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DISEASES AND DISORDERS OF THE HEART 
 
ON 
 
 THE PRINCIPLES WHICH GOVERN 
 
 TREATMENT 
 
 IN 
 
 DISEASES AND DISORDERS 
 
 OF THE 
 
 HEART 
 
 THE LUMLEIAN LECTURES DELIVERED BEFORE THE ROYAL 
 COLLEGE OF PHYSICIANS, LONDON 
 
 BY 
 
 SIR RICHARD DOUGLAS POWELL, Bart., 
 
 M.D. (LoND.) 
 
 fellow of the college; physician in ordinary to her majesty the 
 queen; physician to the Middlesex hospital; consulting physician to 
 
 THE hospital for CONSUMPTION, BROMPTON, AND TO THE VENTNOR 
 
 hospital; knight of grace of the order of ST. JOHN 
 
 OF JERUSALEM 
 
 LONDON 
 H. K. LEWIS, 136 GOWER STREET, W.C. 
 
 1899 
 
PRINTED BY 
 
 H. K. LEWIS, 136 GOWER STREET, 
 
 LONDON, W.C. 
 
CONTENTS. 
 
 LECTURE I. 
 
 PAGE 
 
 Introductory remarks — Plan of lectures — On the innervation of the 
 heart and the vaso-motor mechanism — Definition of "neurosis" 
 and " neurotic " — Characteristics of the neurotic person — Car- 
 dio-vascular neurosis — Diagnosis — Principles of treatment — 
 Angina pectoris, without heart disease, with heart disease — 
 Tachycardia — Bradycardia — Exophthalmic goitre . . . i 
 
 LECTURE n. 
 
 Acute inflammatory diseases of the heart — Rest — Salicylates — Digi- 
 talis — Opium — Importance of prolonged rest in convalescence — 
 Chronic valvular heart disease — Attributes of digitalis — Use of 
 digitalis in the several forms — Mechanism and treatment of 
 dropsy . . • 43 
 
 LECTURE III. 
 
 Exercises in heart disease — Massage — Resistance exercises — 
 Aerated brine baths — Graduated walks — Respiratory exer- 
 cises — Acute heart failure — Fatigue of heart — Permanent 
 damage of heart from repeated over-taxation — The irritable 
 heart — Over-taxation of the heart in young people — Treatment 
 of cardiac overstrain — Infective endocarditis — Pathology and 
 etiology — Treatment by arsenic — Treatment by anti-strepto- 
 coccus serum — Table of 14 cases thus treated — Treatment by 
 yeast — "Backerin," nuclein and nucleinic acid in the treatment 
 of microbic diseases — Case of infective endocarditis treated by 
 nuclein — Concluding remarks .... . . 80 
 
DESCRIPTION OF PLATE I. 
 
 Yelloiv, — Medulla Oblongata, Spinal Cord, Anterior and 
 Posterior Nerve Roots, Vagus and its Cardiac 
 Branches and the Spinal Accessory Nerve. 
 
 Gr^g;^. — Sympathetic Chain. 
 
 Red. — Vaso-Motor Centre and Course of Augmentor 
 and Accelerator Fibres of the Heart. 
 
 Blue. — Course of Inhibitory Fibres of the Heart. 
 
 Black. — Course of Depressor Fibres of the Heart. 
 
 V.M.C. — Vaso-Motor Centre. 
 
 Sp. Ac. — Spinal Accessory Nerve. 
 
 A. of V. — Annulus of Vieussens. 
 
 G. St. — Ganglion Stellatum or ist Thoracic Ganglion. 
 
 2nd, 3rd, 4th and 5th T. R. — 2nd, 3rd, 4th and 5th 
 Thoracic Nerve Roots. 
 
 2nd, 3rd and 4th T. G. — 2nd, 3rd and 4th Thoracic 
 Ganglia of the Sympathetic. 
 
V.M.C 
 
 Medulla_^ 
 Oblongata 
 
 ^-~-^.x 
 
 '"■iiOt^ "^s^*"- 
 
 Spinal Cord — j 
 
 S'bT.R 
 
 DIAGRAM OF THE INNERVATION OF THE HEART 
 
DESCRIPTION OF PLATE 11. 
 
 Yellow. — Medulla Oblongata, Spinal Cord and Spinal 
 
 Nerve Roots. 
 Red.- — Vaso-Motor Centre and Course of Vaso-Motor 
 
 Fibres. 
 Blue. — Vagus its Cardiac Branches and all the Cardiac 
 
 Plexuses. 
 
 Green. — Sympathetic Chain and its Cardiac Branches. 
 
 V.C. — Vaso-Motor Centre. 
 
 S.C.G. — Superior Cervical Ganglion. 
 
 R.L. — Recurrent Laryngeal Nerve. 
 
 D.C.P. — Deep 7 /- j- t->i 
 
 ^ ^ Cardiac Plexus. 
 
 S.C.P. — Superficial} 
 
 f .C.-Left"^} Coronary Plexus. 
 
Va^us 
 
 Upp. limit Lung — 
 
 Lun^ 
 
 Va^us 
 
 Sup. extremity 
 
 ( Upp. limit) 
 
 Upp. limit j_ ^, 
 
 Abd. vise. ^X. 
 
 Upp. limit _[} ^^~ 
 Kidney j i 
 
 Lower limit Lun^yij — -< -{ 
 
 X I J 
 
 r x-^A \ 
 
 Y \.A 
 -T A 
 
 Heart 
 
 |\^ 
 
 1/ 
 
 
 r 
 
 /; 
 
 Splanchnics-S // 
 
 Lower limit Abd. vise \^ 
 
 including Kidne_/ 
 
 I 
 
 ^"'1 
 
 
 i 
 
 "^X^ } Lower limit for Sup. E^trem. 
 
 if 
 
 Upp. limit for Infer Extrem. 
 
 ■4-. 
 
 f 
 
 Inferior Extremity 
 (Lower iimitj 
 
 DIAGRAM OF THE INNERVATION OF THE HEART 
 
THE 
 
 PRINCIPLES WHICH GOVERN TREATMENT 
 
 IN 
 
 DISEASES AND DISORDERS OF THE HEART. 
 
 LECTURE I. 
 
 Mr. President and Fellows, 
 
 It was in a rash moment that on being 
 honoured by the request of the Council of the College 
 that I should this year give the Lumleian Lectures I 
 chose the subject of Heart Disease for my text. 
 
 It was something of the feeling expressed by the 
 late Dr. Stokes* that heart diseases tend still to be 
 regarded from too detached a point of view that led 
 me to this selection. One may, for instance, still read 
 of angina pectoris as a separate and fatal affection of 
 the heart, instead of its being regarded as a painful 
 incident of varied significance that may occur in the 
 course of a wi'de range of functional and organic 
 diseases of the cardio-vascular system. 
 
 Separate chapters must be devoted to describing the 
 peculiarities of aortic, of mitral, of pericardial, of 
 
 * W. Stokes, " Diseases of the Heart and Aorta," Dublin, 1854. 
 
 B 
 
TREATMENT IN DISEASES AND 
 
 trophic diseases of the heart, but the effectual grasp of 
 their practical treatment is weakened unless they be 
 gathered up again for review from more comprehensive 
 standpoints. I have at least no other excuse for again 
 dealing with a subject that has recently and so ably been 
 brought before the College in almost every relation by 
 our distinguished Fellows — Sir W. Broadbent,* Dr. 
 Leechjt Dr. Lauder Brunton,:]; and Dr. Markham 
 Skerritt§ — and treated of in several able works which 
 have recently appeared. 
 
 It is easier to find " books in the running brooks " 
 and " sermons in stones " than to thread into a dis- 
 course, suggestive interesting and helpful, the current 
 knowledge of a subject familiar to those to whose 
 thoughts in their daily work it must be ever recurring. 
 
 It is, however, one of the functions of the Lumleian 
 lecturer to attempt this, to review from the side of 
 experience and clinical observation the net results of 
 most recent researches and to endeavour to show how 
 far they should influence us in our daily practice. 
 
 There is perhaps no branch of medicine in which, 
 notwithstanding much knowledge, the confidence of 
 the practitioner is so easily shaken and in which he is 
 
 * Sir W. Broadbent, " Prognosis in Structural Diseases of the Heart," 
 Lumleian Lectures, 1891. 
 
 f Dr. J. Leech, " Croonian Lectures," British Medical Journal, 1893, 
 vol. i., pp. 4, 56, 108, 169. 
 
 J Lauder Brunton, " Modern Developments of Harvey's Work," 
 Harveian Oration, 1894. 
 
 § Markham Skerritt, " Bradshaw Lecture," British Medical journal, 
 1897, vol. ii., p. 1327. 
 
DISORDERS OF THE HEART. 
 
 so apt to relinquish the courage of his opinions as in 
 heart diseases ; and there is none in which the public, 
 who treat their hearts with too much respect and their 
 nervous system with too little, require such firm and 
 steadfast guidance at the hands of our profession. 
 
 In my endeavour to lay down the lines of treatment 
 of heart disorders and diseases I will first speak of 
 such modifications of the cardiac functions as are the 
 result of disturbed or even organically changed inner- 
 vation of the heart and vessels, the heart itself being 
 sound. Secondly, I must glance at similar disturb- 
 ances of extrinsic sources as they affect an unsound 
 heart. Thirdly, I will endeavour to group from a 
 therapeutic point of view the intrinsic disablements 
 and diseases of the heart mainly under the headings — 
 (i) of heart failure in acute disease ; (2) of cardiac 
 overstrain ; (3) of chronic heart failure ; (4) of acute 
 inflammatory cardiac affections ; (5) of chronic valvular 
 affections of the heart ; and (6) of ulcerative diseases 
 of the endocardium. 
 
 In order to understand so far as is at present 
 possible functional diseases of the heart and to arrive 
 at a point from which we may safely take further steps 
 in their apprehension, we must have clearly traced in 
 our minds the paths of direct and indirect cardiac 
 innervation and the vaso-motor nerve mechanism. 
 
 I have with the kind help of my friend Dr. Risien 
 Russell illustrated these two systems of nerve mechan- 
 ism on separate charts, which show with precision our 
 anatomical and physiological knowledge which has 
 
 B 2 
 
TREATMENT IN DISEASES AND 
 
 been brought to its present degree of completion by 
 the labours of Claud Bernard, Roy, Adami, Bradford, 
 and others, but most especially of Gaskell. These 
 diagrams will be quite sufficient without any further 
 description from me to bring afresh to your minds the 
 main points respecting the innervation of heart and 
 vessels with which you are well acquainted, and will 
 serve for reference at any time in the course of my 
 remarks. 
 
 It is impossible to isolate the heart from the vessels 
 when thinking of its functional disturbance ; we must 
 look upon the cardio-vascular system as a whole. 
 Originally a mere branched contractile tube, it is now 
 but a highly differentiated tubal apparatus with a 
 nervous mechanism which has grown in complexity 
 pari passu with the manifold interests of the circulation 
 in the extended empire to which it has to minister. 
 
 With considerable accuracy the blood may be said 
 to be held in the grasp of the cardio-vascular tubes ; 
 that the blood current is maintained and directed by 
 the rhythmic pumping action of the two ventricles and 
 by the position of the valves. The tendency is for the 
 muscular arterial system to evacuate all the blood into 
 the lax and capacious venous system, but the due pro- 
 portion of blood distributed to the arteries and veins is 
 secured by the controlling action of the small vessels 
 which regulate the flow through the capillaries. 
 
 The heart and vessels are, indeed, an intricate 
 mechanism, one part of which reacts upon another; 
 each section of the circulation is influenced by the 
 
DISORDERS OF THE HEART. 
 
 needs of the organ or tissue which it serves and the 
 whole is coordinated by the central nervous system to 
 the control of which it is in every detail subservient. 
 Whenever any commotion occurs of sufficient intensity 
 beyond the common in any department of the circula- 
 tion, our consciousness becomes aware of it, but it is of 
 disturbances excited in the heart's doings, although 
 they may be but central to a more widely ranging 
 disorder, that our consciousness takes especial note. 
 
 There are unquestionably a large number, perhaps 
 an increasing number, of people who are morbidly 
 conscious of their heart's action, indeed of the function 
 of their cardio-vascular system generally or in parti- 
 cular parts. They feel disturbances, flutterings at the 
 heart, throbbings, flushings, pallors of the surface or 
 noises in the vessels about the head, and apart from 
 and in the intervals of these more definite sensations, 
 they have a sense of their heart beating, and appreciate 
 sometimes a disorder, an intermission, or a faintness in 
 its action. 
 
 This condition, or group of conditions, and the 
 thousand and one variations to which it is subject, 
 is the result of a purely nervous disorder. 
 
 It occurs in people of both sexes, mostly young 
 people between puberty and thirty, of nervous inherit- 
 ance, or who have exhausted their nervous system in 
 various ways by dissipation, excess of tobacco, alcohol, 
 venery, or over-pressure of brain work. It is amongst 
 the class of so-called " neurotics " that functional dis- 
 orders of the heart so largely abound, and it will be 
 
TREATMENT IN DISEASES AND 
 
 well to try to answer the question : — What constitutes 
 a '' neurotic person " ? The term is constantly and 
 increasingly used ; has it any definite meaning ? 
 
 A neurosis is a functional, as apart from an organic, 
 disturbance in a nerve centre and the disturbance is 
 generally manifested as an hypersesthesia. A neurotic 
 person is a person whose whole nervous system, and 
 especially that portion of it known as the visceral 
 nervous system, is hypersensitive and abnormally with- 
 in his cognisance. 
 
 " Neurotic " is sometimes used as a term of re- 
 proach ; it is often confounded with hysteria, which 
 is indeed but one of its lesser manifestations. It is a 
 condition of nervous system, sometimes acquired, but 
 more often hereditary, very widely prevalent even in 
 our cold-blooded race and which is perhaps a national 
 characteristic in some brighter climates. 
 
 The neurotic element is a factor to be reckoned with 
 in practical medicine, and whilst sometimes found 
 amongst the self-indulgent, is quite as often seen in 
 persons with a high degree of self-control, an invin- 
 cible courage and a restless energy and enterprise. It 
 is especially prevalent amongst the educated classes 
 and is a marked feature in many highly gifted and 
 interesting people. 
 
 The tendency of the neurotic is to intemperance in 
 thought and action : he will shrink from a little pain 
 but heedlessly rush into great danger ; his cerebration 
 is quick, alert, often fantastical, and he excels in crafts 
 requiring intensity rather than quantity of cerebral 
 
DISORDERS OF THE HEART. 
 
 function. If we physicians are sometimes dazzled by 
 his mental brilliancy, his powers of acquisition, rapidity 
 of thought, brilliancy of conversation, we are more 
 often bewildered by his powers of suffering. Intro- 
 spective in many ways, he is morbidly so with regard 
 to his own physiology. Just as some persons are 
 gifted with an intensity of hearing which enables them 
 almost painfully to appreciate the overtones in music 
 unrecognised by their fellows, or to perceive sounds 
 and impulses that are appreciable only to single 
 specialised faculties of the lower animals, so there are 
 some persons who are in an exaggerated degree sensi- 
 ble of their own organic mechanism, sensitive to the 
 physiological working of that mechanism as distin- 
 guished from painful and morbid function. 
 
 Our sense of life is probably a pleasurable impres- 
 sion of undiscerned physiology. But it is of our cardio- 
 vascular mechanism that of all functions we most 
 readily become conscious and that, apart from any 
 actual suffering, we most often become unduly con- 
 scious, and it is in this department of their physiology 
 that these over-sensitive persons whom we classify as 
 neurotics are most apt to suffer. 
 
 Although the attentive observer could at sight pick 
 out from a crowd of persons the two or three neurotics 
 present he would be much puzzled to give his reason 
 for so doing. Perhaps an indefinable alertness of the 
 facial muscles, a quickly changing expression, a mobile 
 and slightly contracted pupil, within creased sclerotic 
 exposure, are the characteristic features. 
 
TREATMENT IN DISEASES AND 
 
 These persons have a quick circulation, a somewhat 
 raised and variable arterial tension, their thermic cen- 
 tres are unstable and temperature charts with them 
 have to be discounted. Neuralgic affections are com- 
 mon, and amongst them and in their families will be 
 found the other functional nervous complaints, mi- 
 graine, epilepsy, asthma, hysteria, and the visceral 
 neuroses so well described in this place by our collea- 
 gue Professor Clifford Allbutt.* 
 
 From the social side they are delightfully portrayed 
 in some of the stories of a Member of our College who 
 writes under the pseudonym of " Philip Lafargue." 
 I must apologise for making these digressive remarks 
 on neurotics, but the term has crept into frequent use ; 
 I may have often to use it myself in this lecture and I 
 am anxious to give as much definiteness as possible to 
 the idea it should convey. 
 
 Functional disorders of the heart are sometimes due 
 to a defect in the organ itself, more commonly they 
 are caused by stimuli reflected from distant organs or 
 parts, generally dependent upon morbid states of the 
 blood circulating through the heart or disturbing the 
 centres of its nervous mechanism, an acquired or here- 
 ditary instability of the nervous system being often re- 
 cognisable. 
 
 In endeavouring to lay down the lines of treatment 
 of functional disturbances of the heart we must hold in 
 comprehensive review the vast tangle of circumstances 
 
 * Clifford Allbutt, Gulstouian Lectures, 1884. 
 
DISORDERS OF THE HEART. 
 
 which influence directly or indirectly the now suffi- 
 ciently well-defined cardiac innervation. 
 
 I have endeavoured in this table to summarise the 
 causes of that want of stability which marks the func- 
 tion of the neurotic heart. 
 
 TABLE I. 
 
 Cardio- Vascular Neurosis. 
 
 Definition. — An increased sensibility and a disordered 
 action of the heart and vessels not dependent upon 
 structural change. Want of stability may be located 
 in the cardio-vascular muscle caused by : — 
 
 1. Malnutrition . . . Anaemia. 
 
 2. Defective metabolism . . Fatty infiltration ; retention of 
 
 effete materials. 
 
 3. Morbid blood stream . . Gout ; renal or liver inadequacy 
 
 or surcharge ; anaemia. 
 
 4. Functional overstrain . . Fatigue. 
 
 Want of stability may be located in the nervous 
 system and due to : — 
 
 1. Toxic influences . . . Specific p^-rexias ; nicotine; al- 
 
 cohol ; digitalis ; uric acid and 
 its allies ; excessive absorption 
 from ductless glands ; deficient 
 absorption from ductless glands. 
 
 2. Reflex excitation or depression Abdominal ; gastric, renal, intes- 
 
 tinal, hepatic ; pelvic ; dental. 
 
 3. Direct excitation or depression Emotional ; anxiety, fear, anger. 
 
 Brain disease or injury; con- 
 cussion, compression, menin- 
 gitis, cerebritis, &c. 
 
10 TREATMENT IN DISEASES AND 
 
 There are three stages or degrees — if we may so 
 speak of them for convenience — of cardio-vascular hy- 
 perassthesia. 
 
 The first degree, consisting of that undue apprecia- 
 tion of the heart's action and the blood circulating 
 through the vessels to which I have alluded, is ex- 
 tremely common in nervous introspective people. The 
 heart's action may be quite normal, but it is liable 
 from slight causes to become paroxysmally excited and 
 accelerated. The pulse tension is variable. The patients 
 are all of the neurotic class, the neurosis being heredi- 
 tary or acquired through the usual causes. 
 
 I have described* instances of this degree of cardiac 
 disturbance in a brother and sister whose father died 
 insane, their mother from spinal paralysis, their grand- 
 mother was on the verge of insanity, and the brother 
 was highly neurotic. But alcoholic, social, and tobacco 
 excesses and mental overwork will produce the same 
 effect. 
 
 The next degree is that in which the heart's action 
 is really oppressed to a point varying from a mere 
 vague anxiety such as that alluded to by Hamlet when 
 he says, " But thou wouldst not think how ill all's here 
 about my heart," to a positive discomfort and onwards 
 to the third degree, the acute suffering of angina. 
 
 Increased arterial tension is an essential factor 
 noticeable in the second class of cases. These per- 
 
 * " Introduction to Discussion on Functional Diseases of the Heart." 
 British Medical Association Meeting, Bristol, 1894. British Medical 
 journal, Nov. loth, 1894. 
 
DISORDERS OF THE HEART. 11 
 
 sons, be it remarked, may not be introspective ; their 
 attention is not concentrated upon their circulation, 
 but is compelled thereto by actual discomfort or pain. 
 
 It is interesting to note that that vague and ill- 
 defined anxiety concentrated about the heart, of which 
 so many of these patients complain, is closely allied in 
 character and probably in mechanism, but in verj' 
 mitigated degree, with that cardiac terror so charac- 
 teristic of angina pectoris. Although slight and diffi- 
 cult to define, this discomfort is one of the most 
 common causes of such patients seeking advice " for 
 something wrong about the heart." 
 
 The usual symptoms of increased arterial tension are 
 present and are to be traced to the usual causes of that 
 affection, viz., mental shock, anxiety, hurry in work, 
 sedentary lives, numerous and overlapping social en- 
 gagements, constipation, the threatening of a gouty 
 storm, &c. There is no cardiac lesion necessarily 
 present, although, as we well know, chronic high 
 arterial pressure will in time lead to, and is often 
 attended by, gradual cardiac changes of a degenerative 
 kind. 
 
 It is from amongst the first two classes of cases — 
 not distinct but merging into one another — here re- 
 ferred to that the cases of vaso-motor angina come. 
 It is not difficult to see how shock, chill, emotion, 
 dyspeptic distension of nerve-endings, and other causes 
 referred to in Table I., may so increase arterial resist- 
 ance as to cause cardiac embarrassment and anginal 
 pains. Paroxysmal attacks of palpitation or tumul- 
 
.12 TREATMENT IN DISEASES AND 
 
 tuous action of the heart are not uncommon incidents 
 in connection with especially the second degree of 
 cardio-vascular neurosis described, the attacks being 
 attributable to sudden vaso-motor relaxation or to 
 vagus irritation from dyspeptic or gouty causes. 
 
 Now the first degree of cardiac hyperassthesia is 
 most common in young adult life in both sexes, but 
 more common amongst males than females ; cases are 
 not infrequently met with in females later, about the 
 menopause and even in later life. Those in the second 
 category are far more common amongst males and 
 prevail most from about thirty-five to fifty years of 
 age. 
 
