Compare with this line of treatment that which is indicated in acute cardiac strain after 40. The problem here is not how to deal with a chronically dilated and hypertrophied heart, but with a heart which has just yielded during effort, mainly in consequence of the nutritional impairment of its walls. It is not simply strain of a heart that had begun to be somewhat precariously nourished as a natural result of age; the probability is that the heart was actually gouty in the comprehensive sense of the term, that is, irritated by uric acid and embarrassed by flatulence, both mechanically and reflexly; and, indeed, possibly it was damaged by the atheromatous process. Rest is essential at first in the treatment of this type of case also; indeed, it is automatically secured by the distress which accompanies attempts at movement. But rest must not be carried too far, that is, it must not be of greater degree or duration than is absolutely necessary as indicated by the symptoms and signs, lest it aggravate the state of parietal mal-nutrition and promote fresh gout. At the same time the diet must be controlled strictly or even severely on the lines that I laid down for gout, lest the over-feeding which accompanies rest as a matter of thoughtless routine should have the same unfortunate effects. A course of treatment at some of the good home or Continental spas, with special precautions, is distinctly useful in senile strain, and the Nauheim methods have benefited more than one case of the kind in my experience, the degree of dilatation diminishing whilst the vigour of the heart increased. At the same time cardiac tonics of a medicinal kind are administered judiciously.