attempt to write hurriedly invariably brought on an attack such as I have described above, followed by symptoms which clearly pointed to an aggravation of the cardiac mischief, more particularly to an increase of the dilatation of the right cavities. 3. In those who are the subjects of valvular disease there is considerable danger of increasing the cardiac trouble. One case illustrated this in a marked manner. The patient was a young man whom I had previously treated for mitral regurgitation.

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... had steadily improved, competency was -established, and the amount of regurgitation had become comparatively slight. One evening he was called upon to finish a number of documents in a hurry ; he suffered, as he was doing them, from his heart in the manner which I have described above and on the next day he felt too ill to go out. On my being called to see him I found him in a half-fainting condition with a scarcely perceptible pulse but with a pronounced apex-beat, a markedly accentuated pulmonary second sound, and other evidences of considerable mitral regurgitation. Such a result occurring suddenly seems explicable only on the hypothesis of an interference with the blood-supply to the myocardium, the condition which I have described above as temporary malnutrition. It may be argued that the latter is of too short a duration to have any appreciable influence on the muscular tissue of the organ, but it must be remembered (a) that the regurgitation itself would in its turn tend to keep up the diminution in the amount of blood passing through the coronary arteries, and (b) that pathological changes in the left ventricle taking place as the result of anasmia of its substance are apt to occur with surprising rapidity. While I do not wish to infer that the changes in this case were of a permanent nature still it is feasible to suppose that a serious weakening either of the papillary muscles or of the fibres surrounding the mitral orifice had occurred, with the result above described. 4. The dangers of this condition in middle-aged or elderly persons, especially those presenting any signs of atheroma, are too obvious to need more than a mere mention. In such cases it is of the utmost importance to warn the patients against the harm of writing in a hurry. They are not likely to injure themselves by hill-climbing or athletics and they have probably learned by experience that it is better for them not to run upstairs or hurry to catch trains, but it has never dawned upon them that in their daily correspondence they are liable to a form of exertion equally dangerous both in its immediate and its more remote effects.