 The time at my disposal will not permit me to 
 consider at any length the perverted physiology of 
 neurotic disturbances of the heart and vessels. Its 
 details are well understood — the paths of transmission 
 are anatomically marked out for us ; the causes of 
 disturbances of central origin, those originating in 
 irritation of visceral or peripheral nerve-endings, the 
 toxic effect of undue absorption from glands, thyroid, 
 adrenal, ovarian, testicular, as well as those of retained 
 excretory products, from defective elimination or over- 
 production, are all recognised as more or less potent 
 factors in cardio-vascular disturbances ; and finally, 
 the effects, immediate or remote, of drugs — digitahs, 
 atropine, tobacco, the whole range of hypnotics and 
 analgesics, cocaine, antipyrin, phenacetin, sometimes 
 prescribed by the medical attendant but sometimes 
 taken without his sanction. 
 
DISORDERS OF THE HEART. 13 
 
 It is very difficult precisely to formulate the harm 
 done by amateur drug-taking for pain, sleeplessness, 
 and spasmodic suffering. It seems to me that it may 
 be clinically summarised by saying that the controlling 
 centres of the nervous system suffer chiefly, emotional 
 disturbances are more easily excited, reflex agitation is 
 less controlled, and the cardio-vascular and thermic 
 centres are diminished in tone. 
 
 A neuralgia which in former days necessitated the 
 called for nerve rest is now promptly subdued by a 
 dose of antipyrin or anticalmin, and the patient is 
 enabled thus to take a further step in nervous fatigue 
 without direct suffering. 
 
 Neurotic persons as a class take too little food, are 
 always hurried over the meals and in the details of life, 
 they eat too fast and have a tendency to exceed in 
 nerve stimulants, tea, tobacco, alcohol and certain 
 drugs, or they find their excitement in social enter- 
 tainments. 
 
 It is in all cases essential to make a thorough 
 examination of the heart and to come to an absolute 
 diagnosis, for the treatment rests largely on moral 
 grounds and must be supported if possible by an 
 assurance of physical soundness. 
 
 If on careful examination the position and dimen- 
 sions of the heart be found normal, and the character 
 of the impulse and sounds be such as are not incom- 
 patible with textural soundness of the valves, an 
 absolute opinion can be expressed. 
 
 There is undoubtedly room for anxious consideration 
 
14 TREATMENT IN DISEASES AND 
 
 and hesitation in regard to the character of the impulse 
 and sounds of the heart in many of these cases, for the 
 impulse is often violently increased and apparently 
 extended by undue locomotion of the organ and the 
 sounds are perhaps disorderly, reduplicated, and not 
 infrequently attended with murmurs. Still a careful 
 investigation, selecting a time when the action is more 
 tranquil, will in most cases suffice to convince the 
 experienced observer as to whether such sounds are 
 significant of organic disease or compatible with mere 
 disorder. 
 
 Functional murmurs do not strictly accord in posi- 
 tion and conduction with those due to valve defects. 
 Any such murmurs present are always systolic or post- 
 systolic, often somewhat frictional in character, never 
 in my experience diastolic or presystolic, and most 
 generally are heard with undue loudness over the neck 
 vessels or sometimes are very apparent over the lung 
 even remote from the heart, and especially so during 
 inspiration. 
 
 There is no history of rheumatic fever or of previous 
 heart disease. 
 
 If the patient who suffers from any disturbance of 
 the heart's action, whether it be mere abnormal con- 
 sciousness of its action or the most severe palpitation 
 or anginoid attacks, can be truthfully assured that 
 there is no organic lesion, that his troubles, however 
 painful or distressing are not mortal, a most important 
 step is taken in the treatment. 
 
 On the other hand, we have most of us seen patients 
 
DISORDERS OF THE HEART. 15 
 
 whose lives have been rendered miserable with the 
 ever-present fear of disaster owing to a hasty and ill- 
 considered diagnosis of a weak or a dilated heart — a 
 diagnosis that should never be made without the gravest 
 sense of responsibility and requiring in some cases more 
 than one careful examination. 
 
 It was only very recently that I was consulted by a 
 young married woman, formerly of active, energetic, 
 useful habits, who had been told by a medical man 
 whom she had consulted when away from home that 
 she had a weak heart. She had been taking the 
 utmost care of a healthy organ ever since, resting half 
 the day, never even walking upstairs, until she had 
 become fat, breathless, anaemic, and miserable, and it 
 will be many months before she will be fully weaned 
 back to her former healthy activity, if this ever occurs. 
 
 Having come to a diagnosis and reassured the 
 patient with regard to prognosis the next point is to 
 investigate the patient's mode of life with a view to 
 correct physiological errors, if such there be. 
 
 A sample day's doings noted down and corrected 
 here and there as the case may demand is an elemen- 
 tary measure of treatment. 
 
 The removal of the morning cup of strong tea or its 
 replacement by a small cup of warm milk diluted with 
 Vichy or other water, the arrangement by rising a little 
 earlier for a leisurely breakfast and time for a proper 
 relief of the bowels before entering upon the day's 
 work, the avoidance of rush at the luncheon hour, and 
 the securing of a quiet hour before dinner will, with a 
 
16 TREATMENT IN DISEASES AND 
 
 few sensible directions with regard to the dietary, do 
 much to render digestion more complete, and quiet the 
 nervous system. Many of these people have really but 
 little to do, but they are always in a hurry about it. 
 
 Another considerable portion who earn their daily 
 bread and support their families by hard and exacting 
 toil are yet impelled by their nervous energies to occupy 
 all their leisure evenings, off afternoons and Sundays, 
 with honorary secretarial duties or teaching or amateur 
 philanthropy — all which duties with a heavy heart but 
 a determined mind the physician in these particular 
 cases has to prune down in order that they may con- 
 tinue to do that which is essential for themselves and 
 their families. 
 
 But there is yet another class of men, chiefly in the 
 forties and fifties, who in earlier years have been 
 physically active, even athletic, but of late, with quad- 
 rupled professional, business, domestic and social 
 affairs on hand, have lost leisure for exercise, yet 
 preserve their powers of eating and drinking as regards 
 quantity but enriched in quality. 
 
 All such tend to venous plethora, retarded circulation 
 in their great organs, heightened blood-pressure, fat- 
 laden and infiltrated heart, and from them a large 
 contingent of functional heart disorders are furnished. 
 
 These are the cases in which a yearly course of the 
 waters of Harrogate, Homburg, Carlsbad, Marienbad, 
 &c., are so valuable and in which the terrain cure of 
 Oertel is to be advocated, but a little wise overhauling 
 of the dietary by the physician, the resolute acceptance 
 
DISORDERS OF THE HEART. 17 
 
 of such by the patient, and the adoption of steady 
 daily exercise dovetailed in with the work, will do much 
 to perpetuate cures thus initiated. I shall allude to 
 these cases again and need only now say that their 
 hearts are lazy and hampered, not weak ; they require 
 sensible guidance not to have cardiac introspection as 
 an administered neurosis. 
 
 Having (i) given an absolute diagnosis, and (2) 
 having investigated and corrected the habits of life in 
 whatever respect they may be faulty, we have (3) to 
 ascertain and remove — or, at least, to treat — the excit- 
 ing cause of cardiac disturbance. These are for the 
 most part of reflex origin — gastric, intestinal, rectal, 
 and renal. 
 
 I have seen very striking instances of great func- 
 tional disturbance of the heart and sometimes also 
 pulsation of the abdominal aorta attended with floating 
 kidney. Exostosis, bad teeth and other sources of 
 distal irritability are frequent causes of disturbed 
 cardiac innervation. 
 
 A married woman, aged thirty-six years, seen with 
 Dr. Armstrong of Buxton, had for two years suffered 
 from excessive cardiac irregularity and frequent attacks 
 of spasmodic heart pains. She attributed her illness 
 to much previous mental anxiety. Her symptoms had 
 increased the last few months and the cardiac disturb- 
 ance became so constant that she could neither go into 
 society nor receive friends. 
 
 There was no valvular disease of the heart and its 
 dimensions were normal, but the action was most 
 
 c 
 
18 TREATMENT IN DISEASES AND 
 
 irregular and intermittent. Her teeth were extensively 
 decayed, surrounded with tartar, and the gums were 
 unhealthy. She had declined to have them seen to, 
 however, and she was put through a course of Nauheim 
 baths and resistance exercises and her digestion at- 
 tended to with only slight relief. 
 
 After the consultation she consented, on March 
 28th, 1897, to have all her affected teeth removed 
 under gas and ether, which she took well, and from 
 that time her cardiac symptoms have entirely ceased, 
 although Dr. Armstrong adds: — "She has been ex- 
 posed to even greater nerve-strain than before." In 
 this case there were no marked dyspeptic signs and 
 the cardiac symptoms seemed to be due chiefly to the 
 reflected irritation of the decayed teeth. 
 
 Professor Clifford Allbutt* in his Gulstonian Lec- 
 tures alludes to many cases of cardiac attacks of a 
 functional kind, with very slow, quick, or intermittent 
 action and in some with distinct anginal symptoms, 
 which he had observed to occur in connection with, 
 often in succession to or alternately with, some form 
 of visceral neuralgia, especially gastralgia, or some 
 uterine disturbance, such as menorrhagia. 
 
 Professor Allbutt points out that pulmonary gastric 
 and cardiac neuroses are often concurrent in families, 
 and I have seen a striking instance in which they have 
 each been present at different times in the same 
 individual. 
 
 Here it is clear that we have to do with a central 
 * Loc. cit. 
 
DISORDERS OF THE HEART. 19 
 
 neurosis manifesting itself in different viscera at dif- 
 ferent times. Professor Allbutt is, moreover, careful 
 to point out that in his cases of cardiac disturbance 
 following gastralgia there was no dyspepsia proper. 
 The causes of high tension other than those mentioned 
 must be looked for and, if possible, treated. The gouty 
 disposition has to be reckoned with. 
 
 In this department of inquiry and rectification will 
 come the causes of those conditions of the heart 
 muscle which, rendering the organ especially irritable 
 and inadequate in function, are accountable for breath- 
 lessness, palpitation, and spurious anginal seizures. 
 
 Fatty infiltration of the inter-muscular texture and 
 incomplete removal of waste materials from the cardiac 
 muscle briefly constitute the pathology of these cases. 
 
 Venous plethora is the marked feature in them all, 
 and graduated exercises, restrictions in diet and 
 hepatic depletory medication are the principal mea- 
 sures of treatment. 
 
 The diet should in these latter cases be carefully 
 looked to. It should be spare, slowly eaten, taken at 
 regular meal-times only, and may consist of a good 
 breakfast, a moderate amount of fresh cooked meat 
 without fat for luncheon, and poultry or game for 
 dinner. Starchy and root vegetables and bread should 
 be removed, or only very sparingly allowed with th© 
 lunch and dinner meals, crisp toast or biscuits being 
 substituted for bread. The amount of fluid taken with 
 the meals should be restricted in decided cases to a 
 claret glass with luncheon and two glasses with dinner. 
 
 c 2 
 
20 TREATMENT IN DISEASES AND 
 
 This may consist of one or other of the light wines or 
 diluted spirit in measured quantity. About from an 
 hour to two hours after or from half an hour to an 
 hour before meals a glass of plain hot water should 
 be slowly sipped to supplement the fluids taken. 
 •-^I shall deal further with the question of exercises for 
 these patients later when speaking more specifically 
 of the Oertel and Schott methods of treatment, which 
 are particularly adapted to them. 
 
 The great principle that underlies and shoidd govern 
 the whole treatment of functional and neurotic heart 
 affections is a steadfast endeavour to help the subjects 
 of them through with their lives and not to make 
 invalids of them or to allow them to become so. 
 
 They may require treatment for definite times, 
 amongst them one even meets v/ith some rare neura- 
 sthenic cases requiring the Weir Mitchell treatment, 
 they may require restraint in definite ways — perhaps 
 some limit marked out in their work ; but the utmost 
 care must be exercised to discourage the introspective 
 habit to which they are particularly and from the very 
 nature of their malady prone. 
 
 Where social engagements and professional or other 
 work overlap one or other must of course be curtailed. 
 It is at the same time of the utmost importance to 
 secure to these people their interest in their surround- 
 ings and not ruthlessly to interfere with such duties 
 and amusements, philanthropic, religious, or social, 
 as may be the salt which savours their doings. We 
 have to adjust, to apportion, not to spoil the daily hfe. 
 
DISORDERS OF THE HEART. 21 
 
 All instrumental treatment or observations of them 
 should be avoided. They should be enjoined to take 
 moderately active open-air exercises, during which 
 they should be directed to take the deepest possible 
 inspirations, so as thoroughly to ventilate the lungs 
 and stimulate complete cardiac circulation. Great tem- 
 perance in alcohol and tobacco and moderation both 
 in tea and coffee must be observed. For those who 
 are delicate, easily fatigued, or mentally hard-worked a 
 period of rest before meal times must be insisted upon 
 and particularly before the late dinner. 
 
 In the more pronounced cases the passive exercise 
 and soothing monotony of a well-planned sea voyage 
 is sometimes very advantageous, only, however, for 
 those who are able to eat and sleep well on board 
 ship. The restful regime of a spa suits others, the 
 particular spa being selected for its chalybeate or its 
 eliminative effects as the case may require. 
 
 Again the more formulated treatment by surface 
 stimulation from aerated saline baths, combined with 
 rest and passive resistance exercises, proves very bene- 
 ficial in some cases, more particularly those in which 
 there is a gouty element, the arterial tension ranging 
 high and nervous introspection not being too marked 
 a feature. 
 
 A definite course of spa treatment is often useful— 
 indeed, sometimes essential — in serving the purpose of 
 inculcating the habit of self-discipline and starting the 
 patient on a better regulated and more physiological 
 plan of life. 
 
22 TREATMENT IN DISEASES AND 
 
 Drugs are of course often required in the treatment 
 of functional disturbances of the heart, purgatives or 
 laxatives, and particularly an occasional mercurial to 
 lower arterial tension and to remove irritating mate- 
 rials. Sometimes nerve sedatives of the bromide order 
 are required, or hsematinics, especially arsenic and 
 iron, as tonics to the nervous system and blood 
 restorers. Strychnia is badly borne by patients of the 
 neurotic class, except in small doses for short periods, 
 and where a cardiac tonic is required, caffein is more 
 appropriate. 
 
 In cases of venous plethora a course of salines is 
 sometimes necessary and in gouty cases suitable re- 
 medies. It may, however, be said that there is no 
 special drug treatment for cardiac neuroses except in 
 some of the acute and stormy manifestations to be 
 next considered. 
 
 It is a fact which is perhaps too often forgotten in 
 clinical medicine, but which I am sure the experience 
 of those present will recognise, viz., that functional 
 disturbance similar in kind to those we have been 
 considering is as frequently observed in association 
 with diseased as in healthy hearts and that many of 
 the troubles and some of the catastrophes of cardiac 
 disease are attributable to functional derangement. 
 
 In speaking, therefore, of the treatment of angina 
 pectoris in its place amongst cardiac neuroses, I shall 
 deal with it in so far as it occurs as a neurosis both in 
 connection with healthy and unhealthy hearts, and I 
 shall reserve the other forms of angina for later con- 
 sideration. 
 
DISORDERS OF THE HEART. 23 
 
 The subject of angina pectoris is a difficult one 
 enough to formulate with regard to etiology and 
 morbid mechanism with a view to prophylactic and 
 remedial treatment. The difficulties diminish when 
 we recognise that there is a continuity in the pheno- 
 mena presented to us for treatment from the slighter 
 degrees of introspective recognition of the cardio- 
 vascular mechanism, through the more distinct evi- 
 dence of cardiac anxiety and distress in connection 
 with the higher and more persistent grades of arterial 
 tension to the paroxysmal attacks of acute breast pang 
 associated with a veritable asthma of the blood-vessels 
 which may supervene in any cases of the series, and 
 this continuity is to be observed between so-called 
 false and true angina, although some writers will not 
 admit the term angina except as applicable to the fatal 
 cases of coronary origin. 
 
 We have discussed the neuroses, we have briefly 
 alluded to points of treatment for the condition causing 
 the high tension and leading up to the paroxysms, and 
 we must now briefly outline the treatment of the 
 paroxysm itself. 
 
 In a large proportion of cases angina pectoris is an 
 entirely functional disorder, the main feature of which 
 is sudden increase of blood-pressure and a correspond- 
 ingly sudden caH upon cardiac effort ; it may be on the 
 systemic, it may be on the pulmonary side of the 
 circulation that the strain arises. 
 
 There are many causes that will bring about this 
 arterial spasm and there is the underlying neurosis 
 
24 TREATMENT IN DISEASES AND 
 
 that favours its occurrence. The causes are almost 
 all within our scope of remedial treatment and the 
 neurosis is subject to considerable modification and 
 control. But it is important to remember that in all 
 these cases whilst it is the heart that suffers the angina, 
 the conditions which originate that suffering are out- 
 side the heart, and all our treatment is directed in the 
 first instance to alter these external conditions and in 
 the second to support the heart. 
 
 There is no essential difference save in degree, and 
 not always in degree, between cases of angina in which 
 the heart is sound and those in which it is unsound, 
 but there is every difference in the gravity of prognosis 
 and the urgency for treatment in the two cases. For 
 whilst on the one hand the man or woman who has 
 angina with a sound heart is in no danger of dying, 
 and the object of treatment is to relieve suffering and 
 avert alarm until the perverted physiology has time to 
 rectify itself; in cases, on the other hand, in which 
 there is unsoundness of heart, whether textural or 
 valvular, the patient is in imminent danger and re- 
 quires prompt treatment to relieve suffering and to 
 avert death if death can be averted. 
 
 The cardiac pain in vaso-motor angina is difficult 
 satisfactorily to explain ; it is distinctly a result of 
 intra-ventricular pressure and from its character and 
 radiation it must be primarily an affection of the sen- 
 sory nerves of the heart caused by stretching of its 
 tissues and causing the contraction of the tissues to be 
 attended with pain. 
 
DISORDERS OF THE HEART. 25 
 
 The endocardial surface is more sensitive than the 
 pericardial surface of the heart ; but comparatively 
 insensitive tissues, when stretched become very pain- 
 ful. 
 
 Dr. Allen Sturge* observes that reflected pain is only 
 an ordinary sensation conveyed to a nerve centre in 
 commotion by which it is intensified to a painful 
 sensation. Thus may the reflected pains be accounted 
 for as emanating from the centres disturbed through 
 the cardiac nerves. 
 
 Contrariwise we have only to conceive a slight 
 degree of hyperassthesia of the visceral nerve centres to 
 account for that undue perception of the cardio-vas- 
 cular mechanism which is the first grade of neurotic 
 disturbance and which can readily become a painful 
 perception of increased pressure within the heart. 
 
 The two points requiring consideration in an anginal 
 attack of the kind now under consideration are the 
 pain and the degree of heart failure. 
 
 The pain, which is to a certain extent the measure 
 of the strain upon the heart, is to be attacked by 
 remedies which relax arterial spasm. Amyl nitrite, 
 nitro-glycerine, and the nitrites generally, but especially 
 nitro-glycerine, i min. of the i per cent, solution may 
 be given at intervals of five minutes for two, three, 
 five, or more doses, and at the same time that the 
 anti-spasmodic is given an appropriate cardiac stimu- 
 lant is required. 
 
 In the more purely neurotic cases it is most desirable 
 
 * Allen Sturge, Brain, 1882-83, vol. v., p. 492. 
 
26 TREATMENT IN DISEASES AND 
 
 to avoid alcohol. There is no better stimulant than 
 slowly sipped hot water. Kronecker* has pointed out 
 that sipping is a physiological stimulant to the heart 
 and hot drinks tend to relax arterial spasm. 
 
 A prescription for a carminative draught, including 
 ammonia, chloric ether, and valerian or cardamoms is 
 valuable to be taken in several sips. Warmth to the 
 surface and especially to the extremities is the further 
 requisite. 
 
 The second stage of these cardio-vascular attacks is 
 one of reaction and excitement to be followed by 
 fatigue. 
 
 Often by the time the medical observer arrives the 
 cardiac pressure has already been relieved through the 
 depressor nerve of the heart, excited by intra-ventri- 
 cular pressure, bringing about relaxation of arterial 
 spasm, probably by inhibiting constrictor influences, 
 the first violent throbbing or the threatened stand- 
 still of the heart has already yielded to quick, 
 perhaps somewhat irregular, beats, the tension of the 
 pulse is no longer apparent and this fact has no doubt 
 led many observers to question the alleged mechanism 
 of this form of angina. With the help of a few hours' 
 rest in bed the patient may be again fit for the duties 
 of life, although usually a sense of lassitude and fatigue 
 remains for a few days. 
 
 It is now that the cause of the attacks must be 
 sought out, the conditions of the heart carefully ascer- 
 
 * Quoted by Lauder Brunton, " Disorders of Digestion," Lonr^on, 
 1886, pp. II, 21 and 57. 
 
DISORDERS OF THE HEART. 27 
 
 tained and the daily life, diet and surroundings and 
 functions of the patient must be investigated and 
 corrected where in error. Thus is outlined the bare 
 treatment of the anginal attack. 
 
 If there be no heart disease present the patient must 
 be thoroughly reassured on that point. In cases, how- 
 ever, in which there is heart lesion present much more 
 attention must be given to the after-treatment and the 
 prognosis depends upon the nature of the lesion pre- 
 sent. It is not my duty here to enter upon this latter 
 point. 
 
 I would briefly say that the gravest cases are those 
 in which there is enlargement of the heart without or 
 not accounted for by valvular defect. I would mention 
 the fibro-fatty heart, the syphilitic heart, and the renal 
 heart in this category. 
 
 Aortic stenosis and aortic regurgitation come next, 
 the regurgitant defect being by far the most common. 
 Mitral stenosis is not infrequently attended with 
 anginal seizures, sometimes of a fatal kind, and the 
 attacks would probably be more frequent were it not 
 for the readiness with which pulmonary haemorrhage 
 occurs. 
 
 I had recently in my ward a young man admitted 
 with a second attack of rather severe pulmonary 
 haemorrhage which the physical signs showed to pro- 
 ceed from the base of the left lung. 
 
 On examining the heart it was found to present the 
 pure funnel form of mitral stenosis with right ventricle 
 hypertrophy, &c. His pulse was observed to be re- 
 
28 TREATMENT IN DISEASES AND 
 
 markably tense with well-marked reflux through the 
 palmar arch on compressing the vessel. 
 
