pulsations, nor does it lessen their frequency. I have given the tincture in doses of 30 drops with hardly any perceptible effect. In cases accompanied with anasarca it exercises no appreciable influence in diminishing the exudation. Perhaps it is beneficial in cases of cardiac disease coexistent with kidney lesion, but I have very little knowledge of its power in such instances. shown in the ability which it gives the patient to take increased exercise without suffering from dyspnoea or inordinate cardiac action. I usually begin its administration with a dose of 1% of a grain three times a day, and gradually increase this in the course of a month up to 1 grain. It is well, I think, to give it in combination with wine, although this is by no means necessary. I employ for this purpose the so-called restorative wine of coca, which consists of two grains of the hydrochlorate of cocaine to the pint of Malaga wine. A wineglassful contains one-sixth of a grain of cocaine. After this quantity is taken for two or three days, I have the patient add a powder of one-sixth of a grain to each dose, and so on until the total quantity amounts to a grain. In some cases it is not advisable to increase the dose. Cocaine, more than any other medicine with which I am acquainted, appears to possess the property of exhibiting its effects without an augmentation of the Strophanthus is, however, a far more valuable remedy, though even this agent is not comparable to digitalis. There may be patients who are absolutely intolerant of digitalis (although I must confess to never having seen them), and with these strophanthus might be administered with the confident expectation of obtaining good results. Indeed, it is a fairly good heart tonic, giving tone to this organ, and causing the disappearance of anasarca. But I see no reason for substituting it for the more powerful remedy. It appears to me to bear about the same relation to digitalis that brucine does to strych-dose, and in such instances the original quannine, and when administered with a view to its tonic effect upon the heart, it should be given in much larger doses than those ordinarily prescribed. I have derived very great benefit in the treatment of weak heart from the administration of strychnine in gradually-increasing doses. I usually begin with a prescription consisting of I grain of the sulphate of strychnine to 1 ounce of dilute phosphoric acid, and of this I give the first day 10 drops three times, the next day 11 drops three times, and so on, increasing the doses a drop each day until some indication of the physiological action of the drug is obtained. This usually consists of a slight rigidity of the muscles of the neck or calves of the legs. The administration is then stopped for a day or two, and then resumed as before. This process may be continued as long as appears necessary. I am quite sure that I have frequently succeeded in giving tone to weak hearts when even digitalis has failed to produce permanently beneficial results. Within the last few years I have made great use of cocaine as a heart tonic. So far as I know the first published account of its efficacy in this direction was made by Dr. Beverley Robinson, of New York, but I had employed it, for the purpose of giving tone to the heart, several years before his observations were made known. Its action in this respect is readily perceived by the stethoscope, the sphygmograph, and by feeling the pulse. Moreover, its influence is markedly tity may be continued indefinitely without deleterious effects. On the contrary, usually with marked beneficial results. Perhaps it will be proper to say a few words in regard to that form of weak heart which is developed suddenly, as the result generally of exhausting disease of long duration. In such cases there is very little time for deliberation, and none for remedies to act that are administered through the stomach. By inhalation and by hypodermic injection alone can we reach the circulation and act on its central organ with sufficient rapidity. Several years ago I saved the life of an army officer by injecting about a teaspoonful of brandy into the cellular tissue of the forearm. The pulse had disappeared from the wrist, and the heart's action could not be detected by auscultation. tion came in those long, deep efforts,-thoracic entirely, at intervals of fifteen or twenty seconds, and it was evident that in a very short time life would be extinct. But in a less period than it takes me to relate the details of the event, the pulse began to flutter at the wrist, the breathing became more rapid, the face resumed something of its natural hue, and the crisis was for that occasion over. Digitalin was now administered, in the dose of of a grain in like manner; the brandy was repeated in about an hour, and the patient, who was recovering from an attack of diphtheria, lived for several years afterwards. Respira This is not a single experience, and doubt less like events have occurred in the practice of many present. The nitrite of amyl, administered by inhalation, has several times been effectual in giving at least temporary strength to an enfeebled heart; and on two occasions of profound syncope, when it was impossible to administer it through the air-passages, I have given it by hypodermic injection, with entirely satisfactory results. In these latter cases it appeared to act with as great a degree of rapidity as though inhaled. I gave it in the dose of two drops mixed with thirty minims of glycerin, and it was not necessary to repeat the injection. Nitroglycerin, trinitrin, or glonoin, as it is euphemistically called, is equally efficacious, and may often, in not very pressing cases, be administered by the mouth, in the dose of 1 grain, gradually increased, if