something or to being run into, it is noticed that the little period of cardiac disturbance and chest tension is greater than it should be, the heart needs resting.

If the least excitement or exertion increases the cardiac speed abnormally, it means that for many minutes, if not actually hours during the twenty-four, the heart is contracting too rapidly, and this alone means muscle tire and muscle nutrition lost, even if there is no actual defect in the cardiac muscle or in its own blood supply. If we multiply these extra pulsations or contractions by the number of minutes a day that this extra amount of work is done, it will easily be demonstrable to the physician and the patient what an amount of good a rest, however partial, each twenty-four hours will do to this heart. Of course anything that tends to increase the activity of the disturbance of the heart should be corrected. Overeating, overdrinking (even water), and overuse or perhaps any use of alcohol, tobacco, tea and coffee should all be prevented. In fact, we come right to the discussion of the proper treatment and management of beginning high blood pressure, of the incipiency of arteriosclerosis, of the prevention of chronic interstitial nephritis, and the prevention of cardiovascular-renal disease.

When an otherwise apparently well person begins to complain of weariness, or perhaps drowsiness in the daytime and sleeplessness at night, or his sleep is disturbed, or be has feelings of mental depression, or he says that he "senses" his heart, perhaps for the first time in his life, with or without edema of the feet and legs, or pains referred to the heart or heart region, we should presuppose that there is weakening of the heart muscle until, by perfect examination, we have excluded the heart as being the cause of such disturbance.

Although constantly repeated by all books on the heart and by many articles on cardiac pain, it still is often forgotten that pain due to cardiac disturbance may be referred to the shoulders, to the upper part of the chest, to the axillae, to the arms, and even to the wrists, to the neck, into the head, and into the upper abdomen. It is perhaps generally auricular disturbance that causes pain to ascend, but disturbances of the ventricles can cause pain in the arms and in the region of the stomach. Not infrequently disturbances of the aorta cause pain over the right side of the chest as well as tip into the neck. Real heart pains frequently occur without any valvular lesion, and also when necropsies have shown that there has been no sclerosis of the coronary vessels.

While angina pectoris is a distinct, well recognized condition, pains in the regions mentioned, especially if they occur after exertion or after mental excitement or even after eating (provided a real gastric excuse has been eliminated), are due to a disturbance of the heart, generally to an overstrained heart muscle or to a slight dilatation. Too much or too little blood in the cavity of the heart may cause distress and pain; or an imperfect circulation through the coronary arteries and the vessels of the heart, impairing its nutrition or causing it to tire more readily, may be the cause of these cardiac pains, distress or discomfort.

Palpating the radial artery is not absolutely reliable in all cases of auricular fibrillation, or in another form of arrhythmia called auricular flutter or tachysystole. James and Hart [Footnote: James and Hart: Am. Jour. Med. Sc., 1914, cxlvii, 63.] have found that the pulse is not a true criterion of the condition Of the circulation. There is always a certain amount of heart block associated with auricular fibrillation so that not all of the auricular stimuli pass through the bundle of His. James and Hart determine the heart rate both at the radial pulse and at the apex, the difference being called the pulse deficit. They use this deficit as an aid in deciding when to stop the administration of digitalis. When the pulse deficit is zero, the digitalis is stopped. In this connection they also find that, even though the pulse deficit may be zero, there may be a difference in force and size of the waves at the radial artery. This can be demonstrated by the use of a cuff around the brachial artery and by varying the pressure. It will be found that the greater the pressure, the fewer the number of beats coming through.

Besides the instruments of precision referred to above, more careful percussion, more careful auscultation, more careful measurements, roentgenoscopy and fluoroscopic examination of the heart, and a study of the circulation with the patient standing, sitting, lying and after exercise make the determination of circulatory ability a specialty, and the physician who becomes an expert a specialist. It is a specialization needed today almost more than in any other line of medical science.

So frequently is the cause of these pains, disturbances and weakness overlooked and the stomach or the intestines treated, or treatment aimed at neuralgias, rheumatisms or rheumatic conditions, that a careful examination of the patient, and a consideration of the part the heart is playing in the causation of these symptoms are always necessary.

The treatment required for such a heart, unless there is some complication, as a kidney complication or a too high blood pressure, or arteriosclerosis (and none of these causes necessarily prohibits energetic cardiac treatment), is digitalis. If there is doubt as to the condition of the cardiac arteries, digitalis should be given in small doses. If it causes distinct cardiac pain, it is not indicated and should be stopped. If, on the other hand, improvement occurs, as it generally does, the dose can be regulated by the results. The minimum dose which improves the condition is the proper one. Enough should be given; too much should not be given. Before deciding that digitalis does not improve the condition (provided it does not cause cardiac pain) the physician should know that a good and efficient preparation of digitalis is being taken. Strychnin will sometimes whip up a tired heart and tide it over periods of depression, but it is a whip and not a cardiac tonic. While overeating, all overexertion, and alcohol should be stopped, and the amount of tobacco should be modified, there is no treatment so successful as mental and physical rest and a change of climate and scene, with good clean air.

Many persons with these symptoms of cardiac tire think that they are house-tired, shop-tired, or office-tired, and take on a physical exercise, such as walking, climbing, tennis playing or golf playing, to their injury. Such tired hearts are not ready yet for added physical exercise; they should be rested first.

The treatment of this cardiac tire is not complete until the tonsils, gums, teeth and the nose and its accessory sinuses are in good condition. Various other sources of chronic poisoning from chronic infection should of course be eliminated, whether an uncured gonorrhea, prostatitis, some chronic inflammation of the female pelvic organs, or a chronic appendicitis.

Longcope [Footnote: Longcope, W. T.: The Effect of Repeated Injections of Foreign Protein on the Heart Muscle, Arch. Int. Med., June, 1915, p. 1079.] has recently shown that repeated, and even at times one protein poisoning can cause degeneration of the heart muscle in rabbits. Hence it is quite possible that repeated absorption of protein poisons from the intestines may injure the heart muscle as well as the kidney structure; consequently, in heart weakness, besides removing all evident sources of infection, we should also give such food and cause such intestinal activity as to preclude the absorption of protein poison from the bowels.