 Under treatment by saline aperients and a little 
 mercury the haemorrhage ceased, the pulse softened, 
 and he returned to his former state and left the 
 hospital. 
 
 The heightened peripheral arterial resistance in this 
 case, by embarrassing the left ventricle and throwing 
 back pressure upon the already difficult circulation in 
 the lungs, clearly caused the profuse haemorrhage, 
 whilst the haemorrhage in turn probably saved him 
 from anginal heart failure. 
 
 Mitral regurgitation as the primary disease is rarely 
 accompanied with angina, and when it supervenes 
 upon cases due to degenerative hypertrophy and dila- 
 tation it tends to preserve the patient from future 
 attacks. 
 
 Now on all these cardiac conditions anginal attacks 
 may supervene, having precisely the same mechanism 
 as the attacks I have already considered as unattended 
 with cardiac disease, and the treatment is precisely on 
 the same lines, only it must be more urgently pursued, 
 for the heart may readily fail under the initial strain 
 and can scarcely escape damage therefrom ; moreover, 
 the subsequent fatigue is far more serious. 
 
 A young man was admitted into my ward with well- 
 marked aortic regurgitant disease with characteristic 
 pulse and throbbing of neck vessels. 
 
 He had many attacks of vaso-motory angina, a com- 
 mon event in aortic regurgitation, one of which super- 
 vened whilst he was under examination. 
 
DISORDERS OF THE HEART. 29 
 
 It was curious to note the absolute extinction during 
 the attack, of all the aortic characters in the pulse 
 which became contracted to a small, hard, pulsating 
 thread, whilst as the patient sat forward leaning 
 against a chair, in great pain, the bed shook with the 
 violence of the cardiac beats and his neck and sub- 
 clavian vessels could be seen pulsating with responsive 
 violence. 
 
 A dose of trinitrine quickly brought back the charac- 
 teristic aortic features of the pulse and dissolved the 
 painful scene. 
 
 One could not observe the labouring beat of the 
 heart, the strongly pulsating large vessels contrasted 
 with the almost effaced small vessels without appre- 
 ciating the power of vaso-motor contraction to cause 
 cramp or paralysis of a weak ventricle, j-et their are 
 ph3^sicians who still doubt the efficacy of vaso-motor 
 spasm in the mechanism of angina. 
 
 The initial treatment may be started with nitrite of 
 amyl inhalation and the patient should always have 
 such at hand. But the attack is commonly attended 
 with such acute heart failure that the clinical features 
 of high pressure pulse and labouring heart may be 
 immediately lost. 
 
 Undoubtedly the subcutaneous injection of pure ether 
 to which a minim of nitro-glycerine solution may be 
 added if not already otherwise taken, is the best treat- 
 ment in severe cases if caught at the right moment. 
 The sense of prostration is greater and more defined in 
 these cases. 
 
30 TREATMENT IN DISEASES AND 
 
 Alcoholic stimulants, so much to be avoided in pure 
 vaso-motor cases, are in these imperative. A full dose 
 of brandy should be given in some hot drink. 
 
 In those cases, and they are many, in which flatulent 
 distension forms a marked feature of the attack, if it be 
 not concerned in producing it, a carminative draught 
 is of much service at the earliest stage. 
 
 The heart is left in an exhausted or fatigued condi- 
 tion after the attack and there is a decided tendency to 
 a series of several attacks. For this a mixture of 
 strychnine or caffein may be prescribed with digitalis, 
 so that 15 or 20 minims of liquor strychnia and 20 or 
 30 or 40 of tincture of digitalis are given in twenty-four 
 hours, and the strychnia may be given subcutaneously 
 in, of course, equivalent doses or the caffein in form of 
 salicylate. 
 
 It is probable that digitalis and strychnine influence 
 the heart muscles before that of the vessels, but if the 
 pulse become tightened, as it may be in exceptional 
 cases, the digitalis must be lessened or its effect on the 
 vessels moderated by the addition of ^ minim or i 
 minim doses of nitro-glycerine to the prescription. 
 
 There is another remedy which is a powerful restora- 
 tive to the fatigued heart, and that is oxygen inhala- 
 tion, which may be given for five or ten minutes every 
 hour or two or three hours as may be required. 
 
 These cases often come to us with a history of a 
 recent attack and we have to consider what form of 
 angina it has been, how to avert fresh seizures, and 
 how to repair (if it may be) the failing heart which 
 renders each attack so dangerous. 
 
DISORDERS OF THE HEART. 31 
 
 The presence or absence of heart disease must be 
 
 rigorously ascertained — (i) the soundness or otherwise 
 of valve function ; and (2) the presence or absence of 
 enlargement, dilatation, or hypertrophy of the organ. 
 
 It is important not to form too hasty a judgment 
 and it is often impossible to come to a final diagnosis 
 at or immediately after a seizure. 
 
 In tumultuous action, whether from excitement or 
 violent work, the locomotion of the heart is greatly 
 increased and an inexperienced observer is apt to find 
 great enlargement, displaced apex beat, &c., when 
 none exists. On the other hand, one hears it some- 
 times maintained at inquests and the like that con- 
 siderable organic disease of the heart may exist without 
 any recognisable signs. 
 
 I would venture to say that a careful investigation of 
 the sounds and dimensions of the heart will always 
 establish in such cases a displaced apex beat, an 
 increase in the dimensions, or a recognisable alteration 
 in the sounds of the heart. The converse is, however, 
 frequently true— viz., that much alteration in the heart 
 is conceived to be present when none exists. It re- 
 quires great precision and diagnostic courage to prove 
 a negative and in the presence of functional disturb- 
 ance and discomfort and anasmic bruits mistakes in 
 diagnosis are very frequent and easily made. 
 
 With mitral regurgitation of rheumatic origin high 
 tension pulses do not often supervene, but mitral 
 insufficiency is frequently a sequel to the dilatation of 
 the heart consequent upon chronic high tension and 
 
32 TREATMENT IN DISEASES AND 
 
 secondary cardio-vascular changes, and under these 
 circumstances it is undoubtedly a safeguard against^ 
 over-distension of the ventricle. I have seen cases in 
 which the establishment of mitral incompetence has 
 produced a cessation of anginal attacks which had 
 previously occurred from time to time. 
 
 In senile hearts mitral regurgitation is common and 
 is not to be looked upon seriously, but rather as a 
 favourable element in prognosis — a condition normal 
 to the senile heart. 
 
 Tachycardia, Bradycardia, Exophthalmic 
 Goitre, &c. 
 
 I must frankly confess that neither reading nor a 
 considerable experience of cases has enlightened me to 
 anything approaching an exact appreciation of the 
 mechanism of that persistent hurry of the heart's 
 action which is known under the term — a term which 
 responds well to our ignorance — tachycardia. 
 
 The chief feature of the cases may be briefly 
 enumerated:— I. A persistent hurry of pulse lasting 
 for periods varying from hours to many weeks, dur- 
 ing which the pulse is rapid, from 120 to 200 or 
 more, regular, small, of sustained, I should say, rather 
 than of high tension. 
 
 2. Intervals of severe palpitation attended with pre- 
 cordial pain, notable distress, and more tumultuous, 
 irregular action of the heart. 
 
 3. Although murmurs may be heard and the cardiac 
 
DISORDERS OF THE HEART. 33 
 
 dulness may be broadened during attack, in the 
 intervals the dimensions and sounds of the heart may 
 in the earher stages be perfectly normal. 
 
 4. In the earlier stages and in the most characteristic 
 cases the heart hurry has been observed to begin and 
 to finish quite abruptly. This was so in Dr. R. P. 
 Cotton's* case and in Sir T. Watson's, in the latter the 
 pulse suddenly changing from 216 to 72 with subsi- 
 dence of all symptoms whilst that physician was still 
 in the room. 
 
 5. So far as any exciting cause can be stated it has 
 been for the most part mental shock, mental or 
 physical overstrain. 
 
 The above characteristics are sufficient to show, 
 were demonstration needed, that the condition is a pure 
 neurosis and that the neurosis must be either of the 
 vagus or sympathetic cardiac centre seems fairly cer- 
 tain. It is inconceivable that a paralytic affection of the 
 pneumo-gastric centre should be so persistent, should 
 be attended with a regularity of rhythm so generally 
 notable, and should be capable of such abrupt termina- 
 tion as is observed in some cases. 
 
 The view of sympathetic excitement is perhaps 
 better supported by other phenomena of sympathetic 
 irritation, such as sweatings and flushings of the 
 face. No auto-intoxicant can be recognised in most 
 cases. 
 
 It is worthy of remark, on the one hand, that many 
 people, especially women, suffer from persistent hurry 
 
 * R. P. Cotton, British Medical jfournal, 1867, vol. i , p. 629. 
 
 D 
 
fe4 TREATMENT IN DISEASES AND 
 
 of heart, coming quite within the range of the lower 
 degree of tachycardia, and on the other that there is^ 
 nothing to distinguish such simple tachycardia from, 
 that which is the constant symptom of exophthalmic 
 goitre, the rhythm and quality of pulse being precisely 
 the same. 
 
 It is also to be remarked that there are cases which 
 might be regarded as of a transitional kind, in which, 
 with no enlargement of the thyroid and with no more 
 than a slight beadiness of the eyes, there are present 
 the characteristic hurry of circulation, cardiac mur- 
 murs, &c., and in other cases again these circulatory 
 phenomena precede the thyroid enlargement. 
 
 In the case of a lady, to which I have elsewhere 
 referred,* there was observed, besides moderate but 
 constant tachycardia and slightly prominent eyes, 
 evidence of instability of another portion of the pneu- 
 mogastric nerve in the occurrence of vomiting as an 
 accessory to any, however slight, mental effort or 
 anxiety, such as starting on a journey or to pay a call. 
 
 This neurosis was apparently attributable to anxiety 
 during the long illness of her mother. It lasted for 
 two or three years and then the patient got well. 
 
 That there is vaso-motor paralysis of the thyroid 
 vessels in the pathology of the goitrous form of tachy- 
 cardia is evident, but it would seem to me to be a local 
 and collateral phenomenon, for there is no general 
 evidence of vaso-motor inhibition, the pulse is gener- 
 ally rather small and hard, as one might expect with 
 
 * " Discussion on Functional Diseases of the Heart," loc. cit. 
 
DISORDERS OF THE HEART. 35 
 
 such rapid impulses of blood through the vessels cal- 
 culated to maintain blood-pressure. 
 
 For the present, then, the exact meaning of tachy- 
 cardia must remain unsolved and we may associate it 
 with some other clinical facts, such as persistent 
 elevation of temperature and unexplained continued 
 elevation of arterial tension, the morbid physiology of 
 which is not yet apparent. 
 
 The theory of exophthalmic goitre maintained by 
 Mobius,* Johnston, t Greenfield, J Murray,§ and others, 
 that it is due to an excessive formation and absorption 
 of thyroid secretion and its action on the nerve centres 
 in the medulla, is useful if only as a working hypo- 
 thesis. 
 
 This hypothesis has been suggestive of certain 
 measures of treatment that have been devised for 
 exophthalmic goitre and more successfully for its 
 opposite myxcedema. It would appear to be at 
 least proximately true, although probably some cen- 
 tral medullary change precedes the thyroid pheno- 
 mena and is responsible for them. Some regard 
 the thyroid secretion as modified and having toxic 
 effects. 
 
 This theory is based upon certain very definite obser- 
 vations, viz.: — I. That no definite lesion of nerve cen- 
 
 * Mobius, " Centralbl. f. Nervenheilk.," 1887. 
 t Johnston, Lancet, 1893, vol. ii., p. 1121. 
 
 ^ Greenfield, "Bradshavv Lecture," British Medical yoiirnal, 1893, 
 vol. ii., p. 1261. 
 
 § Murray, Biitish Medical jfonrnal, 1836, vol. ii., p. 893. 
 
 D 2 
 
36 TREATMENT IN DISEASES AND 
 
 tres has been found. 2. That the thyroid is the organ 
 more obviously affected than any other. 3. That its 
 structure is altered in the direction of hypertrophy and 
 over-activity of function and possibly there may be 
 some alteration in the quality of the secretion (Mobius, 
 Murray, Joffroy* and Achard). 4. The symptoms 
 tachycardia, nervous irritability, insomnia, and vibra- 
 tile contraction of voluntary muscles are the reverse of 
 the bradycardia, torpidity, and impaired reflexes char- 
 acteristic of myxoedema, consequent upon atrophy or 
 excision of the thyroid. 5. Whilst moderate doses of 
 thyroid extract will cure or keep in abeyance the phe- 
 nomena of myxoedema an overdose of the extract will 
 produce symptoms resembling those of exophthalmic 
 goitre. 
 
 There has as yet been found no direct means of 
 treating simple tachycardia successfully. Drugs of the 
 digitalis class are useless in this as in almost all cardiac 
 neuroses, except — and the exception is important — in 
 the treatment of the heart fatigue which sooner or 
 later ensues as a consequence of the functional strain 
 on the organ. 
 
 Tachycardia in its various grades is, however, often 
 but a symptom, a prominent expression of a neuro- 
 pathic state which requires to be approached for treat- 
 ment from many sides. 
 
 In exophthalmic goitre, again, having made the 
 diagnosis, the physician has to deliver himself of the 
 
 * Joffroy and Achard, " Arch, de med. exper, et d'anat. path.," Paris, 
 1893, v., p. 807. 
 
DISORDERS OF THE HEART. 37 
 
 somewhat magisterial sentence, " Imprisonment for six 
 months and under surveillance for from two to five 
 years." 
 
 A careful and resourceful observance of this sentence 
 is the only means of radically dealing with this dis- 
 tressing complaint. 
 
 It would be astonishing that a sudden shock could 
 produce a functional disorder that required such pro- 
 longed care did we not know that in all cases the 
 condition is one long prepared for. In some cases a 
 prolonged anxiety or mental strain will account for the 
 illness, in others there is apparently a perverted physi- 
 ology such as a premature menopause from removal of 
 the ovaries. 
 
 In other cases again the cause is inscrutable, but in 
 all cases the fundamental treatment by physical and 
 mental rest is essential. The rest for the first six 
 months should be absolute on bed, sofa, or on a couch 
 in the open air, with the utmost avoidance of all 
 excitement and mental fatigue. 
 
 The patient can then be promoted to bath-chair 
 exercise, quiet walking and driving, or more scientific- 
 ally graduated exercises, and in the course of time 
 recovers. 
 
 The general well-being of the patient can be main- 
 tained and the more distressing local and general 
 symptoms relieved or removed by cold applications to 
 the throat, sedatives of the bromide and valerian order, 
 arsenical and sometimes iron tonics ; digitahs and the 
 like drugs may be given on the appearance of heart 
 
33 TREATMENT IN DISEASES AND 
 
 fatigue, indicated by the signs of dilatation and a pulse 
 irregular in time and force. 
 
 The use of thymus extract is in my experience of 
 some value in diminishing the rapidity of the pulse; 
 the galvanic current has been found useful in some 
 cases. 
 
 Theoretically the Nauheim brine baths should be 
 useful, but practically I have seen no good from them 
 — at least in the more acute stages. 
 
 The treatment of constipation and proper dietetic 
 support are all matters of great importance under the 
 enforced quietude of the patient. 
 
 Operative treatment by partial extirpation of the 
 thyroid gland has been rather extensively tried as has 
 also section or partial resection of the sympathetic 
 nerve in the neck. It must be remembered that 
 any surgical operation will in a certain proportion 
 of instances, in some manner unknown, modify, per- 
 haps even cure, a pure neurosis. Mr. Treves* has 
 recently given som.e instructive illustrations of the 
 truth of this statement, as regards abdominal neu- 
 rosis, in a paper recently read before the Medical 
 Society. 
 
 The partial removal of the thyroid gland in the acute 
 stage of the disease is attended with very considerable 
 danger and only very inadequate success. The best 
 cases were those of Mr. Paul of Liverpool, but of his 
 six cases recorded in the British Medical Journal for 
 
 * Treves, Med. Soc. Trans., 1894, ^o'- xvii., p. 125 ; see also Brit. 
 Med. your., i8g6, vol. i., p. i. - . 
 
DISORDERS OF THE HEART. 39 
 
 1897, vol. ii., p. 6, all except one were of more than 
 two years' standing. 
 
 Abadie and Faure* have had successes from section 
 or ablation of the cervical sympathetic, but of Faure's 
 three cases one was of twelve years' standing and in 
 the others the duration is not stated. Doubtless the 
 section of the sympathetic will slow the heart, but it 
 has not yet been satisfactorily shown to influence the 
 disease, and one would regard with some misgivings 
 the future of a heart deprived of due sympathetic 
 innervation, whilst it is clinically remarkable how well 
 the heart comes out of the long struggle but little 
 damaged when the patient has been carefully steered 
 through by judicious handling. 
 
 It sometimes happens that a disfiguring enlargement 
 or a more serious distortion of the thyroid remains 
 after the tachycardial S3^mptoms have subsided, and 
 in one instance I have seen this condition dealt with 
 very successfully by removal. 
 
 I can but repeat that in our present knowledge of 
 pathology and therapeutics bearing upon tachycardial 
 conditions, including exophthalmic goitre, all remedial 
 measures, however valuable some of them may be on 
 proper occasions and at proper times, are absolutely 
 futile unless they be subordinated to the essential 
 treatment by graduated rest and isolation from all 
 worry, fatigue, and excitement. 
 
 Of the opposite more rare form of cardiac neurosis, 
 bradycardia, I need not say much, for the cases require 
 
 t Progres Medicale, 1897. 
 
40 TREATMENT IN DISEASES AND 
 
 but little treatment. One form is that which some- 
 times follows upon the rapid heart of exophthalmic 
 goitre. 
 
 A few months ago I had a remarkable example of this 
 in my ward at the Middlesex Hospital. The patient was 
 a woman, aged sixty years, who twenty years ago was 
 operated upon by Dr. Galabin at Guy's Hospital for 
 ovarian disease and both ovaries were removed. She 
 almost immediately became the subject of acute 
 Graves' disease. 
 
 Ten years later she came under the observation of 
 Dr. Pringle as an out-patient at the Middlesex Hospital 
 still presenting all the symptoms of active exophthal- 
 mic goitre, — proptosis, enlarged and pulsatile thyroid, 
 a pulse of 136, agitations, tremors, sweatings, &c. 
 She could not come into the hospital but continued 
 her attendance, coming periodically from the east side 
 of London for many years, in the course of which, 
 chiefly under small doses of aconite, belladonna, and 
 bromide, her thyroid gradually dwindled to an atrophic 
 state, her pulse slowed to 60, and her manner changed 
 from one of excitement and nervous agitation to a 
 quiescent, almost an apathetic, demeanour. She still 
 preserved her proptosis, which she has at the present 
 time. 
 
 At no time did Dr. Pringle or Dr. Pasteur, under whom 
 she had more recently been as out-patient, regard her 
 case as presenting the distinct signs of myxoedema. 
 She had no albuminuria, but latterly her legs became 
 somewhat oedematous. Her heart has slowed down to 
 
DISORDERS OF THE HEART. 41 
 
 45 and 30, there has been for some time a basic sys- 
 toHc murmur, and the left ventricle is decidedly hyper- 
 trophied and somewhat dilated. The signs are rather 
 those of degenerative roughening, however, than of 
 constriction of the aorta, for the pulse is of fsiirl}- full 
 volume and regular, although very slow. After a few 
 weeks' rest in bed and some strychnine tonic she has 
 gone to the convalescent home. 
 
 This seems to be a case analogous with regard to the 
 myxoedemic state to those cases of tachycardia I have 
 spoken of as not being distinctly associated with 
 Graves' malady and yet approximating to it. 
 
 Bradycardia is very uncommonly associated with 
 well-marked myxoedema and may continue notwith- 
 standing the disease has been cured or held in check 
 by thyroid treatment. I have seen it in epileptics, in 
 which case the rhythm is not only slow but generally 
 irregular. 
 
 As a temporary condition bradycardia is not infre- 
 quently met with as a sequel to influenza, and also in 
 association with the stage of depressed temperature 
 that frequently follows upon other fevers. In the 
 influenzal cases that I have seen it has been associated 
 with a very high density of urine, with great surcharge 
 of urea, as though there had been some previous 
 accumulation, the urine becoming solid with crystals 
 on the addition of cold nitric acid. Spurious anginal 
 seizures are sometimes observed under these circum- 
 stances. I have never known such to prove fatal, 
 although of course in the presence of any previous 
 
42 TREATMENT IN DISEASES AND 
 
 heart disease they might readily prove so. Chronic 
 high arterial tension is generally associated with a 
 slow, sometimes a very slow, pulse, whereas in acutely 
 raised tension the heart's action is, as I have pointed 
 out, generally quickened. 
 
 In chronic bradycardia, a condition that tends to 
 remain permanent and does not necessarily shorten 
 life, an occasional twenty-four hours' rest in bed should 
 be enjoined and for mental work the recumbent posture 
 should be preferred. 
 
 In cases of a more temporary kind the combination 
 of strychnine with an alkali or iodide of potassium (the 
 two drugs being kept in separate bottles and only 
 mixed at the time of taking) is a very useful one. 
 Caffein is also very useful, especially where the urine is 
 scanty. A five minutes' whiff of oxygen three or four 
 times in the twenty-four hours is a valuable cardiac 
 stimulant. 
 
 In cases of myxoedema of course thyroid extract will 
 be given, but it is not wise to push it to the production 
 of any excitement of circulation. 
 
DISORDERS OF THE HEART. 43 
 
 LECTURE II. 
 
 The general line of treatment of acute inflammatory 
 diseases of the heart is the same in the vast majorit}' 
 of cases. We have chiefly to consider the fundamental 
 complaint of which the cardiac affection is in most 
 cases a part, and this disease is, in the majority of 
 instances, acute rheumatism. 
 
 Now, from the heart point of view, and indeed, from 
 any point of view, I think all authorities are agreed 
 that the right treatment of acute rheumatism is 
 absolute rest in bed in woollen wrappings, a free relief 
 of the bowels, and the administration of salicylate of 
 soda in efficient doses in combination with such 
 alkaline remedies as the condition of the urine may 
 suggest. 
 
 It was shown very emphatically by the late Dr. 
 Sibson* that the difference between absolute and in- 
 complete rest in the treatment of acute rheumatism 
 was an exemption from heart complication of 71 per 
 cent, as contrasted with 44 per cent. 
 
