given internally with advantage. In the absence of a discoverable cause, or when the pain resists other remedies, the administration of one-sixth of a grain of barium chloride in pill form three times a day sometimes gives excellent results.

An attack of palpitation can sometimes be relieved by exercise or by the simple expedient of drawing a few deep breaths.

In general, the treatment of the paroxysm consists in rest in the recumbent position and in the use of stimulants, such as ether, ammonia, valerian, ginger peppermint, camphor, and the like. The compound spirits of ether, in drachm doses, is an efficient remedy under these circumstances. The following prescription is an example of a very serviceable combination in the treatment of palpitation:

R Tincturæ Valerianæ Ammoniatæ 3i.
Tincturæ Lavandula Compositæ
Spiritus Vini Rectificati

Aqua Chloroformi

Fiat Mistura.

3ss.

Zi.

q.s. ad. 3ss.

S. One tablespoonful to be taken every two or three hours.

Alcohol, in some warm vehicle, is also of service, but its administration requires strict supervision. The vagi may also be stimulated through the nasal mucous membrane by means of smelling-salts, snuff, ammonia, etc. Hot or cold applications to the præcordial region usually afford relief, but cold, in the form of an ice-bag, must be employed with caution, more especially if the action of the heart be irregular. In the case of less acute and more protracted attacks of palpitation, the various measures just mentioned must be supplemented by treatment directed to the more remote causes of the cardiac disturbance.

With this object the hygienic and dietetic regulations which were detailed at the beginning of this section should be put into operation. The exhibition of nerve sedatives, more especially of the bromide of sodium or ammonium, is usually of service in neurotic cases. Belladonna, given internally, or applied in the form of a plaster to the præcordial region, is sometimes of service. The use of aconite is strongly recommended by Allbutt, but care must be observed in the employment of this remedy. Digitalis is seldom of much benefit, but the administration of cactus grandiflorus, as a tincture, is not infrequently attended by excellent results. Vasomotor disturbances in connection with palpitation should be corrected and controlled by appropriate treatment. Tonics are frequently of service in the intervals between the attacks.

The treatment of that form of irritable heart which occurs in young people consists in the careful regulation of the habits of the patient as regards the taking of food, exercise, sleep, etc., and the use of such substances as tobacco, tea, coffee, and alcohol. Medicinal treatment is seldom required. Complete rest for a time is sometimes of great benefit in these cases.

The treatment of so-called "soldier's heart" is very unsatisfactory. Absolute rest in bed, and the administration of digitalis and aconite appear to afford the best results. Cardiac asthenia should be treated, according to Da Costa, by rest in bed, followed by graduated shower baths, massage, and Swedish exercises. The diet should be nutritious and liberal as regards quantity. Alcohol is also of service. So far as medicinal treatment is concerned Da Costa strongly advocates the use of strychnine, and, failing this, of arsenic or of the cardiac tonics. Nerve sedatives are occasionally called for. Allbutt suggests that compression of the abdomen by a properly fitted binder or pad might be of use in view of the pathogenesis of this disorder, which he thinks may be a dilatation of the vessels in the splanchnic

area.

The treatment of arrhythmia does not require special consideration, inasmuch as it turns on the application of the general principles already indicated. In all cases treatment should be addressed to the cause of the cardiac disturbance, be this digestive disorder, uterine derangement, or the abuse of tea, alcohol, tobacco, coffee, etc. If the cause cannot be discovered, and provided the patient suffers no inconvenience from the abnormal cardiac action, interference by means of drugs usually does more harm than good, and is therefore to be deprecated.

Tachycardia does not offer much scope for treatment, since the conditions on which the attacks depend are not fully understood. The general health of the patient must be promoted by suitable hygienic and dietetic means, and any functional disturbance of other organs which might stand in causal relation to the attacks should so far as possible be remedied. Digitalis exercises little or no influence on the paroxysms, but strophanthus has occasionally appeared to do good. The bromides are of service in some instances, and they may be given in combination with full doses of belladonna. The salicylates and iodides are also worthy of trial when other measures fail.

Treatment by electricity has not fulfilled expectations, but the application of the continuous current over the nerve trunks in the neck has sometimes appeared to mitigate the severity of the attacks.

The treatment of bradycardia, when this is necessary, should be directed to the cause of the condition.

In the absence of organic disease of the heart, the feeling of faintness which precedes the occurrence of actual syncope and loss of consciousness can usually be relieved by making the patient sit down and bend forwards with the head between the legs.

When fainting has occurred the patient should be placed flat on his back, with the head at a lower level than the rest of the body. The clothes round the neck, chest, and abdomen should be loosened, and a current of cold air allowed to play on the skin with the object of producing contraction of the superficial vessels and of raising blood pressure.

Reflex stimulation of the heart and respiration is accomplished by flicking the face and chest with a wet towel and by the application of ammonia, smelling-salts, and other pungent substances to the nose. If these measures fail to restore consciousness, ammonia, ether, brandy, or strychnine may be injected subcutaneously, or per rectum.

When the syncopal attack is due to hæmorrhage the patient should be inverted, or the limbs bandaged from the feet upwards, with the object of driving blood towards the heart and brain. Meanwhile, hot applications may be made to the præcordial region.

In urgent cases artificial respiration, galvanization of the phrenic nerves, or even transfusion of a saline solution may be required. After consciousness is restored the patient should remain in the recumbent position until all danger of a recurrence of the attack has passed away.