necessary. I have, however, in one instance given it hypodermically, with the effect of instantaneously, as it appeared to me, bringing up to strong action a heart that was apparently in its last throes. This was in the case of a lady who consulted me a few days ago for paralysis of the left arm, following diphtheria. While I was examining the muscles with the faradic current, I saw her face become pale, her pupils dilate, her head fall forward, and, on feeling the wrist, I found the pulsation of the radial artery barely perceptible. I had a one per cent. solution of nitroglycerin on the table within reach, and I at once injected a minim of this into the cellular tissue of the forearm. The effect was instantaneous, and that the lady's life was saved I have no doubt. Only a week or two ago the son of a prominent physician of Brooklyn, who was convalescent from diphtheria, was found dead on the road on which he was walking, and his death was ascertained to be due to heartfailure. It would be well, I think, that the attention of physicians should be specially called to this tendency to cardiac weakness and thrombosis, to which diphtheria renders its subjects liable, and that the proper precautions should be taken in every case against such accidents as those I have mentioned. To return to the consideration of that form of cardiac weakness which, for want of a better term, I may call "chronic," all medication, no matter how effective it may be, when first undertaken, cannot be relied on to produce permanently beneficial results. It should be accompanied by the use of physical exercise and by diminishing the amount of the liquid ingesta. By the first named of these the heart is strengthened, by the second the amount of blood is lessened, and consequently the heart is put to less strain to accomplish its work. In many cases these measures are of themselves sufficient to sɔ alter the condition of the central organ as to insure a sound state of health, so far as it is affected by the ability of the heart to perform its office in the body. In others, in which there is a greater degree of adipose accumulation than is consistent with sound health, the diet must be of such a character as to retard the deposit of fat. In what I shall have to say relative to these therapeutic agents, I, of course, make no claim to originality, being fully aware of what Oertel and others have done in this direction. I am simply giving the results of my own observations. It is well known that walking or any other bodily exercise increases the heart's action, and that in those in whom this organ is weak fatal results have followed upon excessive physical exertion, especially in persons who have passed the meridian of life, or who are overburdened with adipose tissue. Every now and then we read of instances in the daily press of men and women succumbing after having rapidly ascended a long flight of steps or run after a street railway car. It is exceedingly common for persons apparently in good health to suffer greatly from dyspnoea and palpitation of the heart after muscular exercise of a not severe character. These are people who are not in the habit of taking even moderate physical exercise, and whose hearts have in consequence become weak and incapable of properly performing their functions. So long as they are not called upon to make any severe muscular effort, they get along passably well, but in the various exigencies of life the time is almost certain to come when they will be called upon for some physical exertion to which they are not accustomed. Then it is that the heart suffers to such an extent as not infrequently to cause death. The heart is like any other muscle. It is intended to accomplish a certain amount of work, and, if it is deprived of this work, it undergoes degeneration. If a person should resolve not to raise the arm for six months, it would be found that the power to raise it would be greatly diminished; and should he persist in not raising it for a few years, he would find it impossible to do so, from the fact that the muscles had undergone degeneration and atrophy. A like process undoubtedly takes place in the heart when it is deprived of its due amount of exercise. Few persons in my experience are in the habit of giving the organ the amount of work which it ought to have. We have all of us had many patients who could not walk across a room without having the pulsations of the heart nearly doubled in frequency. As Oertel has pointed out, no means for exercising the body so as to strengthen the heart is comparable to ascending heights. The person subjected to this kind of exercise lifts the body from the ground, and thus does an amount of work equivalent to that of raising a corresponding weight of iron, for instance, with each step that he takes. Besides this, he brings many more muscles into action. Of course this is a form of exercise that should be used with great discretion in cases of feeble heart, for otherwise we might get such deplorable results as we almost daily see follow upon severe muscular efforts made by those unaccustomed to them. It will not do to tell a man or woman 50 years of age that he must climb a steep hill or ascend briskly several flights of steps. The process must be a gradual one, and should always be undertaken, at least in its beginning, under the supervision of a physician. I have ascertained that we have in the heart itself a very accurate measurer of the extent to which the physical exercise recommended should be practised at any one time. If by the effort the pulsations of the heart are increased more than fifteen beats in a minute, it should not be carried any farther at that time, and it may be persevered with, within, of course, reasonable limits, so long as the