 We never see now those cases of acute rheumatism 
 involving from three to six weeks' acute suffering so 
 little influenced by treatment as to render possible the 
 
 * " Collected Works," vol. iv., p. 347. 
 
44 TREATMENT IN DISEASES AND 
 
 warm discussions of not thirty years ago at our clinical 
 societies respecting the relative merits of alkaline 
 drenches, multiple blisters, or mint-water drinks and 
 dry cotton-wool applications in that disease. But few 
 cases endure more than five days' suffering under the 
 salicylate treatment, and a treatment of the general 
 disease thus successful can scarcely fail with due care 
 and foresight to prove in some degree preventive of 
 cardiac lesions, which are true manifestations of the 
 rheumatic poison usually of somewhat later appearance 
 than the joint phenomena. 
 
 The earlier statistics, both with regard to the in- 
 fluence of salicylates and of other drug treatments in 
 lessening the tendency to heart disease in rheumatism, 
 are for the most part valueless, being based on hospital 
 cases, the previous existence of heart affection not 
 being certified and the treatment before entering 
 hospital not given. 
 
 It can scarcely be doubted, however, that the current 
 view that salicylates do not lessen the liability to 
 cardiac lesions is founded on the fallacy that cases 
 early relieved of pain and fever by salicylates are often 
 allowed to get up too soon. The so-called relapses are 
 rightly described by Dr. R. P. Howard* as rather 
 "recrudescences of a disease not yet terminated." 
 
 The average time spent in hospital for acute rheu- 
 matism, thirty days, is nearly the same under all 
 treatments, the full alkaline method having a slight 
 
 * Howard, " Pepper's System of Practical Medicine," 1885, vol. ii., 
 P- 51- 
 
DISORDERS OF THE HEART. 45 
 
 advantage, and during the greater part of this time the 
 patient must remain in bed under strict treatment by 
 warmth and rest and appropriate drugs. SaHcylate 
 remedies do not alter the actual duration of the 
 rheumatic poison. 
 
 If, therefore, on the relief of pain and reduction of 
 temperature the patient be regarded as convalescent 
 and be allowed out of bed he assumes the position of 
 one with acute rheumatism still upon him treated with 
 incomplete rest and so becomes doubly liable to cardiac 
 manifestations. 
 
 I may pass by the local treatment of cardiac dis- 
 ease in rheumatism with the remark that it varies 
 according to the views of particular physicians. There 
 is no doubt that a certain few cases are wisely treated 
 variously at the physician's discretion by cold or 
 warmth, by blisters or leeches, according to parti- 
 cular indications. It cannot be said that any one 
 plan of treatment is to be recommended as superior in 
 all cases. 
 
 Whilst the treatment of acute cardiac diseases in 
 rjieumatism is not guided by stethoscopic indications, 
 I need not in this place remark that in any febrile 
 illness in an infant or child until its nature be fully 
 declared, the heart must be especially scrutinised 
 again and again. For cardiac rheumatism is in the 
 young child frequently associated with little or no joint 
 manifestations. Dr. Barlow*, Dr. Warner and Dr. 
 
 * Barlow and Warner, "Trans. Inter. Med. Cong.," 1881, vol. iv., 
 p. 116. 
 
46 TREATMENT IN DISEASES AND 
 
 Cheadle* have drawn special attention to the presence 
 of painless superficial fibrous rheumatic nodules in 
 young subjects and Dr. Cheadle regards these as 
 especially apt to be associated with severe cardiac 
 affection. 
 
 My point of view with regard to children's rheuma- 
 tism is that the frequency with which it is overlooked 
 in the early days of the disease is responsible for much 
 of the peculiar gravity and frequency of cardiac lesions 
 in the young child. Such cases come indeed into the 
 category of those incompletely treated by rest and 
 therefore especially liable to heart implication. 
 
 And why should rest, absolute recumbency, be so 
 important in acute heart affections ? We cannot still 
 the heart, but we can lighten its burdens and lessen 
 its restlessness. The mere difference between lying 
 down and standing up to the healthy heart is lo 
 beats a minute or 600 beats an hour. How much 
 greater may it not be to the heart irritated by acute 
 disease ? 
 
 The pulse naturally quickens as the temperature 
 rises. Hence by mitigating pyrexia we cceteris paribus 
 rest the heart. It is generally held by pathologists 
 that pyrexia lowers arterial pressure, but the conditions 
 that attend rheumatic pyrexia, multiple joint inflamma- 
 tion and excessive metabolism with high density of 
 urine would favour heightened arterial tension. 
 
 Our alkaline and salicylate remedies reduce arterial 
 pressure both directly and indirectly by stimulating skin 
 
 * Cheadle, " The Rheumatic State in Childhood," London, iS8g. 
 
DISORDERS OF THE HEART. 47 
 
 and kidney function. So that the general remedies 
 most appHcable to the fundamental disease are at the 
 same time specially suitable for the requirements of the 
 local malady. 
 
 Are there any special remedies to be employed for 
 the heart condition? There are but few. 
 
 The group of heart medicines is not, as a rule, 
 applicable until the case has fully emerged from the 
 general disease, and has become a single organ malady. 
 It may be said, generally speaking, that digitalis and 
 its class are useless in acute inflammatory heart affec- 
 tions and that aconite, with certain exceptions, is 
 harmful. Mercury has long been abandoned with 
 venesection and other violent measures. 
 
 There are two forms of cardiac lesion, however, 
 which may frequently be treated by moderate doses of 
 opium with great advantage. They are peri- and 
 ■«iyocarditis, conditions often conjoined, the especial 
 indications being pain particularly manifested in some 
 (not all) cases of pericarditis and irregularity of 
 rhythm, tending to tumultuous action with failing 
 power, characteristic of myocarditis. The pain of 
 myocarditis is never acute unless there be also peri- 
 carditis ; it is rather a restlessness and an indefinable 
 oppression written in the face and movements of 
 children and described by adults. 
 
 Small doses of opium at frequent intervals are of 
 very great service in such cases, calming nerve irrita- 
 tion, lessening general restlessness, and so securing 
 more rest to the heart. 
 
48 TREATMENT IN DISEASES AND 
 
 Endocarditis in rheumatic fever affects the mitral 
 valve most commonly, the aortic orifice much less 
 frequently ; the more complex mitral flaps stiffened, 
 and with their opposed surfaces thickened by vegeta- 
 tions, permit of regurgitation, whilst the aortic valves, 
 losing their flaccidity and being roughened by vegeta- 
 tion, are unduly salient during systole and so cause 
 obstructive murmurs. 
 
 Neither of these conditions call for, or respond to, at 
 this stage any treatment additional to that already 
 laid down for the dominant complaint. It is some- 
 what inadequately argued that salicylate of soda does 
 not influence heart affections in rheumatic fever. This 
 view is founded upon a manifold misconception. 
 
 In the first place, the murmur or pericardial friction 
 heard in endo- or pericarditis are results of altered 
 mechanism rather than evidences of active disease. 
 Their continued presence does not show unchecked 
 activity of lesion nor could they be expected to dis- 
 appear Hke the fading blush over the rheumatic 
 joint. 
 
 More than this, cardiac rheumatism affects a part in 
 constant functional activity, to which the term rest is 
 only relatively applicable, and, further, the mild degree 
 of daily pyrexia, which is often prolonged in endocar- 
 ditis, is probably partly due to contamination of the 
 blood-stream by sero-fibrinous material exuded from 
 inflamed surfaces, which, although not septic, has yet 
 become foreign through alteration by products of cell 
 proliferation. 
 
DISORDERS OF THE HEART. 49 
 
 After the third or fourth week the salicylates may be 
 replaced by quinine and arsenic as remedies better 
 suited to combat this phase of the malady. 
 
 There are various considerations which emphasise 
 the importance of more prolonged rest in cases of acute 
 rheumatism accompanied by cardiac lesions. 
 
 The difference is a striking one between ephemeral 
 results of other rheumatic inflammations in a joint or 
 even in a fascial membrane and the same affection of a 
 cardiac valve, the pericardial sac, or even the pleura. 
 But this different result is well accounted for by the 
 condition of unrest that in different degrees obtain in 
 each of the three latter parts. 
 
 This condition depends on an automatic mechanism 
 happily beyond our control, but, as pointed out in 
 speaking of the acute phase, we can very materially 
 lighten the labour of the heart and lessen the strain 
 upon the valves by maintaining the body in recumbent 
 repose. 
 
 It is true that in the milder cases of endocarditis the 
 inflammation may be mainly seated at, or even limited 
 to, the lines of contact of the valves, the points of great- 
 est strain, as has been pointed out by Moxon*, Sibsont 
 and other authors, but in more severe cases the whole 
 valve partakes in the inflammatory hyperaemia and is 
 the more liable to become so involved the more it be 
 subjected to premature functional strain. And for a 
 
 * Wilks and Moxon, " Pathological Anatomy," London, 1875, 
 p. 128. 
 
 t Sibson, loc. cit., vol. iv., p. 233. 
 
 E 
 
5b TREATMENT IN DISEASES AND 
 
 considerable time after acute inflammation has passed, 
 a time varying much in different cases, a smouldering 
 endocarditis goes on attended with a slight daily rise of 
 temperature, so slight sometimes as to be ignored by 
 the attendants, and during and beyond all this time 
 absolute rest is necessary. 
 
 The valves are softened and thickened by nuclear 
 granulation tissue and new fibrous formation. They 
 readily yield and become distorted under any increase 
 of blood-pressure, whilst the nuclear tissue further 
 developes into hard and contractile cicatricial tissue 
 which fixes and further distorts the valve. 
 
 It occasionally, but not often, happens that after the 
 lapse of a considerable time in severe cases of aortic or 
 mitral endocarditis a slight affix or prefix to the systolic 
 sounds may begin to appear. But it is much more 
 common for patients to return to the hospital with a 
 second attack of rheumatism, or for some other cause, 
 and to then present evidence of a stenosis at the mitral 
 orifice or an incompetence of the aortic valves which 
 did not exist before. 
 
 No doubt in some instances this may be an inevitable 
 occurrence from natural changes of a cicatricial and 
 deforming kind occurring in the new tissue of the valve 
 consequent upon the primary endocarditis. But it is 
 always aggravated by, and often entirely due to, pre^ 
 mature strain upon valves softened and impaired by 
 inflammatory change. 
 
 The infrequency with which aortic regurgitation and 
 mitral stenosis are met with in primary cases of rheu- 
 
DISORDERS OF THE HEART. 51 
 
 matic fever cannot fail to have impressed clinical 
 observers, but the lesson to be received from this fact 
 has not been duly learned. 
 
 Dr. Sibson* points out that of 24 cases of acute 
 rheumatism with primary endocarditis treated by a 
 rigid system of rest, only one gave evidence of aortic 
 as well as mitral disease, whereas in 19 instances out 
 of 127, or one in 6*7 cases, not so rigidly treated in 
 this respect aortic regurgitation was present. But 
 even Dr. Sibson did not point the lesson, for he only 
 insisted upon the importance of maintaining rest for 
 "a period of several days after the complete disappear- 
 ance of the local inflammation of the joints." 
 
 If it be true that aortic regurgitation and mitral 
 stenosis, rarely met with in primary rheumatism, are 
 the results of secondary changes in the valves caused 
 by (i) strain upon the softened valves, and (2) by 
 cicatricial deforming changes in them ; the first of 
 these can be to a great extent prevented and the 
 second to a great extent lessened and modified by 
 maintaining the patient quiescent for a sufficient 
 length of time. 
 
 The exigencies of hospital routine, the pressure of 
 perhaps more urgent cases, and the natural anxiety of 
 the patients themselves to get home, result in the dis- 
 charge of rheumatic fever cases, even with heart com- 
 plications, within a month or five weeks, when perhaps 
 another month's rest would add many years to the 
 
 * Ibid,, vol. iv., p. 384. 
 
 E2 
 
52 TREATMENT IN DISEASES AND 
 
 life estimate. A very bad lesson is thus taught to 
 students. 
 
 In private practice, in dealing with children and 
 young people especially (and they are numerically by 
 far the most important cases), it is not difficult with 
 sufficient firmness in explaining the position to secure 
 an adequate period of rest to allow of a complete sub- 
 sidence of inflammatory change and a restoration of 
 due resisting power in the weakened valve. 
 
 At least two months after an attack of rheumatism 
 involving the heart, and in some severe cases, from 
 four to six months are necessary for this purpose. 
 
 A minute attention to the temperature chart and 
 pulse and careful investigation of the cardiac sounds 
 will be the chief guides in regulating the rest treatment 
 of these cases. For a further ill-defined period of 
 months very gradual and careful return to an amount 
 of activity suitable to the case must be permitted. 
 
 Under this system of management very striking 
 results — in many instances practically complete cure — 
 will be obtained, especially in children and young 
 people. It was taught in my student times by the 
 greatest of living clinical teachers that children grew 
 into rather than out of heart disease. I have been 
 surprised since to meet with many instances to the 
 contrary, and I venture to think that the opinion was 
 based largely upon the experience of the Children's 
 Hospital, dealing with poor children who were not 
 maintained long enough at rest and who returned later 
 with the results of the deforming endocarditis. 
 
DISORDERS OF THE HEART. 53 
 
 It would be tedious were I to do more than mention 
 that in the subject of a severe peri- or myocarditis 
 allowed to move about too soon, the softened heart 
 walls yield and the fibro-nuclear changes proceeding 
 tend to render such yielding permanent. 
 
 I have restricted my remarks so far to rheumatic 
 cases since they constitute the vast majority, if not all, 
 of the cases that occur and at least of those that are 
 under our control, and such other cases as may be met 
 with from acute overstrain, scarlet fever, or other 
 fevers would fall under the same lines of treatment. 
 
 ■ I have pointed out that the cardiac group of drugs is 
 of little value in the early stages of heart disease. Our 
 object is to promote resolution and the healing process. 
 Our primary object is not at this stage to increase 
 heart power, which would, indeed, only antagonise our 
 views of easing valve function. 
 
 As the acute rheumatic features fade, general anaemia 
 and cardiac fatigue often present themselves for con- 
 sideration in treatment, and such drugs as arsenic, 
 strychnine and iron are strongly indicated. 
 
 At this stage, particularly in pericardial and in some 
 endocardial cases, the employment of moderate doses 
 of iodide — e.g., a five-grain dose of combined iodides of 
 soda, ammonia, and potash— three times a day have 
 seemed to me to be of some advantage in helping the 
 resolution of the inflammatory thickenings. A due 
 regard would, however, be paid to the toleration of 
 the iodide and it would in all cases be combined with 
 some tonic, such as strychnia, arsenic, or iron. 
 
54 TREATMENT IN DISEASES AND 
 
 It is at this time, at the end of the pyrexial interval, 
 that the question as to the usefulness of digitalis comes 
 in. A quickened and irregular rhythm, one or both 
 arising from want of power to deal with a valve defect, 
 is the particular indication for the employment of digi- 
 talis. The drug is of little, if any use, and may do 
 harm if the quickened action be the result of inflam- 
 matory irritation. Hence, where the irregularity is 
 attributable to peri- or myocarditis the drug is useless ; 
 when the soft low pitched murmurs with raised tem- 
 perature indicate active changes going on in the valves, 
 digitalis should be withheld unless positively demanded 
 by a failing ventricle, the special signs of which would 
 be congestion of the lungs, enlarging liver, oedema of 
 the limbs and very scanty urine. But these symptoms 
 are only present in very grave cases. In the majority 
 of instances during active valve changes, as I have 
 said, digitalis is not needed. In some cases when the 
 patient begins to get about it may be necessary to 
 combine for a time moderate dosss of digitalis with the 
 general tonic in order to maintain the tone of the 
 newly acquired hypertrophy commensurate with the 
 valve defect. 
 
 In the selection of change of air for convalescent 
 cases of endocarditis the first consideration is freedom 
 from wetness of subsoil. Seaside towns are generally 
 preferable to country districts on account of the ground 
 being well-drained, the walks easy, the sunshine abun- 
 dant, and facilities in the way of bath-chair exercise, 
 sunny balconies, &c., greater. 
 
DISORDERS OF THE HEART. 55 
 
 I may here mention a matter of extreme importance 
 to which I shall allude again in speaking of ulcerative 
 endocarditis, and that is the necessity of perfect sani- 
 tation bearing in mind the susceptibility of the recently 
 inflamed valves to bacterial invasion. 
 
 In cases in which the lesions are grave, the progress 
 tedious, and the necessity for rest prolonged, general 
 nutrition maybe maintained by judicious massage such 
 as to stimulate muscle nutrition and facilitate venous 
 circulation. Thus do they become better prepared for 
 gentle forms of exercise on first getting up ; these 
 exercises may be taken in some definite and prescribed 
 form as at a spa, or they may be simply directed by 
 the knowledge and common sense of the doctor. 
 
 On being consulted about a case of valvular heart 
 disease the physician has, of course, first to make an 
 accurate diagnosis, not only as to the particular valve 
 defect in the heart, for in that a diligent fourth-year 
 student could equal the most experienced, but to form 
 a just estimate of all the conditions present and to 
 decide what are the essential factors in the diseased 
 state, and in what symptoms or group of symptoms the 
 objective for treatment is to be found. 
 
 Secondly, having arrived at this point the physician's 
 further deliberations mainly turn upon whether (a) the 
 case is a suitable one for the employment of remedies 
 of the digitalis order and to what extent they shall be 
 pushed ; (b) does the case require complete rest ? or (c) 
 what degree and kind of exercise will be beneficial or 
 may be permitted ? and (d) the general state of the 
 
56 TREATMENT IN DISEASES AND 
 
 patient, his nervous system, condition of nutrition, 
 blood state, &c., will have to be considered as well as 
 those special functions of kidney and liver and the 
 dropsical state which are a part of the perturbed 
 circulatory condition. 
 
 It is of course quite unnecessary for me here to 
 discuss any points of physical diagnosis and I will at 
 once pass on to a brief consideration of the properties 
 of digitalis upon which we have to rely in practical 
 therapeutics. 
 
 There is no drug so familiar to us as digitalis and 
 there is no one drug which has added so many years to 
 the sum of human life. It may also be said that the 
 difference between the effects upon the heart of digi- 
 talis in skilful and unskilful hands is as great as the 
 difference in the effect of the curb rein on a restive 
 horse under the same circumstances. 
 
 And although most that one can say about the drug 
 and about the small group which it represents is but 
 trite and commonplace, and must especially appear so 
 to so experienced an audience as I now address, there 
 are one or two points about the action of the drug an 
 imperfect knowledge of which for the moment rather 
 embarrasses than strengthens the hands of the practi- 
 tioner in its use. 
 
 What are the attributes of digitalis upon which we 
 rely in our daily practice ? 
 
 I. Digitalis slows the heart's action concentrating 
 the force expended upon fewer and more efficient con- 
 tractions. 
 
DISORDERS OF THE HEART. 57 
 
 2. It is Stated that digitalis also directly stimulates 
 the heart's action (Williams).* The more obvious 
 effect clinically is rather a concentration of force and 
 gathering of small, irregular beats into efficient con- 
 tractions. 
 
 3. It is generally agreed that the drug affects the 
 cardio-vascular muscles directly. Although the ulti- 
 mate plasmic distribution of the vagus in the heart is 
 presumably the special sphere of its influence it is 
 highly probable that its effects extend also to the nerve 
 centres. It is difficult otherwise to explain the second- 
 ary effects of digitahs, especially its vaso-motor effects 
 and the peculiar nausea, resembhng that of sea- 
 sickness, which often proves so important a result of 
 its continued use. 
 
 4. Digitahs contracts the arterioles and this effect, 
 in combination with the increase in the contractile 
 force of the heart, raises the blood-pressure in the 
 arteries. 
 
 5. The effect of the contraction of the arterioles is to 
 maintain the blood-pressure between the cardiac beats. 
 This effect of digitahs in contracting the arterioles has 
 been known for thirty years, and as Dr. Lauder 
 Bruntont was among the first to experimentally prove 
 it, so he has by a series of experiments made with Dr. 
 TunnicliffeJ quite recently maintained the importance 
 
 * Quoted with acceptance by Lauder Brunton, Joiirnal of Physiology , 
 vol. XX., 1896, p. 357. 
 
 t Lauder Brunton and A. B. Meyer, J ournal of Anatomy and Physio- 
 logy , vol. vii., p. 134. 
 
 + Lauder Brunton and F. W. Tunnicliffe, Jotinial of Physiology, 
 1896, vol. XX., p. 354. 
 
58 TREATMENT IN DISEASES AND 
 
 of arteriole contraction in sustaining the blood-pressure 
 between the beats of the heart. 
 
 Some timidity has arisen in the use of the drug lest 
 by increasing arterial resistance and at the same time 
 stimulating ventricle action it should lead to cardiac 
 overstrain and exhaustion. 
 
 The possible occurrence of such strain and the 
 detrimental effects arising from it, must, of course, 
 be taken into consideration in prescribing digitalis in 
 certain cardiac conditions, but its action on the vessels 
 is really one of the most valuable attributes of the drug 
 supplementary to its cardiac effect. 
 
 It must be remembered, as shown in both series of 
 Dr. Brunton's admirable experiments, that the blood- 
 pressure is maintained in the arteries in the intervals of 
 systole ; that is to say, that under digitalis influence 
 after closure of the aortic valves the aortic resilience 
 more gradually effects the emptying of the arteries 
 through the capillaries. Now this effect is of great 
 clinical importance. 
 
 1. It maintains the blood longer in the arteries and 
 hence favours the more effectual irrigation of organs, 
 particularly of the secreting organs. 
 
 2. By the better distribution of the ventricle force 
 venous congestion is avoided and the venous current 
 more sustained, the heart has less immediately to over- 
 come venous inertia, and the less bulky and stagnant 
 venous stream is more readily respondent to vis a /route 
 influences. 
 
 3. Provided always, however, that corresponding 
 
DISORDERS OF THE HEART. 59 
 
 with a longer maintained arterial pressure the digi- 
 tahs produces a slower heart beat. For it is ob- 
 vious that if with increased slowness of distribution 
 of cardiac force we have no corresponding diminu- 
 tion in frequency of the cardiac contractions we 
 may get the resistance mounting up to a dangerous 
 pitch. 
 
 From clinical observations I should have said that 
 in medicinal doses digitalis affects the heart before the 
 vessels, and so the proportionate conditions of its 
 effective and beneficial action are in suitable cases 
 secured, although experimentally with the drug intro- 
 duced directly into the circulation in full physiological 
 doses the vessels have been found to react sooner than 
 the heart. 
 
