Various acute cardiac affections, especially endo- and pericarditis, are local manifestations of specific rheumatism, pneumo-coccic infection, infection with mitigated septic bacteria etc. Thus the diet should be that appropriate to fevers of this general nature.

Special pains should be taken to feed in the recumbent posture, preferably with the head turned to one side, and using a spoon, feeding cup with spout, a bent glass tube etc. So far as practicable, the diet should favor elimination by containing plenty of water although overfulness of the alimentary canal, too high arterial tension and overwork of the kidneys should be avoided. As straining at stool is a factor of danger, the diet should, so far as practicable, be laxative.

W. Howship Dickinson has emphasized that alkalies are more important than salicylates in preventing subsequent valvular lesions.

All of these indications are met by a cereal and milk diet, using fruit juices as beverages, but avoiding meat extracts and meat in any form during the acute stage, and also avoiding tea, coffee and chocolate.

Care should be taken, however, to avoid cardiac dilatation, various forms of myocardial degeneration and imperfect repair of acute valvular defects - so far as these are preventable - by nourishing adequately after the febrile stage has passed. This implies a relatively early return to semisolid and then to ordinary solid diet.

There is some reason to believe that cardiac degeneration, including even valvular disease, may develop from intestinal auto-intoxication, the dietetic prophylaxis and treatment of which are discussed elsewhere. At any rate, the prevention of gaseous distention of the alimentary canal during either acute or chronic conditions of cardiac disease, is important. Even effervescent beverages should be used with caution.

The idiosyncratic origin - with special allusion to dietetic idiosyncrasies - of cases resembling if not properly included under angina pectoris, should be borne in mind. The cardiac rhythm and functional power are especially apt to be disturbed by tobacco, coffee, alcohol, and products of alimentary decomposition. Purin excess is a less conspicuous factor.

In chronic circulatory lesions, of various kinds, including valvular lesions, aneurysms, cardie-vascular degenerations etc., the two acute dangers are heart failure and vascular rupture. Hence excessive blood pressure or great fluctuations of blood pressure are to be avoided. Just as alternate hot and cold ingesta increase the effect of each extreme on the teeth and stomach, so the alternate relaxation and contraction of arterioles by tobacco and coffee or tea, may be more dangerous than the maintenance of a steady high pressure. The same principle applies to alcohol and tea, respectively, to irregular medication with nitrites and nitroglycerin, to balneotherapeutics etc.

A hearty meal, especially if of excessive bulk directly, or by containing effervescent liquids or substances that yield gas by inorganic chemic action, such as carbonates, or by fermentation, not only tends to disturb the cardiac action by pressure against the diaphragm, but to increase general abdominal pressure and hence, intrathoracic and even intravascular pressure. The last is also increased by relatively rapid absorption of water along with salts and sugars etc.

On the other hand, the physical and metabolic functions necessary to the digestion and assimilation of a hearty meal, may constitute an appreciable strain, quite analogous to that of excessive exercise, mental effort, emotion etc.

Aneurysms located along the oesophagus may be ruptured by the swallowing of large or hard boluses.

But, while chronic cardio-vascular lesions require care in eating, they also demand adequate nourishment. Thus, the

Tufnell treatment of aneurysm, though logical in so far as the physical rest and avoidance of alimentary strain are concerned, is illogical in that the close approach to starvation diminishes the coagulability of the blood and whatever tendency to repair may be present.

An abundance of gelatin and of lime are indicated to increase the coagulability of the blood in aneurysm. On the other hand, these patients generally manifest a tendency to calcareous degeneration which contraindicates the use of lime, so far as it is avoidable, unless for the urgent indication in case of aneurysm.

In practically all forms of chronic cardio-vascular disease, the diet should be adequate but not excessive, either in bulk or in the metabolic demands imposed on the system. Hence it should be relatively solid, including cereals, legumes, nuts, potatoes etc., but not the innutritious fodder vegetables, moderate amounts of eggs, milk and meat but not viscera. Both by choice of foods and methods of preparation, digestion should be rendered as easy as possible and thorough mastication should be insisted upon. Artificial comminution and predigestion should be employed if necessary. Fermentation and putrefaction should be avoided.

While sugar and starch are indicated on account of their production of energy, they should be used cautiously to avoid fer-mentation and the former especially because of the tendency to thirst and hence the ingestion of too much water, also because of the possibility of hepatic and pancreatic lesions interfering with glycogenesis and glycolysis. Tea, coffee etc., should not be employed unless there is a distinct indication for their medicinal use as heart tonics and diuretics.

The use of water and salines depends largely upon the presence of indications for elimination or the resorption of dropsical effusions. Even when these are present, there should not be too great deviation from the normal standard of about 3000 c.c. of total water, ordinarily implying the ingestion of 1000 c.c. as such. Nor should the ingestion of common salt vary much from the normal of about 10 grams. However, it should be remembered that only in extreme cases should surgical measures be adopted for the removal of dropsical effusions, and that the withholding of salt, except in minimum quantity - that contained in the organic food stuffs - is almost as necessary as the'restriction of water, to produce resorption of transudates. The diuretic, diaphoretic and cathartic removal of water, though largely medicinal, may be expedited by such dietetic measures as the use of fruits, of hot catnip and other herb teas, and saccharine and cellulose-rich fruits, respectively.

Angiosclerosis, mainly apparent and important as arteriosclerosis, may be prevented to some degree, by the avoidance or very temperate use of alcohol, tobacco, tea and coffee, the avoidance of malfermentation and putrefaction in the alimentary canal, as well as of dyspepsia in the most general sense, the avoidance of hard water, not to mention hygienic measures having no special connexion with dietetics.

After angiosclerosis has developed, the same precautions should be instituted to prevent, if possible, its further progress. The general dietetic management has been discussed.

Trunecek has proposed the use of a "serum" containing the inorganic constituents of blood serum, as a prophylactic and treatment of arteriosclerosis. Leopold Levi believes that this may be used internally and suggests the following modification:

Sodium chlorid........................ 10.

Sodium sulphate...................... 1.

Sodium carbonate......................40

Sodium phosphate..................... .30

Calcium phosphate.....................75

Magnesium phosphate...................75

The above is divided into 13 parts, each of which contains the mineral ingredients of 15 c.c. of Trunecek's serum or 150 c.c. of human serum. Allowing for the introduction of salts in foods, the equivalent of 1000 c.c. of blood serum would be a fair average dose for a day.

The above formula has the following objections: it does not correspond accurately to the ordinary analyses of blood plasma, the carbonate in blood is due mainly to carbon dioxid in process of elimination and hence is not an essential ingredient and the car-ixmatc in the formula causes a precipitate; the lime is objectionable on general principles. Hence, the author has employed the following original modification:

Sodium chlorid........................ 5.54

Sodium phosphate......................27

Potassium chlorid......................36

Potassium sulphate.....................28

Magnesium phosphate...................22

(or the lust may be omitted and the sodium phosphate increased to 0.50;.

The above may be considered as a close approximation of the mineral ingredients of 1000 c.c. of blood plasma and may be conveniently dispensed in 10 times this strength in solution with distilled water and further diluted as required. For instance, 20 times the amounts indicated may be added to the ordinary 2 liter bottle of distilled water, sold by various firms.

It is worth remembering that death from sudden heart failure, rupture of degenerated vessels, with or without macroscopic aneurysm, and including ordinary apoplexy, often occurs at or immediately after a meal. Hence it is important to avoid overloading the stomach, the concomitant use of alcohol, and such emotional causes as disgust at badly served food, anger, excessive merriment etc., which are very likely to occur at the table.