pulsations are not increased above that number. For instance, if I find in a patient with a pulse of 80 in a minute that ascending one flight of steps increases the number to 95, I have him stop, sit down, and rest for a few minutes, or until the pulsations have fallen to about the normal number. I then have him resume the exercise, and again count the pulsations. It will generally be found that this time they are not increased 15 beats. If, however, they should show this or a greater increase, I keep on repeating the process, even if it should take an hour or more, till the number of additional beats is considerably less than 15. In cases such as those to which I have reference, it will, according to my experience, invariably be found that one such séance-if I may use a word not strictly accurate in the present relation-has produced a decided ad vance, and that the heart has gained a degree of tone that it will never lose if the system be continued. Of course, to stop after one or a few such experiments could lead to no permanently good results. But the comfort which the patient experiences from this treatment is such that there is no danger of its being interrupted. I have mentioned the staircase as a ready means of enforcing this particular kind of physical exercise, but it will readily be understood that there is nothing special about such an arrangement beyond its general adaptability and the facility with which. it can always be obtained. If the patient lives in the country, where hills exist, they will on some accounts be preferable, for they admit of the exercise being taken in the open air, which is often a matter of considerable moment. In the Sanitarium, which I am conducting in Washington City, a feature in which I take great interest, is what I may call the treadmill, for it is made upon the same principle as that which prevails with the apparatus for punishment or labor with that name. It is so arranged that it can be moved by persons of different weights who may stand on it, and I think it affords very admirable means of applying the principle involved in climbing heights to the treatment of weak hearts. It admits of accurate adjustment to the amount of work which the patient is deemed capable of performing. It has been contended by some authorities that exercise of the muscles of the upper extremities is more efficacious in giving tone to the heart than when the lower extremities alone are brought into action. I think that there is some truth in this opinion. At any rate it is better that the arms and chest should be exercised in conjuction with the special movements of the lower limbs than that they should be allowed to be passive. Wrestling at arm's length is a very admirable means of exercising the muscles of the upper part of the body. Dumb-bells, Indian clubs, and the lifting of moderately heavy weights are also efficacious measures. It must not, however, be forgotten that in wrestling the desire to be pre-eminent is likely to be a prominent feature, and that this feeling may tempt the contestants to go further than is safe. No such contests should ever be permitted to take place between patients, but should be conducted under the immediate observation of the physician or well-instructed attendant. Of course in all these cases the general health must be attended to, and it is well that some one or more of the heart tonics I have mentioned, as well as the measures next to be referred to, should be employed. We would think very poorly of the general who, undertaking to capture a fortification, and having several guns that he could bring to bear on the enemy's works, should persist in firing only one. Reducing the quantity of liquid habitually imbibed is scarcely of secondary importance to systematic exercise. And as it is generally the case that persons suffering from weak heart are particularly addicted to the excessive drinking of water and other fluids, it is imperatively necessary that the point receive due attention from the physician. Very little, if any, of the liquid taken into the system passes directly out through the intestinal canal. It is first absorbed into the blood by osmosis, where, for the time at least, it adds to the volume of the circulating fluid, and must pass through the heart, to be excreted by the lungs, skin, and the kidneys. Thus the work of the heart is rendered more severe than it should be. It is overtaxed, and suffers in consequence. The effect is very different from that caused by proper physical exercise, for this latter only increases the action of the heart within its normal limits. The matter may, perhaps, be more clearly explained by the consideration of the fact that it would be easier for a man to lift twenty pounds weight five times, in even rapid succession, than it would be for him to lift a hundred pounds once. The former would cause nothing like so much strain to the muscular tissue as would the latter. Now a medium amount of blood corresponds in the necessary action of the heart to move it to moderate exercise frequently repeated, while an excessive amount of blood produces analogous effects to those resulting from an undue muscular effort. We have in the disease, one of the names of which is exophthalmic goitre, a condition of the heart similar in some respects to the affection now under consideration. Its action is exceedingly frequent, its pulsation feeble, and the most moderate physical exertion, as well as very slgiht mental disturbance, are sufficient to increase the degree of deviation from the normal standard. In two cases of this disease, one of which, I think, came also under the observation of Dr. Satterthwaite, of New York, I reduced the total amount of fluid ingested in twenty-four hours to sixteen ounces. This included everything in the way of liquids-water, milk, coffee, tea, etc.