 4. Pushed beyond its therapeutic limits digitalis 
 appears to paralyse the cardiac vagus, the heart's 
 action becomes rapid, peristaltic and finally stops in 
 systole. The failure in heart power seems to arise 
 from inefficient and finally extinguished diastole and 
 the arterioles generally maintain their contraction to 
 the end. 
 
 In considering the cases of cardiac disease, and for 
 the moment speaking of valvular disease of the heart, 
 the first thing to remark is that there are to be ob- 
 served a type of pulse and heart rhythm, adapted to, 
 and characteristic of, each form of valvular disease of 
 the heart which may be regarded as normal to that 
 lesion, and it should be the object of the physician to 
 consider whether the rhythm of beat and the result of 
 
60 TREATMENT IN DISEASES AND 
 
 estimated cardiac force as registered by the pulse are 
 in full accord with the altered circumstances produced 
 by the valve defect. 
 
 How far the pulse varies from that of health is a 
 preliminary part of the diagnosis, the question for 
 treatment is whether the character of the pulse is 
 normal to the lesion found, or does it vary from what 
 it ought to be under the circumstances, and to what is 
 the variation due. 
 
 On thinking the matter over in this light we perceive 
 that in the therapeutics of cardiac affections after the 
 acute stage we do not treat the valve defect, but we 
 treat the heart, whilst it will be remembered that in 
 thinking over the treatment of cardiac affections in the 
 acute stage we found that our measures were not 
 directed to the heart so much as to the affected valves 
 or pericardium ; we found in fact but little employ- 
 ment for drugs of the digitalis order in acute cardiac 
 affections, and that in many cases their employment 
 was positively to be avoided. 
 
 There has been much dispute as to whether digitalis 
 — and in mentioning digitalis I speak for the whole 
 therapeutic group — should be used in the treatment of 
 aortic regurgitation. Now in the most typical cases of 
 aortic regurgitation the patients are very well, they 
 may be quite unconscious that they have anything the 
 matter with them, they lead active, even athletic, lives 
 and will be shocked, on presenting themselves before 
 an insurance society, at being refused or very greatly 
 surcharged. 
 
DISORDERS OF THE HEART. 61 
 
 Except for accidents in the way of functional dis- 
 turbances of reflex origin, vaso-motor angina, to which 
 they are very Hable, and sudden or gradual overstrain, 
 to which their unguided energies tend to lead them, 
 these patients, if they follow rationally prescribed lines 
 of conduct, may go on very well until the degeneration 
 period of life. 
 
 They may, like other people, require a tonic from 
 time to time, but so long as they present the most 
 characteristic marks of their special lesion they do not 
 require digitalis. 
 
 Now the conditions of good compensation are 
 steady, regular, forcible ventricle beats — an increase 
 in the capacity of the left ventricle to accommodate 
 a larger measure of blood in diastole and a vigorous 
 and truly muscular hypertrophy to enable the ventricle 
 with little supplementary support from the aortic 
 valves to propel the blood through the capillaries 
 and maintain the venous current. 
 
 Under these conditions, which are faithfully recorded 
 in the steady, regular pulse, with a strong, abrupt beat, 
 rapid subsidence and low tension of artery, digitalis is 
 not wanted and a powerful drug when there is no indi- 
 cation for it cannot but be harmful. In all cases, 
 however, of aortic regurgitation which are not inter- 
 rupted in mid-career by some of the accidents to which 
 I have alluded the time comes when the employment 
 of digitalis is of the greatest value. 
 
 What are the indications for its use ? In one word, 
 they are the symptoms of commencing failure of the 
 
■62 TREATMENT IN DISEASES AND 
 
 left ventricle fully to respond to the heavy call upon it, 
 provided that failure be under conditions otherwise 
 normal to the disease. 
 
 It may be, for instance, that the ventricle is tem- 
 porarily overburdened by the results of some nervous, 
 dyspeptic, or gouty storm reflected upon the small 
 vessels and causing a measure of high tension to 
 supervene upon that relaxed condition of the arterial 
 system which is normal to aortic regurgitation and 
 which is probably a natural compensatory effect, in- 
 duced by the relaxing influence of the depressor nerve 
 in response to the increased pressure within the ven- 
 tricle. Under the conditions of high arterial tension 
 thus induced it would be very faulty practice to give 
 digitalis ; any result it might have in forcing increased 
 work out of the already willing muscle would be neces- 
 sarily at the expense of later exhaustion. 
 
 Obviously under these conditions a mercurial and 
 saline or such other treatment as may especially meet 
 the cause of the increased arterial resistance is the first 
 measure in combination with a little extra quietude 
 and to be followed b}' a tonic calculated to restore the 
 fatigued heart. I have already dealt with the treat- 
 ment of acute high tension accompanied by anginal 
 symptoms in aortic disease. 
 
 It has been said that the heart in aortic regurgita- 
 tion is sometimes too vigorous, its hypertrophy ex- 
 cessive, and that it is necessary to use drugs of the 
 aconite order to lessen ventricular expenditure. I con- 
 fess I have never recognised a case of the kind and 
 
DISORDERS OF THE HEART. 63 
 
 that in my experience unduly laboured heart's action 
 in this disease is always to be explained by reflected 
 functional disturbance or increased arterial resistance. 
 
 The one thing we have to look to in aortic regurgi- 
 tation is the maintenance of heart power, and any sign 
 of over struggle is rather to be met by measures calcu- 
 lated to diminish peripheral resistance, (i) Irregu- 
 larity in the heart's action. (2) A want of precision 
 and sharpness in the character of the pulse. (3) In- 
 creased displacement of the apex beat to the left, and 
 extended impulse upwards. (4) The occurrence of 
 irregular smaller beats as marked in the pulse and 
 appreciated at the heart. (5) The supervention of a 
 soft systolic bruit over the mitral area. (6) Extension 
 of the cardiac dulness to the right ; and finally, (7) The 
 almost complete replacement of the regular, strong, 
 slow, collapsing pulse and simple hypertrophic heart's 
 action, normal to aortic regurgitation by a rapid heart's 
 action irregular in force and frequency, with a corres- 
 ponding small pulse, having the characters of mitral 
 rather than of aortic disease— such are in gradation the 
 ingravescent signs of ventricle failure in aortic regurgi- 
 tant disease and the increasingly imperative indications 
 for the employment of digitalis in its treatment. 
 
 As the above signs develop we observe important 
 symptoms of the changed arena of struggle from the 
 left to the right heart territories of the circulation. 
 Congestion rales appear at the bases of the lungs, ful- 
 ness to enlargement of the liver, oedema of the extre- 
 mities- and scantiness of the urine. 
 
64 TREATMENT IN DISEASES AND 
 
 There is no doubt that the symptomatology of fail- 
 ing heart in aortic regurgitation concentres round the 
 fact that with a yielding ventricle systole becomes in- 
 complete and an increasing amount of residual blood 
 is left behind necessitating presently a supplementary 
 intermediate contraction, until finally little better than 
 a disordered cardiac peristalsis ensues incapable of 
 maintaining due arterial pressure, the blood gathers on 
 the venous side, and the right ventricle embarrassed 
 by the counter blast through the relaxed mitral orifice 
 and unassisted by any aspiratory influence on the part 
 of the left ventricle in its turn begins to fail. 
 
 The peculiar effects of digitalis under these condi- 
 tions are precisely called for to slow the action of the 
 heart, to render its contractions more complete and 
 regular, and thus to check the gathering of residual 
 blood in the ventricle and restore the efficient applica- 
 tion of the mitral flaps by approximating their attach- 
 ments. 
 
 I have before remarked that clinically digitalis 
 appears to influence the heart before the vessels. 
 There is, indeed, in all probability proportionate 
 relationship between its effects upon these two sections 
 of the circulation. 
 
 If as we believe the drug acts directly upon the 
 cardio-vascular muscle we may safely infer that the bulk 
 of the muscle concentred in the heart being more than 
 equal to that of the muscle distributed in the vessels 
 the predominant effect should remain with the heart. 
 
 We must not, of course, push this argument too far. 
 
DISORDERS OF THE HEART. 65 
 
 but in carefully graduated doses we may observe that 
 digitalis rarely affects the vessels prematurely or dis- 
 proportionately in aortic regurgitant heart failure ; on 
 the contrary by improving arterial tone it does no more 
 than prevent that rapid emptying of the arteries, which 
 requires a corresponding rapidity or suddenness of 
 ventricle contraction in order to maintain an arterial 
 pressure sufficient for vital functions which is very 
 exhausting to the enervated and failing hearts under 
 consideration. 
 
 The maintenance of a strict recumbency is of course 
 essential in the grave cases I have described and with 
 a suitable dietary the heart soon begins to respond to a 
 steady daily administration of from thirty to ninety or 
 more minims of tincture of digitalis or an equivalent 
 preparation, with proper adjuncts in the form of an 
 occasional mercurial and saline. 
 
 With the increasing efficiency of the vis a tergo the 
 blood-pressure in the arteries rises and with the 
 similarly increased efficiency of the vis a fronte — for 
 the drug not only indirectly helps but directly stimu- 
 lates the right heart as the left — the venous current is 
 hastened, the pulse will begin to steady, and at about 
 the third day the urine will increase in quantity, the 
 signs of venous congestion begin to diminish, the pulse 
 to assume more and more its proper aortic characters, 
 and the patient gradually recovers to a point short, 
 however, of that degree of health and heart-power he 
 before enjoyed. 
 
 Thus again and even again have we most of us seen 
 
66 TREATMENT IN DISEASES AND 
 
 patients with heart failure in aortic regurgitation 
 restored, put on their legs by the action of digitalis. 
 Having once passed through this ordeal they can never 
 be said to be entirely independent of the drug. 
 
 I have put the extreme case, but it is needless to say 
 that by watchfulness in recognising the earlier phe- 
 nomena of heart failure, which I enumerated as nearly 
 as possible in chronological order, and by the timely 
 employment of an occasional course of digitalis, the 
 more desperate symptoms may be long postponed. 
 
 One of the greatest difficulties in practical medicine 
 is to decide when to omit treatment, and this difficulty 
 is particularly felt by many in regard to digitalis. 
 I shall allude perhaps more fittingly to this point 
 later, and will content myself now with the remark 
 that the general condition of the patient, his anaemia 
 or otherwise, his general nerve tone, the due activity 
 of his other functions must be carefully watched and 
 the use of other remedies accordingly employed with 
 a mitigation or suspension as the case requires of the 
 digitalis treatment. 
 
 The final word with regard to the treatment of 
 aortic regurgitation would seem then to be — await the 
 distinct indication of altered pulse characters, even 
 asc&rtain whether there are not general conditions of 
 over-fatigue or strain or impaired general tone from 
 anaemia or other debility before giving digitalis, and 
 having commenced with it pursue the treatment boldly 
 and steadily and look under its influence and as a sign 
 of its success for a return of the characters which are 
 normal in the pulse of this disease. 
 
DISORDERS OF THE HEART. 67 
 
 With regard to aortic stenosis the same argument 
 holds good— that is, that as soon as the normal pulse 
 of this affection — a small, rather slow and regular pulse 
 — becomes replaced by irregularity and frequency, 
 accompanied by the usual signs of failing compen- 
 sation, digitalis is needed. 
 
 Aortic stenosis is, indeed, a rare form of cardiac 
 disease, although the so called aortic constrictive mur- 
 mur is one of the most common of the morbid sounds 
 of the heart. Any roughening of the orifice, any want 
 of proportion between the orifice and the calibre of the 
 aorta beyond, any undue salience or rigidity of the 
 valves, even with a dilated orifice, will beget a systolic 
 murmur. 
 
 I do not think that with regard to the use of digi- 
 talis in this affection I have anything more to say. 
 So long as the heart is beating quietly and regularly 
 nothing but harm can come from the use of digitalis, 
 with irregularity and disorder nothing but good, 
 provided it be carefully watched and mitigated with 
 returning regularity. 
 
 An important principle underlying the whole ques- 
 tion of treatment of cardiac diseases by digitalis is that 
 laid down by the late Dr. Herbert Davies* who, with 
 the cooperation of Professor Haughton established 
 with at least approximate success the proposition that 
 equal volumes of blood are synchronously propelled 
 from the cavities on the two sides of the heart. 
 
 * Davies, " The Mechanism of the Circulation through Diseased 
 Hearts," London, i88g, p. 47. 
 
 F 2 
 
68 TREATMENT IN DISEASES AND 
 
 We have seen that in aortic regurgitation a certain 
 degree of dilatation of the left ventricle is normal ; this 
 is to accommodate a certain amount of residual blood 
 equivalent to the back flow from the aorta which is an 
 addition to, and has to be returned with, the normal 
 output. When with increasing dilatation this residue 
 accumulates (or if in unpreparedness of the ventricle as 
 when surprised by a sudden injury to the valves it 
 cannot be accommodated) embarrassment telling back- 
 wards on the pulmonary side commences. 
 
 In mitral stenosis the strain to effect this equilibrium 
 of the two circulations falls upon the right ventricle, 
 which, assisted by the left auricle, has to supply the 
 left ventricle with sufficient blood notwithstanding the 
 narrowed mitral orifice. 
 
 In the pure funnel form of mitral stenosis, a disease 
 which is, I am convinced, often of congenital origin, 
 the right ventricle and left auricle undergo correspond- 
 ing hypertrophy and increase of capacity and are able 
 without artificial aid to maintain the circulation, some- 
 times for the first forty or five-and-forty years of life. 
 
 The features of mitral stenosis are a high pulmonary 
 and a low systemic blood-pressure, a regular, slow 
 pulse, a tendency to pulmonary congestion, and sys- 
 temic anaemia. Whilst these conditions are main- 
 tained digitalis can do no good ; the right ventricle 
 is in full work, the left has got scarcely work 
 enough to do, the intra-pulmonary pressure is al- 
 ready near the point of strain, and the prolonged 
 diastolic pause natural to the lesion is precisely 
 
DISORDERS OF THE HEART. 69 
 
 adapted to the needs of the slowly filling left ven- 
 tricle. Any constriction of the systemic arterioles 
 would be disastrous under such conditions, as was 
 seen in the case I related of mitral stenosis with 
 vaso-motory constriction of vessels and pulmonary 
 haemorrhage. 
 
 The first indication on cardiac distress arising in 
 mitral stenosis would be to relieve the right heart. 
 The venous system should be unloaded by direct vene- 
 section or by intestinal and hepatic derivatives com- 
 bined with a restricted diet and the treatment of 
 pulmonary complications as the urgency of the sym- 
 ptoms might require. But when, these conditions 
 being satisfied, the pulse still remains quick and irregu- 
 lar and the right heart embarrassed, the employment 
 of digitalis is certainly indicated on the same principle 
 as before. And in the presence of cardiac need we 
 may, as a rule, disregard considerations of raised 
 arterial tension, since as I have urged, the first and 
 predominating influence of the drug is upon the heart. 
 
 The moment, however, the cardiac action is restored 
 to regularity we must again remember the arterial 
 effects of the drug and, endeavouring to maintain 
 without increasing its effect upon the heart by greatly- 
 mitigated doses, to watch for and avoid any undue 
 action on the vessels. 
 
 In mitral regurgitation with commencing or estab.- 
 lished heart failure we find all the conditions calling for 
 the beneficent action of digitalis and the mere presence 
 of a mitral murmur is often regarded as an indication 
 
70 TREATMENT IN DISEASES AND 
 
 for the use — it may be the very guarded use — of the 
 drug. 
 
 It must be remembered that I am not speaking of 
 acute cases, nor would digitahs be suggested by the 
 mere presence of a mitral regurgitation in the senile 
 heart, of which it is almost a characteristic and often a 
 very advantageous factor. Nor again in those cases in 
 which the regurgitation occurs as a compensatory safe- 
 guard in overstrained ventricle from chronic high 
 arterial tension is it often desirable — except with much 
 caution — to prescribe digitalis. 
 
 It is in commencing heart failure in chronic mitral 
 lesion from rheumatic endocarditis that digitalis is so 
 valuable. What are the features of this state ? A 
 quick, small pulse is normal to mitral regurgitation, 
 and even some irregularity of rhythm or force is 
 of no great moment, although even now short tonic 
 courses of the drug may be useful. But when irregu- 
 larity is a marked feature, when a few beats are large 
 and turbulent, to be followed by several small beats, 
 when the pulse no longer corresponds in number with 
 the "Cardiac contractions, when the heart itself shows 
 signs of hypertrophy and extending dilatation of both 
 ventricles with dulness extending upwards over the 
 conus and left auricle, when the neck veins become full, 
 fill from below and pulsate, the liver enlarges, the 
 cellular tissue becomes dropsical, the lungs congested, 
 and the urine scanty : — with these symptoms and signs 
 we have with increasing urgency the conditions calling 
 for digitalis. 
 
DISORDERS OF THE HEART. 71 
 
 These conditions begin, it will be observed, with the 
 pulse and heart characters which replace those which 
 are normal to other forms of cardiac disease when 
 failure is commencing and digitalis is called for. This 
 fact about mitral disease is to be noted in prognosis. 
 
 Whilst symptoms of heart failure are earlier in 
 appearance in mitral disease of any gravity they are 
 perhaps longer amenable to treatment, the considerable 
 reserve capacity of the left auricle and the relative 
 shortness of the pulmonary circulation being favourable 
 for a longer struggle against the valve defect, but that 
 struggle begins to be serious at an earlier date. 
 
 On the other hand the accidents of mitral disease are 
 fewer than those of any other cardiac disease, sudden 
 death from syncope, angina, or cerebral embolism 
 being common both in aortic regurgitation and mitral 
 stenosis, very rare in mitral regurgitation, but with 
 these two diseases and with aortic stenosis it is — with 
 equal relative gravity— longer before the heart mechan- 
 ism fails. 
 
 A congestion of the pulmonary and venous system 
 and an ansemia of the arterial system are the under- 
 lying factors in this condition as in mitral stenosis. 
 But the diiference is that in mitral regurgitation the 
 congestion is all backward, each blood thrust of the 
 right ventricle is met by a counterblast from the left, 
 the left auricle is not protected by its valve from 
 invasion backwards, and cannot therefore efficiently 
 cooperate with the right ventricle, and the cusps of the 
 pulmonary valve have to take up in part the function of 
 the mitral valve. 
 
72 TREATMENT IN DISEASES AND 
 
 Of course, there are cases and cases of mitral 
 regurgitation, they do not all require digitalis. In 
 some the leakage is so slight as to cause no incon- 
 venience. The skilled practitioner can discriminate to 
 a nicety as to the gravity of the case by the degree 
 with which the first sound is replaced by murmur and 
 by estimating the relation between expenditure of force 
 by the heart, and the result effected in the pulse show- 
 ing the degree of waste in the mechanism. 
 
 I cannot, Sir, but here recall the heroic assiduity of 
 our late Fellow and Vice-President, my illustrious 
 colleague, Sir Richard Quain,* who when mortally ill 
 brought his last work before the Royal Society in an 
 endeavour to explain the much-debated mechanism of 
 the first sound of the heart. Any conclusion arrived 
 at by so acute and thoughtful an observer must com- 
 mand our reverent respect. It is difficult, however, 
 except on the hypothesis that the closure of the 
 mitral valve contributes to the first sound, to ex- 
 plain the great value in diagnosis of the degree of 
 replacement of that sound by murmur as an estimate 
 of the degree of imperfection of the valve and the con- 
 sequent gravity of the lesion. 
 
 The most common mistake that one observes in the 
 use of digitalis is that too large a dose is prescribed at 
 first, which tends to premature arterial contraction and 
 cumulative effects. Then with the appearance of these 
 physiological symptoms the drug is stopped and some 
 other medicine substituted until the pulse again calls 
 
 * Sir Richard Quain, Proc. Roy. Soc, 1897 vol. Ixi., p. 331. 
 
DISORDERS OF THE HEART. 73 
 
 for its administration. In this haphazard way of 
 using digitalis the heart is never held in good con- 
 trol. It is alternately checked and allowed to run 
 away again. 
 
 In exceptional cases, where there is urgent need to 
 push the drug, digitaline is best used subcutaneously. 
 In ordinary cases a dose of lo minims of the tincture 
 every four hours, or 15 minims every eight hours, or 5 
 minims every waking hour is sufficient. Thus given, 
 the patient being at rest, it generally takes about three 
 days before the pulse is under control and the urine 
 begins to increase. When its decided effects are thus 
 gradually developed the drug should be steadily con- 
 tinued in doses calculated to maintain them. 
 
 With ordinary watchfulness there is no risk what- 
 ever, timely warning of excess is given by the pulse, 
 which having become slow begins to exhibit small 
 intermediate beats and especially a tendenc}- to go in 
 couples. This is always a sign to reduce the doses or 
 to omit for a few hours. 
 
 The sickness that too often supervenes under treat- 
 ment with digitalis is most troublesome. An occasional 
 mercurial will sometimes prevent it, a change to digi- 
 taline in equivalent doses may be tried, or a tumbler 
 of very hot water taken occasionally. In some cases 
 it is not to be overcome except by omitting the drug ; 
 but the patient is usually well under its influence 
 before this symptom appears, and a small dose of 
 digitaline by the mouth or hypodermically may be 
 sufficient to maintain its effects on the heart. 
 
74 TREATMENT IN DISEASES AND 
 
 If it be true as maintained in all modern textbooks 
 that the action of digitalis is upon the cardiac muscle 
 and not through the cardiac nerves or their centres, 
 then one can see that a point of coronary impairment 
 or textural muscle change may arise when the heart or 
 that portion of it we may want to influence is no 
 longer amenable to the drug, and practically we find 
 that the time actually comes when attempting to 
 stimulate the heart by digitalis is like to use an 
 Americanism, " whipping a dead horse." But it is 
 also beyond doubt that the heart will sometimes get 
 accustomed to digitalis and will no longer react to it, 
 when a change to one of the allied drugs, e.g., stroph- 
 anthus will be found useful. Caffein and strychnine 
 act as stimulants through the nervous system. 
 
 In over-dosage with digitalis the vagus ends are 
 paralysed, vagus control lost, ventricle cavity dimin- 
 ished and diastolic filling incompleted. The beats 
 become rapid, faulty, peristaltic, and terminate in 
 systolic spasm. 
 
