that has been bestowed.

A word as to warmth and clothing, and I have finished what I have to say on points of practice. Persons who suffer from intermittent action of the heart, whether they be young or old, should at no time expose themselves to loss of bodily heat. They should not, for example, take cold baths nor shower baths, but should in every habit study to follow a medium course. In every season the body should be so clothed that sensation of coldness shall not be felt. Flannel should be worn next the skin at all times; thin flannel in hot, thick in cold weather. Care should be taken, also, to protect the body from damp and wet. In a word, every such provision should be made as will sustain equality of vital process, so that the nervously disabled heart may neither wait long for new support nor be taxed with labours it cannot, at its best, fulfil.