-taken into the system, with the effect of materially increasing the force of the heart's pulsations and lessening their fre quency. In both cases the number fell from over 160 per minute to less than 100, and in one of them to less than 90, and this within forty-eight hours after initiating the measure. The ultimate results were that one of these patients was greatly relieved, perhaps cured, for I have not heard from her for over a year, while the other entirely recovered in about four months under no other treatment than this, with digitalis and the hydrobromate of hyoscine. This last named remedy was only used for about a month. Its effects were very decided, but were much more markedly exhibited when the reduction in the quantity of the fluid ingesta was well under way. Relative to diet and such means as are proper, in addition to those mentioned for lessening the amount of fat deposited, I would strenuously insist upon the eating of as small an amount of the carbohydrates and hydrocarbon as is consistent with good health. Potatoes, rice, and other farinaceous vegetables should be absolutely prohibited. Bread, especially that made from the finer grades of wheat flour, should be almost as rigidly enjoined. I never allow more than two ounces of such bread daily, and this in the form of toast. I require the patient to weigh it accurately on a little letter-balance, which is admirably adapted for the purpose. Buckwheat I find still more admissible, and of this as much as three or four ounces, in the form of griddle-cakes, may be taken daily. Buckwheat, as is probably known to most of those present, may be ingested in considerable quantity without increasing the amount of sugar in the urine of diabetics. I allow the green vegetables, such as cabbage, cauliflower, Brussels-sprouts, celery, spinach, asparagus, lettuce, etc., ad libitum. Tomatoes, egg-plant, apples, cucumbers, and a few other non-saccharine or non-amylaceous vegetables, or which, at least, contain sugar and starch in small proportion, may also be permitted in reasonable amounts. As to fats and oils, the less taken of them the better. A little butter may be allowed, say half an ounce daily, but beyond this it is not advisable to go with the hydrocarbons. Animal food is best in the form of fish, oysters, crabs, lobsters, eggs, lean beef, mutton, fowls, and game in moderation. It is now well known that highly nitrogenous food, when taken in excess, is broken up into fat, and is deposited as such in the tissues of the body, especially if at the same time the habit of the individual is sedentary. Doubtless many cases of cardiac weakness are the direct result of either fatty degeneration of the muscular substance of the heart, or of an excessive deposit of adipose tissue interstitially or on the periphery of the organ. In the one case, the muscular tissue loses part of its normal power; in the other, its action is impeded. I am quite sure that by the method of treatment described the fat begins to disappear from the heart before a like process is initiated in any other part of the body. This is seen from the greater comfort while taking exercise, due directly to the lessening of the dyspnoea, the effect being generally perceived after two or three days have. elapsed. Of course, as the body loses weight, the improvement becomes still more marked, until, in a short time, varying from a week to a month, the patient can run and climb heights and indulge in other violent exertion, which would have been absolutely impossible, without danger to life, during his former condition. method is said to be especially applicable to erysipelas of the face and of the hairy scalp. In the method of treatment of Nussbaum and Brunn, ichthyol is employed in collodion. Hallopeau recommends the use of a solution of 1 part to 20 of salicylate of sodium. Thick cloths are wet with this solution, then applied to the affected parts, and then covered with a layer of rubber-cloth, so as to prevent evaporation. Almost immediate relief is obtained, and a cure is said to follow on the third to the fifth day. Hunter recommends the injection of carbolic acid into the healthy skin at a distance from the part infected. This method of treatment is extremely painful, and is only applicable in cases of grave nature of the face or hairy scalp. Dr. Kraske advises making an incision in the healthy skin around the erysipelatous patch before applying the antiseptic substance. Wolfler makes use of mechanical compression by bandages applied so as to circumscribe the inflamed tissue, while Dr. Kraske proposes elastic rubber bands to accomplish the same effect where these are applicable.— La Practique Médicale, No. 33, 1890. NEW METHODS OF TREATING ERY Rosenbach's method consists in washing not only the erysipelatous patch but the entire neighboring surface with soap, and then bathing daily these patches with five per cent. solution of phenic acid dissolved in absolute alcohol. Very brilliant results are claimed to follow this method, both as regards the course of the disease and the febrile phenomena. Even absolute alcohol is said to produce a favorable action. In Nolte's method the entire affected surface and surrounding zone is painted twice daily with a mucilage of gum-arabic, containing from three to five per cent. of phenic Good results are claimed to follow, is also the case when the phenic acid is mixed with vaseline. acid. as The method of Koch consists in applying, by means of a camel's-hair pencil, the following ointment in a perfectly thin layer over the affected parts: Creoline, I part; Iodoform, 4 parts; Lanolin, 10 parts. After the ointment is applied, it is then covered with a thin layer of gutta-percha. This |