 We have always ample warning, if we look for it, 
 of the digitalis being pushed too far : — 
 
 1. The rhythm which has become slowed and regu- 
 lated becomes interspersed with intermediate small 
 beats. This is a sure sign to diminish the daily dose. 
 
 2. Arterial contraction becomes excessive. This is 
 a much less sure indication to diminish the drug 
 because in some individuals the vessels are more 
 sensitive to digitalis than in others, and we may often 
 prefer to persevere with its use guarded by minute 
 doses of trinitrine. 
 
DISORDERS OF THE HEART. 75 
 
 3. The urine, which has increased, diminishes with 
 excess of the drug. This may be due to either the 
 effect on the heart, diminishing blood pressure, or on 
 the vessels lessening efficient circulation. In the latter 
 case it will be corrected by remedies of the trinitrine 
 order. 
 
 In speaking of digitalis I have regarded that drug as 
 representing the whole therapeutic group. Digitalis is 
 to my mind so far in front of all the others in efficacy 
 that in critical cases I should never think of prescribing 
 any other member of the group before it. 
 
 Strophanthus comes next to it in usefulness and in 
 physiological experiment is even more powerful. Clin- 
 ically one is not so well satisfied with it ; this may 
 possibly be prejudice, but I have had doubts about its 
 stability in prescriptions. It causes the same trouble- 
 some nausea. The one reason for its use is that 
 it affects the small vessels less ; this gives it an 
 advantage in some cases, particularly, perhaps, in 
 carrying on the effects of digitalis in convalescent 
 aortic regurgitation and mitral stenosis cases. But, 
 as I have endeavoured to point out, under most 
 conditions calling for its use this very action upon 
 the arterioles is one of the valuable attributes of 
 digitalis and explains possibly its superiority over 
 strophanthus. 
 
 I frequently, however, combine the two drugs when 
 I want to secure an increased cardiac effect without 
 using digitalis in doses large enough to contract the 
 vessels too much. 
 
76 TREATMENT IN DISEASES AND 
 
 Convallaria comes next as a cardiac tonic in mild 
 cases, useful for timid women who are terrified at 
 foxglove and arrow poison, but take kindly to the 
 humble lily of the valley. I have only very occasionally 
 used sparteine. 
 
 One may observe that the earliest sign of amend- 
 ment in cardiac failure is an increased flow of urine. 
 This rarely occurs until a perceptible influence has 
 been obtained over the pulse, and it corresponds 
 with an increased fulness of the arterial system, 
 an improved blood-pressure and a lessened venous 
 stasis. 
 
 A somewhat analogous relief of the stress of symp- 
 toms will often be observed with the commencement of 
 dropsical effusion, provided that effusion of course be 
 limited to the cellular tissue and peritoneum. The 
 peculiar restlessness and discomfort that precedes the 
 onset of drops}^ is sometimes very remarkable and the 
 dropsical effusion should rightly be regarded as one of 
 those compromises of nature which enable the vital 
 machinery to go on a little longer. 
 
 Dropsy is primarily due to a leakage from the con- 
 gested capillaries into the cellular tissue. It is also 
 due to a retarded removal of the fluids by the lymphatic 
 vessels. From a therapeutic point of view the osmotic 
 circulation in the cellular tissue and serous and mucous 
 cavities is scarcely less important than the vessel circu- 
 lation discovered by Harvey. 
 
 The interchange between the two circulations 
 amounts normally to many pints in the twenty-four 
 
DISORDERS OF THE HEART. 77 
 
 hours and cellular tissue and lymphatic vessels conduct 
 a considerable share of it. The current of lymph is of 
 extremely low pressure and is a resultant (i) of the 
 difference between the capillary blood-pressure and 
 that in the veins near the heart, (2) being further pro- 
 moted by contraction of muscles, respiratory aspira- 
 tion, and contraction of muscular coats of lymphatics. 
 A very slight backward pressure in the veins will 
 embarrass it. 
 
 Amongst the conditions favouring dropsy there is 
 not only venous retardation in the capillaries encourag- 
 ing excessive exudation, but also retarded current in 
 the great veins as a further obstruction to removal by 
 the lymphatic vessels. Thus a considerable collection 
 of fluid, even many pints, may be removed from the 
 circulation by leakage into the cellular tissue, the im- 
 mediate effect of which is often a very decided rehef 
 to the patient's distress. 
 
 The occurrence of dropsy may thus sometimes afford 
 time for the readjustment of the circulatory balance in 
 the heart and vessels. But if with the help of remedies 
 this does not take place, if the dropsy advances and it 
 is estimated that the pressure in the cellular tissue 
 becomes great enough to equal or exceed the pressure 
 in the capillaries then interference becomes imperative 
 and the fluid should be removed by the employment of 
 Southey's tubes, incisions or simple punctures with 
 most strict antiseptic precautions. The neglect of such 
 measures will invariably be followed by erythematous 
 or erysipelatous inflammation and more or less cellu- 
 
78 TREATMENT IN DISEASES AND 
 
 litis. Very striking instances of long abiding relief are 
 met with from time to time from this treatment. 
 
 In some cases dropsy occurs in the absence of heart 
 phenomena which would appear sufficient to produce 
 it. A lady, of about fifty years of age, had been undef 
 my observation for some few years for most intense 
 chronic asthma with emphysema and recurrent attacks 
 of bronchitis. Her condition at many times seemed 
 almost hopeless, but the one redeeming feature about 
 her was the heart's action, which remained steady and 
 well sustained through her worst attacks ; although 
 there was undoubtedly some dilatation and hyper- 
 trophy of the right side of the heart there was no sign 
 of heart failure. 
 
 Towards the end of a bad summer in 1896 her legs 
 began to swell and as her distress increased with the 
 cold weather they filled up and by December the 
 thighs and abdominal walls were greatly distended. 
 She was in other respects so ill from her bronchitis 
 and asthma at this time, that I hesitated to tap the 
 legs until they became too prominent a factor in her 
 distress. 
 
 Even now, although the heart's action was feeble, it 
 was neither irregular nor very quick and there were no 
 murmurs. She was placed in a chair and by means of 
 four Southey's tubes 20 pints of fluid were withdrawn 
 in the course of 52 hours. Now it is remarkable that 
 there has never been any return of the dropsy although 
 she has not been free from bronchitic attacks ; the 
 limbs are perfectly slim and natural, without a trace of 
 
DISORDERS OF THE HEART. 79 
 
 oedema at the present time (August, i8g8). The 
 heart's action is as well maintained as before. It 
 only partially failed for a few days after the removal 
 of fluid. 
 
 I may say that this patient has never been able to 
 take digitalis or any drug of that series with advantage 
 and it has never been prescribed for her except for 
 short times at rare intervals and in very small doses. 
 
 I should regard the retarded venous return from the 
 great emphysema obstructing the lungs, in combina- 
 tion with an over-burdened right heart, as responsible 
 for the dropsy, but the case is one of a few I have 
 seen of the kind, difficult satisfactorily to explain. It 
 is possible that it may be an unusually prominent 
 example of the effect of a mechanism that has more to 
 do with dropsy than has been generally allowed— viz., 
 obstructed venous return in the chest from "-reat 
 emphysema and dilated right heart, retarding lym- 
 phatic current and lessening the readiness of its escape 
 into the innominate vein and thus holding in abeyance 
 the share taken by lymphatic absorption in the removal 
 of dropsical fluids. 
 
80 TREATMENT IN DISEASES AND 
 
 LECTURE III. 
 
 Exercises have been reduced to a system in three 
 grades : massage, the resistance exercises or their 
 equivalent in the mechanical methods introduced by 
 Zander of Stockholm in 1872* and others, and gradu- 
 ated walking exercises of Oertel. 
 
 The principal object of massage is to stimulate the 
 arterial circulation in the muscle, to hasten the venous 
 currents, and to promote also the passage of lymph 
 through the lymphatic vessels. The metabolism of the 
 body is thus maintained and secondary, and therefore 
 primary, digestion improved in those who from any 
 cause are unable to take active exercise. 
 
 It is at once apparent that we have here a means of 
 helping on the convalescent stage of acute heart affec- 
 tions and of combating the tendency to stagnant 
 circulation in those who are disabled by chronic heart 
 disease. 
 
 Still more useful is the treatment in maintaining the 
 circulation and mildly but sufficiently stimulating the 
 coronary circulation in those who, bed- or sofa-ridden 
 from any other cause, on that account tend to im- 
 pairment of heart nutrition and suffer from chilly 
 extremities, feeble pulse, torpid digestion, and passive 
 congestion of the lungs. 
 
 * Groedel : St. Petersburg Med. Wochenschrift, No. 13, 1897. 
 
DISORDERS OF THE HEART. 81 
 
 In regard to acute heart affections, it will be 
 gathered from what has already been said that 
 the treatment is not to be advised. Most cases of 
 acute endocarditis occur in young people whose 
 hearts are not disposed to degeneration and whose 
 muscles, although they become weak, recover with 
 a rapidity and develope an energy which has to be 
 restrained rather than encouraged. The heart is 
 always in exercise, the coronaries are in full function, 
 and whilst there is the slightest activity or softness 
 about the valve lesions our object is in no way to 
 excite the heart to increased action. The themometer 
 is our guide and so long as there is any daily rise of 
 temperature all such treatment, unless for some very 
 special reason, should be discouraged. 
 
 Resistance exercises, now so well known by the 
 name of Schott* or Nauheim exercises as to require 
 no description, are governed by more complex prin- 
 ciples and considerations. By being brought to 
 act successively against regulated resistance every 
 set of muscles in the body can be exercised, and by 
 graduating the degree of resistance and securing 
 a short rest after each set of movements every 
 gradation in the severity of the exercises can be 
 obtained. 
 
 Certain special effects are claimed by Dr. Schott and 
 
 his disciples to be produced upon the heart under 
 
 almost all forms of disablement and disease by the 
 
 graduated exercises in combination with aerated brine 
 
 * Schott, Lancet, iMay 23rd and 30th, 1891, 
 
 G 
 
82 TREATMENT IN DISEASES AND 
 
 baths, but although the effects of these two treatments 
 are a Httle confused it seems clear that in Dr. Schott's 
 opinion the benefit of the exercises in these cases arise 
 from the following conditions : — 
 
 1. The periodical and regulated stimulation of the 
 heart leads to increased action, the muscles of that 
 organ obeying the natural law of the relation between 
 exercise on the one hand and nutrition or growth on 
 the other as surely as do other muscles in which the 
 changes are more apparent to the eye. 
 
 2. It is further maintained by Dr. Schott and his 
 coadjutors that contraction of the dilated heart and 
 distinct gain in the force of the pulse, as well as relief 
 of dyspnoea, &c., are clearly observed to be rapidly 
 induced by both baths and gymnastic exercises. 
 
 3. Schott, apparently as a later observation, finds 
 that the gymnastic course is capable of inducmg the 
 same results as the baths, the heart being stimulated 
 to more complete contraction by reflex stimulation of 
 the cardiac centres through the influence of exercise 
 upon the motor nerves, i.e., similar in effect to the 
 influence of aerated brine water upon the sensory 
 nerves reflecting upon the same centre ; and in this 
 opinion Dr. Bezly Thorne* agrees. 
 
 Whilst I think no one could for a moment dispute 
 the accuracy of the first proposition, which is, indeed, 
 a matter of everyday knowledge, there do not seem to 
 me to be any sufficiently trustworthy data in support 
 of either of the other two. 
 
 * Bezly Thorne, " The Schott Methods of the Treatment of Chronic 
 Diseases of the Heart," 2nd edit., London, i8g6. 
 
DISORDERS OF THE HEART. 83 
 
 The occurrence of shrinking of the cardiac area as 
 an immediate effect of the bath or resistance exercises 
 has been denied by very competent observers (Groedel, 
 Guntz, Leyden) and the question of baths and exer- 
 cises producing their alleged effects by reflex influence 
 upon nerve-centres is still undecided. 
 
 4. Dr. G. Oliver has thrown some scientific light 
 upon the effect of exercise in showing b}' a very simple 
 experiment that the mass of blood in the muscles 
 is thereby increased, so that, e.g., an arm after exercise 
 would displace a larger volume of water than before. 
 
 5. Dr. Oliver* has further shown that as a result of 
 muscular exercises the blood thickens, the proportion 
 of corpuscles in a given measure being increased, and 
 he attributes this to the transfer of fluid ingredients 
 from the blood into the substance of the muscles and 
 lymphatic spaces. 
 
 6. He quotes Brunton and Tunnicliffe's experiments 
 in confirmation of the previously recognised effect of 
 muscular exercise in first raising and secondly lowering 
 the blood-pressure. 
 
 7. It is probably true that the circulation through 
 muscles in action is more rapid and easy (after the 
 first pressure effect of the muscle upon the vessels has 
 passed off) and that the determination of blood to 
 them may relieve the congestion of other organs. It 
 is difficult to see how such replacement of blood should 
 have any special effect in depleting the chambers of 
 
 * " Recent Discus'~-ion at the British Balneological and Climatological 
 Society." See The Lancet, Feb. 5th, 1898. 
 
 G 2 
 
84 TREATMENT IN DISEASES AND 
 
 the heart except by facilitating the general circula- 
 tion. 
 
 8. The effect of resistance exercises in slowing the 
 pulse is not constant and would naturally vary with 
 the degree of exercise and the condition of the circu- 
 lation beforehand. Walking smartly across a room 
 once or twice will often diminish the rapidity and 
 increase the force for the time of a quickly and weakly 
 acting heart. 
 
 The effect of the Nauheim exercises may, then, be 
 said to be a stimulation of the heart's action with some 
 steadying effect and increased completion of systole — 
 an improved circulation through the coronary vessels 
 and an increased mobility of the blood by its readier 
 passage in greater bulk through the muscles, thus 
 relieving stagnation in the great internal organs, es- 
 pecially on their venous side. 
 
 In what cases are these exercises to be advised ? 
 The employment of the carefully graduated and ob- 
 served exercises of Schott and Oertel may be re- 
 garded as a counsel of perfection to be advised for 
 certain cases only as a preliminary to the return to 
 that measure of active life of which their heart con- 
 dition admits, and as serving the purpose of indicating 
 what that measure will be and by what degree of ordi- 
 nary exercise it may be arrived at. 
 
 Resistance exercises are especially adapted for the 
 initial treatment of those flabby, irritable, "stuffy" 
 hearts, if I may use the term, as applied to cases of 
 fatty infiltration and impaired metabolism, which are 
 met with in people of venous plethora. 
 
DISORDERS OF THE HEART. 85 
 
 In cases of chlorosis with dilated heart after a pre- 
 liminary week or two of complete rest the Schott 
 treatment is valuable if combined with a dry, bracing 
 climate and some chalybeate. 
 
 In the first commencing failure of heart in chronic 
 valve lesions the treatment may be employed combined 
 with a more or less complete cessation from all other 
 exercises and similarly after such cases have been 
 restored up to a certain point by digitalis treatment. 
 
 Further, certain cases in which from the symptoms 
 and signs we recognise the presence of atheromatous 
 change in the coronary vessels, the treatment may be 
 cautiously tried in combination with much rest. These 
 cases are characterised by a certain degree of plethora 
 and by breathlessness, attended with cardiac pain on 
 arriving at a certain stage of walking or inclined 
 walking exercise. If the treatment be mainly confined 
 to these lines it is undoubtedly an aid to our thera- 
 peutics. 
 
 There are other cases again in which it should not 
 be employed. All cases of acute endocarditis, whilst 
 there is any trace of activity of lesion remaining are 
 still more unsuitable for this than for the massage 
 treatment. Cases of advanced cardio-vascular changes 
 of the nature of sclerosis and particularly when asso- 
 ciated with granular kidneys are absolutely unsuited. 
 In cases of introspective people with neurotic hearts, 
 the treatment is best avoided. The numberless cases 
 of imaginary weak hearts that would naturally flock to 
 specified "cures" require a diagnosis and a better 
 
TREATMENT IN DISEASES AND 
 
 occupation than that of indoor g3^mnastics. The 
 exercises have in my experience not proved successful 
 in tachycardial cases. For exophthalmic goitre in the 
 early stages they seem eminently unfitted. 
 
 A still more pronounced treatment is the Oertel* 
 treatment of graduated walking exercises with a dietary 
 restricted in fluids. A dry, highly nitrogenous diet 
 with avoidance of fats and a very sparing allow- 
 ance of starch, with fluids restricted to 36 ounces 
 a day all told, and steady walking exercise for 
 distance and steepness of ascents adapted to the 
 condition of the patient. The gentlest incline walks 
 can be arranged with frequent rests or the exer- 
 cise can be pushed to the point at which deep gasp- 
 ing respirations are excited and a profuse action of 
 the skin is produced. 
 
 This treatment is fully described in Ziemssen's 
 Cyclopaedia. It has been replaced very much by the 
 Schott exercises, to which, however, it may be re- 
 garded as a sequel. The guiding principles and 
 restrictions of its use are sufficiently obvious. Its 
 chief advantage is that it is undertaken in the open 
 air. 
 
 There is no doubt that some of the discomfort which 
 ensues from massage and passive exercises, the un- 
 expected sense of fatigue and languor, may often be 
 attributed to want of good air in abundance adapted to 
 the increased oxidation produced. 
 
 * Oertel, " Kreislaufs-Storungen," v. Ziemssen's " Handbuch," 
 B. vii., 18&4, and B. iv., 1891. 
 
DISORDERS OF THE HEART. 87 
 
 And this leads me to mention another point of great 
 importance in the treatment of impaired hearts, and 
 that is the desirabihty of the patient's taking full 
 inspirations, especially during the limited open-air 
 exercise allowed to them. The constant aspiration of 
 the elastic lung as an aid to the circulation is scarcely 
 yet appreciated in practical medicine. I endeavoured 
 to emphasise its importance many years ago as a force 
 of constant action even through the whole period of 
 expiration and as increasing with the inspiratory 
 expansion of the lungs.* 
 
 I have been in the habit often of advising bedridden 
 people to take an occasional series of deep inspirations 
 with the view of lessening venous stagnation. 
 
 Dr. Oliver, in his Croonian Lectures, and quite 
 recently in his remarks at the British Balneological 
 and Climatological Society, has drawn attention to the 
 effects of deep, slow inspirations with firm contraction 
 of the abdominal parietes in emptying the hepatic and 
 other abdominal veins and in increasing splanchnic 
 vaso-motor tone. 
 
 All the points which have been noted with respect 
 to formulated exercises are common to other less 
 regulated kinds of exertion of similar degree and 
 severity. The wielding of a salmon rod is a resist- 
 ance exercise equal to and more amusing than any 
 of those of Nauheim. We should probably find 
 the muscles swell, the blood thicken, the blood- 
 
 * " On Some Effects of Lung Elasticity in Health and Disease." 
 Transactions of the Medico-Chirurgical Society, vol. lix., 1876. 
 
88 TREATMENT IN DISEASES AND 
 
 pressure at first rise and then fall, the venous cur- 
 rents quicken and internal congestion relieved after 
 a similar manner. 
 
 Any physiologist might see the same phenomena on 
 a milder scale when observing the enthusiastic golfer 
 with his whole mind occupied and his every muscle 
 braced and restrained in accomplishing some delicfate 
 stroke of the game. 
 
 The " sense of strength " in billiards is only another 
 still more delicate balance of muscular work. 
 
 We have since the beginning of the world been 
 undergoing in our sports and pastimes resistance 
 exercises — every one set of muscles checked and regu- 
 lated by the opposing muscles. But exercises have 
 not been organised in any graduated scale calculated 
 to be beneficial and not harmful for those whose hearts 
 are weak or partially disabled. Hence, although we 
 have many of us seen for years past, perhaps, since 
 the teachings of Stokes sank into the professional 
 mind, the beneficial effects of well-advised and 
 guarded exercise in cases of heart disease, it is 
 nevertheless certain that we have learned from the 
 advocacy of elaborate exercises by Oertel* and Schottf 
 and by Dr. Thorne:]: in this country, a greater con- 
 fidence in their use from a more precise knowledge of 
 their effects. 
 
 Exercises of most varied kinds can be devised 
 suitable to all degrees of cases in which any exercise 
 at all is desirable. Level walks with frequent pauses, 
 
 * Oertel, loc. cit. j Schott, loc. cit. + Thorne, loc. cit. 
 
DISORDERS OF THE HEART. 89 
 
 similarly taken inclined walks combined with a num- 
 bered succession of deep inspirations, golf, croquet, 
 cricket, fishing, shooting, tennis, cycling and such-like 
 sports taken in the open air can be graduated with 
 considerable nicety, and are certainly as a rule to be 
 preferred to mere gymnastics within doors. 
 
 Formerly weak-hearted people were not allowed to 
 move ; now they are made to walk. The swing of 
 the pendulum is tending, perhaps too much, towards 
 exercise. Schott, in his paper to The Lancet in 
 i8gi,* with the exception of aggravated cases be- 
 yond the reach of any treatment, allows onl}' two 
 conditions of heart to contra-indicate the treatment 
 by baths and resistance exercise — viz., aneurysm and 
 progressive arterio-sclerosis, and not all cases of the 
 latter. 
 
 One has witnessed many an apparent triumph of 
 quickly restored strength and apparent well-being in 
 young people with acute endocarditis who have been 
 too soon allowed to resume their exercises. It is only 
 in the latter months that the effects of the chronic 
 deforming lesion of the strained softened valve are 
 manifested. 
 
 The strong brine and aerated baths of Nauheim and 
 other places are unquestionably of much service in 
 some circulatory disorders. They are perhaps most 
 suitable for cases of chronic rheumatism and gout 
 associated with high arterial tension and secondary 
 cardiac disturbance. 
 
 * The Lancet, May 23rd and 30th, 1891. 
 
90 TREATMENT IN DISEASES AND 
 
 In cases of functional excitement of the heart's action 
 in connection with quiescent or only imperfectly com- 
 pensated valvular affections they may be used. In the 
 latter cases at first in combination with more or less 
 complete rest, then with graduated exercises. 
 
 In the high tension and less quiescent cases the 
 higher temperature, calculated to lower tension and 
 to stimulate surface circulation, is the more useful. 
 
 In the more neurotic cases with sound hearts the 
 more tonic and comparatively lower temperatures may 
 be employed of shortened duration. 
 
 It is well pointed out by Dr. Groedel that the baths 
 and exercises are two separate therapeutic agents and 
 that in perhaps only twenty per cent, of the cases are 
 they usefully employed in combination, although mas- 
 sage may be more frequently employed. Beneke*, 
 who originated the bath treatment at Nauheim, was 
 very sound in his doctrine to avoid all gymnastic 
 exercises until after the lapse of six months from any 
 acute endocarditis. 
 
 We now come to the treatment of acute heart failure 
 which may perhaps be best referred to in connection 
 with that acute disease in which it is frequently met 
 and of which it too often forms the fatal turning point 
 — viz., pneumonia, in which disease the invalidating 
 conditions affecting the heart are (i) stress of labour ; 
 (2) blood-supply and nutrition impoverished and viti- 
 ated ; and (3) innervation excited and debilitated by 
 the effects of shock and pyrexia. 
 
 * Beneke, Berlin Klin. Wochenschrift, No. 22, 1870 
 
DISORDERS OF THE HEART. 91 
 
 How are we to meet, and it may be to anticipate, 
 heart failure under these circumstances ? This is 
 really the kernel of the problem before the physician 
 in every case of severe pneumonia. 
 
 All rational treatment of the early stages of pneu- 
 monia tends to lessen the blood-pressure in the lungs. 
 It is in the latter stages, towards the crisis, when the 
 lungs are most extensively consolidated, when the 
 nervous excitement of early pyrexia is yielding to 
 exhaustion, and when the blood aeration is most defec- 
 tive, that acute heart failure is apt to supervene. A 
 running pulse, irregular from loss of vagus control, 
 is the first symptom, soon to be followed by oedema of 
 the unconsolidated portions of the lungs frothing up 
 through the bronchial tract to produce that ominous 
 tracheal rattle with which we are too familiar ; these 
 are the signs of heart failure threatening life. 
 
 There can be little doubt that an exhausted nerve cen- 
 tre is at the root of most of the cases of cardiac failure 
 rather than mere overstrain from impeded pulmonary 
 circulation. There are two symptoms which especi- 
 ally tend to heart failure and are largely instrumental 
 in causing the nerve exhaustion which brings it about — 
 viz., a temperature above 104° F. and sleeplessness. 
 
 It will be generally noted that the failure comes on 
 suddenly; there may have been one or two preliminary 
 warnings of partial collapse with running pulse and 
 cold extremities from which the patient may rally but 
 which are generally followed by more severe and often 
 fatal attacks. At the very commencement of such 
 
92 TREATMENT IN DISEASES AND 
 
 signs ammonia, which my experience would lead me to 
 infer after a few days of usefulness tends rather to 
 produce cardiac depression, should be changed for a 
 mineral acid of which dilute phosphoric acid is the 
 best. Some digitalis or strophanthus should be added 
 to the mixture and strychnine should be given separ- 
 ately either in an extra quantity of stimulant or sub- 
 cutaneously if the absorbing powers of the patient are 
 at all doubtful. 
 
 But the most powerful remedial agent is oxygen, 
 since it attacks one of the chief causes of cardiac 
 failure by securing a supply of oxygenated blood to the 
 coronary vessels and the pulse will be observed to 
 become slower and fuller under its influence. It 
 should be at hand in all severe cases and should be 
 given in good time as an occasional inhalation. 
 
 Whilst as a rule we need not in pneumonia attach 
 much importance to a high temperature, in any case 
 where heart failure threatens it must be reduced to a 
 safer level — i.e., by a degree or two — by hot or cold 
 sponging or, if necessary, by the dripping cold pack. 
 
 Another question presses at about this time ; it is 
 that of sleep. Most cases of pneumonia get frequent 
 short snatches of " dog sleep," which is all that we can 
 expect and serves to tide them on to the crisis ; but 
 who has not witnessed that wide-eyed delirious vigil in 
 pneumonia, and especially in influenzal pneumonia, in 
 which the mind is painfully alert and the senses preter- 
 naturally acute, sleep being entirely absent ? 
 
 I am in the habit of suggesting help for wakefulness 
 
DISORDERS OF THE HEART. 93 
 
 in pneumonia in the form of a small dose of lo gr. or 
 20 gr. of sulphonal taken in hot fluid at 8 or 9 p.m., 
 and with this preliminary a 20 gr. dose of bromide 
 taken at 10.30 is often sufficient to secure some restful 
 sleep. When the temperature is high a single dose of 
 from 7 to 10 gr. of phenacetin may be added to the 
 bromide. When delirium is a marked feature hyoscin 
 in doses of ^^o gr. subcutaneously and repeated once or 
 twice may be used sometimes with great advantage. 
 
 Cases of persistent sleeplessness almost invariably 
 prove fatal with heart failure, a running pulse, the 
 cardiac action becoming at last merely peristaUic as 
 the blood-clot accumulates in the auricles. Bromides, 
 chloral, sulphonal, are almost useless and with the 
 gathering serum in the tubes one hesitates to give 
 opiates. And yet I believe that in these severe cases 
 morphia should be given to secure a few hours' sleep 
 and to give the nervous system time to recuperate and 
 to allow of some restoration of heart power before it is 
 too late. 
 
 I have seen some cases in which death has appeared 
 to be adverted by (i) a strong dose of food and stimu- 
 lant ; (2) ^ gr. of morphia with atropine ; (3) aeration 
 being maintained by the oxygen current being fre- 
 quently played over the mouth and nostrils for a few 
 minutes at a time. The oxygen may be warmed as it 
 enters the bag by passing it through a coil of tubing 
 immersed in hot water. 
 
 It has seemed to me that strychnine has rather 
 favoured this peculiar sleeplessness of patients whea 
 
94 TREATMENT IN DISEASES AND 
 
 utterly exhausted, but its powers as a cardiac stimulant 
 is unrivalled and its use in cases severe enough to lead 
 up to this condition is quite essential and it may be 
 renewed on the effects of morphia passing. 
 
 The remarks I have just made are applicable to 
 heart failure in pneumonia and I have endeavoured to 
 indicate the measures that tend to advert it and to 
 combat it when present. I have not dealt with the 
 treatment of pneumonia in any other sense, for to treat 
 the vast majority of cases of pneumonia with alcohol, 
 strychnine, oxygen, morphia and the like would be at 
 best like storming a mud hut with Armstrong guns ; to 
 use dangerous remedies in cases which require only the 
 gentlest treatment and careful nursing is a great 
 blunder. 
 
 The fatigue of heart that follows such tempestuous 
 periods is sometimes very great. It is partly nerve 
 fatigue and is associated with an often greatly depressed 
 temperature lasting for many days. It is in part also 
 muscular fatigue. The pulse either remains quick and 
 very soft or it may become very slow and vacillating. 
 
 Patients should always remain in bed until the 
 temperature, which after the crisis frequently descends 
 considerably below the normal, has had at least a 
 sufficient interval to return to or near the normal 
 range, and cardiac and nerve tonics such as strychnine, 
 caffein, and the hypophosphites will prove valuable on 
 convalescence. 
 
 Exercise in these cases must be cautiously resumed, 
 keeping well within the limits of fatigue until heart 
 power is quite restored. 
 
DISORDERS OF THE HEART. 95 
 
 Acute heart failure in other diseases and from other 
 
 causes requires a similar handling, varied to meet 
 varieties in the case. Time will not permit me to 
 allude to them further. 
 
 I should like, however, to draw attention to the 
 great value of oxygen inhalations in the treatment of 
 heart failure in old people, due to fatty degeneration of 
 the organ. 
 
 These cases are characterised by the usual signs of a 
 rather large and feebly acting heart, together with 
 irregularity of rhythm, there being perhaps twenty or 
 thirty beats fairly reaching the wrist, whilst amongst 
 them are twice as many beats which only ver}^ imper- 
 fectly do so. Cheyne-Stokes breathing is another re- 
 markable symptom which is especially apt to super- 
 vene after any fatigue and to come on during sleep. 
 This form of breathing bears no direct relationship 
 to the pulse and is probably an associated degenerative 
 neurosis. 
 
 The employment of oxygen inhalations several times 
 in the twenty-four hours has a decidedly strengthening 
 influence upon the heart, no doubt by sending some 
 extra-oxygenated blood through the coronary arteries, 
 and it also lessens the Cheyne-Stokes breathing and 
 refreshes the patient. Strychnia is the most useful 
 cardiac stimulant in these cases- 
 Coming to that large class of sub-acute or chronic 
 heart failure dependent upon degeneration or other 
 changes in the heart wall, we find them separable for 
 the purposes of treatment into those in which the 
 
96 TREATMENT IN DISEASES AND 
 
 impairment is temporary and remediable, as from (i) 
 anaemia ; (2) fatty infiltration ; and (3) overstrain ; and 
 into those in which it is permanent as in (i) fatty or 
 fibro-fatty change from coronary disease ; (2) chronic 
 fibroid change from other causes, syphilis, alcoholism, 
 or associated with chronic high arterial pressure in 
 gout, renal disease, &c. ; and (3) senile changes. 
 
 In anaemia the atonic and badly nourished heart 
 frequently yields before the blood-pressure, is slightly 
 enlarged, irritable in function, and besides the usual 
 haemic bruits presents a murmur at the mitral area. 
 Such cases are frequent in hospital practice, and it may 
 be said that the routine treatment of cases of chlorosis 
 bad enough to come into hospital is a fortnight's rest 
 in bed, with the necessary laxatives and ferruginous 
 tonics and further treatment at a convalescent hospital. 
 
 The heart is capable of being severely taxed, pro- 
 vided it be a healthy organ in a fairly young subject, 
 without being overstrained, the difference being that 
 between functional fatigues and actual damage to valve 
 or muscular wall. Of course too frequently repeated 
 over-taxation will cause permanent enlargement with 
 some change in the muscular texture not only of the 
 heart but also of the vessels. 
 
 Case. — A naval officer, aged 48, consulted me re- 
 cently on account of his being sensible of his heart's 
 action, especially when lying on the left side. He was 
 accustomed in early life to run quarter mile races 
 and whenever he left his ship he always indulged in 
 hard sports especially polo. Twelve months ago in 
 
DISORDERS OF THE HEART. 97 
 
 Australia, after a hard game at polo, he was exhausted 
 and felt faint and shaky the next day. On examination 
 he presented a moderate degree of hypertrophy of the 
 left ventricle, the apex beat being somewhat thrusting 
 just within the nipple line, and the impulse too diffused 
 inwards towards the sternum. The pulse was 80 and 
 regular and compressible, but the radial vessel was 
 large and somewhat thickened and wanting in elas- 
 ticity. Here was a case of cardio-vessel change con- 
 sequent upon repeated over-taxation of the circulation 
 sometimes when not in good condition owing to con- 
 finement on board ship. The present condition, a 
 permanent one, is compatible with a life of moderate 
 activity, but further straining efforts would be likely to 
 lead to aneurysm or grave valve lesion. 
 
 It is, however, prolonged taxation of the heart ex- 
 tending over the period of fatigue that is very apt to 
 cause changes of a more or less permanent kind which 
 constitutes overstrain. The irritable heart of soldiers 
 described by Da Costa, and the forms of heart disease 
 found so frequently in lightermen and professional 
 athletes, are of this source. 
 
 It is extremely important that in young people 
 undergoing active growth and development' sports 
 should be so arranged as not habitually to tax the 
 heart and circulation beyond the period of fatigue, the 
 point to be remembered being that young people can 
 do almost anything in short spells or spurts with rest 
 between, but their hearts will not bear with advantage 
 prolonged and fatiguing exertion, the reason being that 
 
 H 
 
98 TREATMENT IN DISEASES AND 
 
 nutrition changes of waste and restoration are quick 
 and cardiac innervation excitable. 
 
 In full-grown adult life great exertion can be more 
 prolonged and as life advances the heart is much more 
 liable to damage from quick spurts of effort than from 
 prolonged and steady exertion. 
 
 In my belief with perhaps the single exception that 
 in some cases long runs and paper-chases are not suffi- 
 ciently supervised with regard to the varied ages and 
 physique of the boys the usual public school sports are 
 admirabl}^ adapted for them.* 
 
 I would here make an observation which is probably 
 in accord with the experience of others, although I 
 have not seen it alluded to — viz., that in young people, 
 especially boys between seven and twelve j-ears of age, 
 
 * The medical officer to one of our great public schools writes to 
 me : — " I enclose you a list of our runs. Up to two years ago the same 
 runs were run by boys of 13 and ig years of age, with these occasional 
 results — vomiting on the road ; vomiting in the evening after a run ; 
 lying on the road exhausted; and in one instance a fatal termination. 
 
 " Under our present regime, which it has taken 25 years of persistent 
 advocacy to establish, no ill effects ever arise, and boys are keen to join 
 in the runs ; whereas formerly the small boys would try to evade them 
 in every conceivable way. 
 
 " A. Twelve miles. 
 
 " Exclusively for boys above 17 years of age with leave obtained from 
 home and House Master, and whose names are placed on a special list. 
 Every boy who runs to be in good training. 
 
 " B. About nine miles. 
 
 " For boys above 16, with leave from home and special leave from 
 House Master. 
 
 " C. House runs — seven and five miles. 
 
 " No time limit. To be run separately by senior (7 miles) and 
 
DISORDERS OF THE HEART. 99 
 
 it is common to iind the heart relatively large, the 
 apex beat slightly outside the normal, the impulse of 
 the left ventricle relatively strong. I believe this con- 
 dition to be by no means abnormal and that it is 
 attributable to the restless activity of early youth and 
 to the cardiac development being somewhat ahead of 
 the pulmonary. It would be an error to regard it as 
 morbid. 
 
 As an instance of what I mean by over-taxation of 
 the heart in young people which would lead to over- 
 strain, I may quote the following case. 
 
 I was a short time ago consulted about a line, high- 
 spirited little lad, aged fourteen 3'ears, well-built, full of 
 courage, and who had been a successful competitor in 
 most school sports. These had probably done him no 
 harm. But in the holidays he was allowed to associate 
 in sports with older people. He would do bicycle 
 races with his elder brothers : he would go out for 
 whole long autumn days shooting with grown up 
 sportsmen ; in fact, he pursued to extreme fatigue 
 sports for which he was unfitted, and the result was 
 a degree of hypertrophy and dilatation of the heart 
 which caused him to be refused for the public service 
 and he was then brought to me for an opinion. 
 
 junior (5 miles), each run being in charge of at least two responsible 
 persons. 
 
 " D. Little side rtms. Distance 3 to 3^ miles. 
 
 " Time one hour. Not more than three hundred yards to be run at a 
 stretch, with slow walks between each. 
 
 " No boy may under any circumstances join in a run of a class superior 
 to the number against his name." 
 
 H 2 
 
100 TREATMENT IN DISEASES AND 
 
 Whilst the youthful heart soon recovers, a degree of 
 stress of work that calls forth full reserve powers and 
 some temporary enlargement, it is when the quick 
 waste of youthful tissues is forgotten and efforts are 
 allowed to be too prolonged or too quickly repeated 
 without sufficient intervals for rest and repair that 
 harm may arise. A full training involves a certain 
 amount of hypertroph}' and dilatation up to physio- 
 logical limits of reserve capacity. We want to know 
 more about the phenomena of involution in such hearts 
 on the cessation of effort and training after the event 
 has come off, and some of our members at the Univer- 
 sities, or who have opportunities of watching athletic 
 training elsewhere might collect for us some valuable 
 information. 
 
 My own limited experience of those who have over- 
 done it in training is that they become anaemic, that 
 their cardiac innervation suffers and that the ventricles 
 yield from impairment of muscular nutrition. An anae- 
 mic condition of such patients and an occasional hesita- 
 tion in the cardiac rhythm are the earliest phenomena. 
 
 The treatment of an overtaxed heart and the lighter 
 degrees of overstrain is simply a short period of com- 
 plete rest followed by steady but carefully graduated 
 exercise, calculated to maintain cardiac and general 
 muscular circulation and nutrition without exciting the 
 heart's action or increasing the blood pressure. 
 
 I think special heart exercises are better avoided ; 
 we do not want to make heart " crocks " of our 3^oung 
 people. Children have great powers for complete 
 recovery in their rapid renewal of tissue. 
 
DISORDERS UP THE HEART. .101 
 
 Overstrain of unsound hearts is, of course, a matter 
 of daily experience, and is the immediate cause which 
 brings such cases under obser\-ation. Its treatment is 
 involved in that of the heart disease upon which it 
 supervenes and the same remark applies to the more 
 severe effects of strain such as rupture of valves, 
 aneurysms, and the like. 
 
 The time remaining at my disposal may perhaps 
 with greatest interest be devoted to a consideration of 
 Infective Endocarditis, the true significance of which 
 was, as is well known, first recognised by the late Dr. 
 Senhouse Kirkes in 1853. He was followed by 
 Virchow, who with you yourself, Sir, in the pages of 
 that mine of pathological wealth, the Guy's Hospital 
 Reports,* were amongst the pioneers of modern 
 clinical medicine who recognised the essential charac- 
 ters of the disease. 
 
 Its pathology will be broadly covered for our present 
 purpose by saying (i) that it is a disease most commonly 
 (61 cases out of 69 Conpland) supervening upon valve 
 changes the result of former endocarditis ; (2) that it is 
 produced by the lodgment and local cultivation of 
 microbes ; (3) that its secondary results are occasioned 
 by the toxins yielded to the blood by these organisms 
 and by the detachment of microbe bearing fibrinous 
 emboli occluding vessels in various organs and parts ; 
 (4) that the organisms regarded as capable of setting 
 up infective endocarditis are of more than one kind,t 
 
 * "Guy's Hospital Reports," 1870, vol. xv., p. 33. 
 f Dr. Dreschfeld (Allbutt's " System of Medicine," vol. i., p. 629) 
 enumerates twelve kinds of organisms as having been found. 
 
102 TREATMENT IN DISEASES AND 
 
 but that streptococci and staphylococci pyogenes are 
 the most frequently found, pneumococci next in fre- 
 quency, gonococci and others being occasionally met 
 with ; (5) it is stated that in some cases organisms have 
 been found peculiar to the lesions. 
 
 The disease is frequently started from infection 
 through septic surfaces or centres, endometritis, otitis, 
 gonorrhoea, intestinal or faucial sloughings, &c. 
 
 In other and a numerous class of cases the disease 
 arises without any intermediate illness from exposure 
 to sewer-gas emanations, but in the latter cases in 
 my experience it has almost always happened that 
 previous valve lesions from former endocarditis have 
 existed. 
 
 I have only met with one instance in which the in- 
 fective disease has supervened in continuity upon acute 
 rheumatic endocarditis, and this case was complicated 
 quite in the early period of the rheumatic endocarditis 
 by a left apex pneumonia, pointing to a possible source 
 of the infection. But this does not seem to be the 
 experience of others and one would regard such cases 
 as very possible, given acute rheumatic endocarditis in 
 the presence of insanitary surroundings. It is a curious 
 instance of that fallaciousness of experience which is 
 so aptly alluded to in our College motto, that whereas 
 it is stated that pneumonia is a common antecedent of 
 ulcerative endocarditis, I have only myself met with 
 this one instance of it. 
 
 The facts which stand salient with regard to infec- 
 tive endocarditis are the frequent concomitance of 
 
DISORDERS OF THE HEART. 10^ 
 
 previous valve defect and exposure to sewer-gas 
 emanations or other sources of septic infection, and 
 these factors will be found to underlie and initiate 
 the whole pathology of the disease in the vast majority 
 of instances. They are in my belief the objectives of 
 our prophylactic and therapeutic treatment. 
 
 A due recognition of these facts will add to the care 
 with which on sending a patient convalescent from 
 rheumatic fever with endocarditis to a seaside or 
 country resort we should satisfy ourselves as to the 
 sanitary condition of the house to be occupied. For 
 with as yet unprotected and imperfectly healed lesions 
 exposed in the current of the blood, such a patient is 
 very accessible to microbic infection. 
 
 Obviously the first inquiry in any case presenting 
 symptoms suggesting infective endocarditis is into his 
 sanitary surroundings and into every possible source of 
 autogenetic infection, such as otitis, chronic gleet, 
 pelvic abscess, and the like, and to at once deal with 
 any such defect. 
 
 The next point which strikes the clinical observer is 
 the fact that with a mild remittent fever there are 
 associated more or less periodical outbreaks of high 
 temperature with great fluctuations of from a few 
 hours' to two or three days' duration. 
 
 These may be explained either by the toxic products 
 of the microbe cultivation requiring sometime to 
 accumulate before they produce their characteristic 
 symptoms, or, and I am inclined to think more pro- 
 bably, by embolic fragments, detached colonies of 
 
104 TREATMENT IN DISEASES AND 
 
 microbes causing sudden accessions to the dose of 
 toxins, for it is a fact that most of the higher pyrexial 
 excursions are attended with fresh embohc phenomena. 
 In any case there are certain intervals between the 
 stormy accessions during which remedies have a chance 
 of influencing the disease. 
 
 A gentleman, a former member of our profession, 
 recently remarked on a public occasion that apart from 
 surgical measures the only function left to the healing 
 art was of a prophylatic kind. I can only trust that 
 when that gentleman's time shall come to be smitten 
 with illness it will be of a kind accessible to surgery. 
 He might, indeed, point in justification of his satire 
 upon those who have to deal with the more occult 
 phenomena of disease to the position which thera- 
 peutics stand with regard to infective endocarditis at 
 the present moment. 
 
 We can often prevent this appalling malady ; we 
 may sometimes nip in the bud by prophylactic mea- 
 sures its dire development. What can we do in its 
 treatment ? 
 
 Of drugs arsenic is the only one under a course of 
 which I have seen this disease get well. I do not re- 
 member to have seen any appreciable result from 
 quinine, sulpho-carbolates, guaiacol, mercury, or other 
 remedies of the antiperiodic or antiseptic class. But 
 in the face of the dreadful mortality of at least 80 per 
 cent, of the cases that prevails arsenical treatment 
 must promptly be abandoned for any more promising 
 remedy. And looking to the pathology of the disease 
 
DISORDERS OF THE HEART. 105 
 
 it would seem that in the modem development of serum 
 therapeutics there is most to be hoped for in its future 
 treatment. 
 
 It is hazardous to trust the reports of any new 
 method of treatment until a sufficient time has elapsed 
 for the favourable cases which have brought it into 
 vogue to be duly apportioned to those in which it has 
 failed. There have been recently reported four cases 
 treated by the anti-streptococcus serum with the very 
 encouraging result of three recoveries. 
 
 It must not be concluded, however, that this repre- 
 sents anything like a just account of the results of the 
 treatment. A considerable and as yet unpubhshed 
 experience at the various large hospitals and in private 
 has already gone far to moderate enthusiasm for this 
 method of treatment. 
 
 I have here a table of all the cases that have come 
 within my personal knowledge through inquiry amongst 
 my friends and at some of the principal London 
 hospitals. 
 
 They are 14 in number, which include the 3 success- 
 ful cases already published, 9 deaths, and 2 in which no 
 favourable result has ensued. 
 
 We must allow for the fact that in some of these 
 cases the anti-streptococcus serum has, from a natural 
 hesitancy with regard to its efficiency and some timidity 
 of possible risks in its employment, been only employed 
 in later-and almost hopeless stages of the disease when 
 already large embolic detachments have set up centres 
 of cultivation in many positions, so that the accom- 
 

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108 TREATMENT IN DISEASES AND 
 
 panying table need not be regarded as so discouraging 
 as would at first appear. 
 
 It may be laid down as a principle governing treat- 
 ment by this particular serum that the more distinct 
 the history of a previous endocardial lesion and a 
 subsequent exposure to infection through a suppurative 
 medium or a sewer gas sepsis the more appropriate the 
 case for the treatment. This rule would discourage its 
 employment in cases in which the pneumococcus, 
 gonococcus, or some other microbes divergent in 
 character from the strepto- and staphylo-cocci were 
 concerned, and if with the recognition of this principle 
 and its earlier and bolder carrying out more encourag- 
 ing results are obtained it will certainly follow that 
 analogous measures will be found for the circumvention 
 of the other forms of microbic action. 
 
 There is a further point in the natural history of in- 
 fective endocarditis which is well illustrated in Chart I. 
 — viz., that towards the close of the case when the 
 vital powers are at a low ebb the temperature tends 
 to fall apart from any treatment and the reactions to 
 embolic incidents are much less marked or do not 
 occur at all. It is possible that thus, if the serum be 
 used late in the case, it may have effects attributed to 
 it which should be otherwise accounted for. 
 
 I will venture now to allude to a case treated by the 
 subcutaneous use of another material — viz., yeast — 
 which, although it occurred four years ago and struck 
 me very much at the time, it did not seem then advis- 
 able to publish, for as it stood it might perhaps 
 
DISORDERS OF THE HEART. 109 
 
 equally well illustrate the value of a treatment or the 
 fallacy of drawing any deduction from a single case. 
 
 I had some months previously seen a case of infective 
 endocarditis of long standing with Sir W. Broadbent 
 in which he had for a time employed yeast given b}- 
 the mouth with the apparent effect that during the 
 several weeks of the treatment the temperature had 
 preserved a lower although not a normal range ; the 
 patient, however, became nauseated and would not 
 continue the remedy and finally died from the disease. 
 
 A 3'oung man, aged twenty-one years, with slight 
 defect at the aortic valve, lived in a room over an 
 archway which covered a former inlet of the Thames 
 and presented a surface of stagnant Thames mud, 
 sometimes dry, often wetted with surface water from 
 the extended basement of an ancient building. He 
 was given to violent exercises— bicycling, gymnastics, 
 and engineering work — and the presumption is that he 
 overstrained an old-standing valve lesion. 
 
 On May 15th, 1895, he dined out with a friend and 
 was taken ill with vomiting and faintness in the train 
 going home. He was seen by Dr. Davis, of Dorset 
 Square, on the i6th, when he had a temperature of 
 102° F., general malaise, and a cardiac murmur of 
 aortic regurgitant character. The temperature con- 
 tinued raised for four daj^s, when I saw him in consul- 
 tation with Dr. Davis. 
 
 The heart condition did not seem to account for the 
 temperature and from the first some more general 
 cause was suspected. There were no rheumatic sym- 
 
110 TREATMENT IN DISEASES AND 
 
 ptoms nor were there any special symptoms of enteric 
 fever. On about the eighth day he had a severe rigor and 
 the temperature, which had been ranging between 102° 
 and 100°, suddenly amounted to 105°, running down 
 again to 100° in a few hours ; after fluctuating at the 
 original level for four or five days another rise to 105° 
 would take place with a rigor as before. Sometimes a 
 second rigor would closely follow the first with a cor- 
 responding acute rise of temperature. With the rigors 
 there was sometimes sharp pain over the splenic region 
 and the spleen was distinctly enlarged. 
 
 On June ist he was removed to a perfectly sanitary 
 nursing home, but the symptoms remained unaltered. 
 
 Salicylate of soda was at first administered and 
 quinine was then given in 5 gr. doses without result 
 and moderate doses of arsenic were tried, but these 
 drugs did not influence the symptoms. The aortic 
 regurgitant murmur became very marked and a curious, 
 rough, somewhat churning, but mainly systolic mur- 
 mur was heard over the left auricular region. 
 
 On July ist injections of yeast culture were em- 
 ployed, from 20 to 30 minims of the yeast being 
 injected into the cellular tissue each second day, 
 and these were steadily continued until September ist. 
 Sir W. Broadbent joined us in consultation on July 
 14th, when the murmur was noted as most audible to 
 the left of the sternum and as not affected b}' inspira- 
 tion but prolonged during expiration. The deep car- 
 diac dulness was increased both upwards and to the 
 right. The systolic rough bruit was much more loud 
 
DISORDERS OF THE HEART. Ill 
 
 and rough during high pyrexial periods. There were 
 never any signs of renal emboli. 
 
 Soon after the commencement of the yeast treatment 
 he had acute right pleurisy with some effusion. This 
 began with two or three of the usual rigors in quick 
 succession and uprisings of temperature, but the tem- 
 perature remained high for a few days. With this in- 
 terruption the intervals of four days between the rigors 
 which had pretty steadily been observed appeared 
 broken by the yeast injection and prolonged to six 
 or seven days. The temperature became normal, or 
 nearly so, in the intervals and altogether normal about 
 August 14th, three months from the commencement 
 of the illness with complete cessation of rigors. 
 
 The patient went to Brighton on Sept. ist and 
 rapidly convalesced and has remained active and well 
 since. 
 
 In this case the 3^east culture (a fairly concentrated 
 cultivation of yeast in saccharine water) was obtained 
 from Messrs. Burroughs and Wellcome. It was an in- 
 convenient and unstable preparation, although it seemed 
 to serve a very good purpose. 
 
 Dr. De Bacher of Paris seems to have originated the 
 yeast ferment treatment of microbic diseases and it 
 was from a reference (after my observation of Sir W. 
 Broadbent's case) to his experiments* with "Backerin," 
 an aseptic preparation of fermentable material contain- 
 ing the yeast fungus, that I was induced to use the 
 yeast preparation subcutaneously. 
 
 * " Journal des Sciences Medicales de Lille," 1893, review of MM.- 
 De Bacher's and Bruchet's experiments by Professor Lemiere. 
 
112 TREATMENT IN DISEASES AND 
 
 " Backerin " could not be obtained at this time and 
 I have not been able to procure it since. De Bacher* 
 explained the efficiency of the yeast fungus in microbic 
 diseases by the cells attracting into their interior and 
 finally killing various microbes and thus helping the 
 germicidal function of the white corpuscles. 
 
 I have used yeast subcutaneously in four other cases, 
 in one of the four using it also in the form of dry yeast 
 in 30 grain doses by the stomach, but I cannot say 
 that any marked result followed. The cases, were, it 
 is true, all rather advanced with splenic and other 
 embolisms. One case was a sequel to gonorrhoea, one 
 to suppurative otitis, and the other two of less defined 
 source. 
 
 Dr. Vaughan,t Professor of Hygiene and Physio- 
 logical Chemistry at Michigan in 1894, advocated the 
 use of solutions of nuclein and nucleinic acid in the 
 treatment of microbic diseases. Dr. Vaughan con- 
 trasts the toxin diseases with those in which the 
 phenomena presented are due to more direct microbic 
 action — in the one class there being an acute intoxica- 
 tion of the system by the action of microbes or fer- 
 ments of very limited life duration, in the other a more 
 continued life and virulence of the organism ; and he 
 regards the nucleins as possessing practically no influ- 
 
 * " Les Ferments Therapeutiques," Paris, 1896, p, 73 et seq. 
 
 f "The Nuclein and Nuclein Therapy," Transactions of the Michigan 
 State Medical Society, Medical News, New York, Feb. 27th, 1897. 
 " The Physiological Action and Therapeutic Uses of Yeast, Nucleinic 
 Acid. With special references to its employment in Tuberculosis."' 
 V. C. Vaughan, M.D. 
 
DISORDERS OF THE HEART. li:j 
 
 ence as antitoxins whilst being powerful indirect 
 germicides. 
 
 From experiment he finds the subcutaneous injection 
 of nuclein to increase the number of white corpuscles 
 both in healthy and tuberculous persons, the increase 
 being variable in degree from slight to threefold and 
 principally of the polynuclear cells. This increase is 
 most evident at the fifth hoqr and disappears after the 
 forty-eighth hour. Dr. Vaughan* bases the assumed 
 efficacy of his nuclein treatment of microbic disease, 
 upon the observations of Fodon, Nutall, Buchner, and 
 others, showing that the germicidal properties of blood 
 serum depend upon constituents yielded to it by the 
 white, and especially the polynuclear white corpuscles, 
 arguing that this natural resistance to bacterial disease 
 will be strengthened by a physiological increase of these 
 corpuscles induced by the introduction of the most dis- 
 tinctive constituent of these cells — viz., nuclein. 
 
 The dose of the nuclein for subcutaneous use is 20 
 minims and upwards of a one per cent, solution or a 
 teaspoonful of a five per cent, solution taken by the 
 mouth between meal-times. It is needless to say that 
 the strictest antiseptic cleanliness with regard to 
 syringes and preparation of the skin surfaces is abso- 
 lutely necessary in the subcutaneous use of the pre- 
 parations. 
 
 I do not for a moment claim to express any opinion 
 as to how far this treatment may prove useful in infec- 
 tive endocarditis. I am not aware that it has been tried 
 
 * Loc. cit. 
 
 I 
 
114 TREATMENT IN DISEASES AND 
 
 except in the treatment of tuberculosis, although it has 
 been advocated both in the form of the original pre- 
 parations of Dr. De Bacher and as nuclein solutions in 
 the treatment of all microbic affections. It has occurred 
 to me that nuclein derived from the young yeast cells 
 may have been the material responsible for the apparent 
 usefulness of yeast in Sir W. Broadbent's and my cases 
 and that it may be worthy of trial in cases at all events 
 in which anti-streptococcus serum would not be ap- 
 plicable. 
 
 The only case of infective endocarditis in which I 
 have used nuclein is one seen by me in consultation 
 with Mr. Christopherson of Hastings, of which I have 
 here a chart (Chart II.) with sufficient marginal notes 
 for the identification of the case. The effect appears 
 very striking the temperature falling to the normal, but 
 after an interval of eighteen days it again rises with 
 what appears to be an embolic incident. With regard 
 to this case, which was treated by nuclein with appar- 
 ently a marked although a temporary result, it should 
 be recorded that Mr. Christopherson, with whom I on 
 two occasions saw the case, has sent me a further note 
 and a chart carefully recorded since the nuclein was 
 first administered. The boy has had many relapses 
 and although he has gradually improved, it cannot 
 fairly be said that any appreciable effect upon the tem- 
 perature has again been observed from the nuclein. 
 
 I regret that time has not allowed me to allude more 
 fully to some forms of cardiac disease, more especially 
 to the subject of senile and prematurely degenerative 
 
DISORDERS OF THE HEART. 
 
 115 
 
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116 DISORDERS OF THE HEART. 
 
 diseases of the heart. A reference to them must have 
 been somewhat discursive, for whilst they admit of 
 much management they necessaril}^ allow of little 
 direct treatment. And, indeed, in trying to seek out 
 points for treatment which are scattered here and there 
 amidst groups of symptoms I fear I have already been 
 too discursive. 
 
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 treatment rather than to touch upon details, the recog- 
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 exercise, of drug administration, of restrictions in diet 
 upon which we formulate our more percise manage- 
 ment of individual cases. Finally, by a due acceptance 
 in cardiac therapeutics of the principle of submission 
 we may better help the patient to acquiesce in his 
 restricted life, caged within the narrowed conditions 
 under which alone it can be maintained and continue 
 useful. 
 
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 UBOLIC ni5C OF TEMPERATURE 
 
 FALL OF TEMPERATURE PRECEDING DEATH LATE EMBOLIC INCIOEW 
 
 LATE EMBOLIC INCIDENT 
 
INDEX. 
 
 Aconite, 47 
 
 Alcoholic stimulants, 26, 30 
 
 Amateur drug taking, 13 
 
 Amyl nitrite, 25, 29 
 
 Anaemia, 96 
 
 Angina pectoris, 11, 23 
 
 Aortic regurgitation, 28, 50 
 
 stenosis, 67 
 
 Arsenic, 49 
 
 Arterial tension increased, 10 
 
 Baths, saline, 21, 89 
 Bradycardia, 39 
 Bromide, 93 
 
 Caffein, 42 
 
 Cardiac innervation, 3 
 
 neurosis, 33, 39 
 
 Cardio- vascular hypersesthesia, 10 
 
 neurosis, 9 
 
 system, 4 
 
 Children, rheumatism in, 46 
 Chlorosis, 85 
 
 Consciousness of morbid heart con- 
 ditions, 5 
 Convallaria, 76 
 
 Degeneration of heart wall, 95 
 
 Diagnosis, 14. 3I1 55 
 
 Diet, 19 
 
 Digitalis, 30, 47, 54, 56, 69, 72 
 
 over dosage, 74 
 
 Dropsy, 76 
 
 Endocarditis, infective, loi 
 
 in rheumatic fever, 48, 70, 81 
 
 Ether, 29 
 
 Examination of neurotics, 14 
 
 Exercises, 19, 37, 80 
 
 unsuitable cases, 85 
 
 Exophthalmic goitre, 35 
 
 Functional disorders of heart, 4, 8 
 cause of, 17 
 
 Heart, discomfort of, n 
 
 failure, 64, 70, 90, 95 
 
 fatty infiltration of, 19 
 
 functional disturljance of, 4, 8 
 
 hurry of, 32 
 
 infantile, in febrile states, 45 
 
 irritable, 97 
 
 large of.boys, 99 
 
 Hyosein, 93 
 Hyperaesthesia, 10 
 
 Infective endocarditis, loi 
 Innervation of heart, 3 
 Inspiration treatment, 87 
 Iodides, treatment by, 53 
 Irritable heart of soldiers, 97 
 
 Kidney, floating, 17 
 
 Massage, 55, 80 
 
 Mitral regurgitation, 31, 6g 
 
118 
 
 INDEX. 
 
 Mitral stenosis, 27, 50, 68 
 Morphia, 93 
 
 Murmurs, functional, 14 
 Myocarditis, 47 
 Myxcedema, 41, 42 
 
 Nauheim treatment, 81 
 
 Nerve exhaustion in pneumonia, gi 
 
 Neuralgia, visceral, 18 
 
 Neurotic heart, 9 
 
 Neurotics, 5 
 
 Nitro-glycerine, 25, 30 
 
 Nuclein, 112 
 
 Oertel treatment, 86 
 Operative treatment, 38 
 Opium, 47 
 
 Over-taxation of heart, 96, gg 
 Oxygen, 30, 42, 92, 95 
 
 Pain of angina pectoris, 24 
 Pericarditis, 47 
 Phenacetin, 93 
 Pneumonia, 90 
 
 Quinine, 49 
 
 Resistance exercises, 87 
 Rest, 26, 37, 43, 51 
 Rheumatism, acute, 43 
 
 Salicylates, 44 
 
 Salines, 22 
 
 Sanitation, importance ot, 55 
 
 Sea voyage, 21 
 
 Schott treatment, 81 
 
 Senile hearts, gs 
 
 Serum therapeutics, 105 
 
 Sewer gas emanations, 102 
 
 Sleeplessness, 93 
 Spa treatment, 16, 21, 54 
 Sports, 98 
 Strophanthus, 75 
 Strychnine, 30, 42, 94 
 Sulphonal, 93 
 
 Tachycardia, 32 
 
 Teeth, bad, 18 
 
 Thymus extract, 38 
 
 Thyroid secretion, 35 
 
 Treatment of acute heart failure, go 
 
 inflammatory disease ot 
 
 heart, 43 
 
 rheumatism, 51 
 
 angina pectoris, 23 
 
 aortic regurgitation, 60 
 
 exophthalmic goitre, 37 
 
 fatigued heart, 30 
 
 functional disorders of heart, 
 
 8, 16 
 
 infective endocarditis, 104 
 
 mitral stenosis, 69 
 
 neurotic heart, 13 
 
 overstrain, 100 
 
 pneumonia, 92 
 
 tachycardia, 36 
 
 Trinitrine, 29 
 
 Ulcerative endocarditis, cases of, 
 
 106 
 Valvular heart disease, 55, 59 
 Vaso-motor nerve mechanism, 3 
 
 Want of stability in neurotic heart, 
 
 9 
 Water, hot, 26 
 
 Yeast, treatment by, 108 
 
October, 1898. 
 
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10 Catalogue of Works Published by H. K. Lewis. 
 
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Catalogue of Works Published by H. K. Lewis, 11 
 
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Catalogue of Works Published by H. K. Lewis. 13 
 
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Catalogue of Works Published by H. K. Lewis. 15 
 
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16 Catalogue of Works Published by H. K. Lewis. 
 
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Catalogue of Works Published by H. K. Lewis. 17 
 
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 11. 
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 WILLIAM MURRAY, m.d., f.r.c.p. lond, 
 I. 
 ROUGH NOTES ON REMEDIES. Second Edition, crown Svo, 3s. 6d. 
 
 [Now ready. 
 II. 
 ILLUSTRATIONS OP THE INDUCTIVE METHOD IN MEDI- 
 cine. Crown Svo, 3s. 6d. 
 
18 Catalogue of Works Piiblished by H. K. Lewis. 
 
 WILLIAM MURRELL, m.d., f.r.c.p. 
 Physician to, and Lecturer on Pliarmacology and Therapeutics at, the Westminster Hospital, &c. 
 
 I. 
 
 WHAT TO DO 114^ CASES OP POISONING. Eighth Edition, 
 royal 32mo, 3s. 6d. [Now ready. 
 
 II. 
 MASSOTHEBAPEUTICS, OR MASSAGE AS A MODE OP 
 
 Treatment. Fifth Edition, with Illustrations, crown 8vo, 4s. 6d. 
 
 HENRY D. NOYES, a.m., m.d. 
 
 Professor of Ophthalmology and Otology in Belleviie Hospital Medical College ; Executive Surgeon to 
 the New York Eye and Ear Infirmary, &c. 
 
 A TEXTBOOK ON DISEASES OP THE EYE. Second and revised 
 Edition, Illustrated by 5 chromo-lithographic plates, 10 plates in black and colours 
 and 269 wood engravings, 8vo, 28s. nett. 
 
 GEORGE OLIVER, m.d., f.r.c.p. 
 
 I. 
 
 PULSE- GAUGING: A Clinical Study of Radial Measurement 
 
 and Pulse Pressure. With Illustrations, fcap. 8vo, 3s. 6d. 
 
 II. 
 HARROGATE AND ITS WATERS: Notes on the Climate of 
 Harrogate, and on the Chemistry of the Mineral Spring. With Map of the 
 Wells, crown 8vo, 2S. 6d. 
 
 III. 
 ON BEDSIDE URINE TESTING: a Clinical Guide to the 
 Observation of Urine in the course of Work. Fourth Edition, fcap. 8vo, 3s. 6d. 
 
 DR. A. ONODI. 
 
 Lecturer on Rhino-Laryngology in the University of Budapest. 
 
 THE ANATOMY OP THE NASAL CAVITY, AND ITS ACCES- 
 
 sory Sinuses. An Atlas for Practitioners and Students. Translated by St Clair 
 Thomson, M.D. Lond., F.R.C.S. Eng., M.R.C.P. Lond. Plates, sm.all 4to, 6s. neit. 
 
 SAML. OSBORN, f.r.c.s. 
 
 Knight of Grace of the Order of St. John of Jerusalem ; Lecturer and Examiner to the St. John 
 Ambulance Association ; Surgeon to the Hospital for Women, Soho Square, &c. 
 
 I. 
 
 AMBULANCE LECTURES : PIRST AID TO THE INJURED, 
 
 Third Edition, with Illustrations, fcap. 8vo, 2s. 
 
 11. 
 AMBULANCE LECTURES: HOME NURSING AND HY- 
 
 giene. Third Edition, with Illustrations, fcap. 8vo, 2s. 
 
 WILLIAM OSLER, m.d., f.r.c.p. lond. 
 
 Presidentof the Association of American Physicians ; Professor 0) Medicine. Johns Hopkins University ^ 
 
 and Physician-in-Chief Johns Hopkins Hospital, Baltimore. 
 
 I. 
 
 ON CHOREA AND CHOREIPORM APPECTIONS. Large 8vo, 5s. 
 
 II. 
 THE CEREBRAL PALSIES OP CHILDREN. A Clinical Study 
 
 from the Infirmary for Nervous Diseases, Philadelphia. Demy 8vo, 5s. 
 
 KURRE W. OSTROM. 
 
 Instructor in Massage and Swedish Movements in the Philadelphia Polyclinic and College for 
 Graduates in Medicine. 
 
 MASSAGE AND THE ORIGINAL SWEDISH MOVEMENTS? 
 
 their application to various diseases of the body. Third Edition, with Illustra- 
 tions, i2mo, 3s. 6d. nett. 
 
Catalogue of Works Published by H. K. Lewis, 19 
 
 CHARLES A. PARKER, f.r.c.s. edin. 
 
 Assistant Surgeon to the Hospital for Diseases of the Throat, Golden Square, London. 
 
 POST-WASAL GROWTHS. Demy 8vo, 4s. 6d. 
 
 ROBERT W. PARKER. 
 
 Senior Surgeon to the East London Hospital for Children ; Surgeon to the German Hospital. 
 
 I. 
 
 DIPHTHERIA: ITS NATURE AND TREATMENT, WITH 
 
 Special Reference to the Operation, After-Treatment, and Complications of 
 Tracheotomy. Third Edition, with Illustrations, 8vo, 6s. 
 
 II. 
 CONGENITAL CLUB-FOOT; ITS NATURE AND TREAT- 
 
 meat. With special reference to the subcutaneous division of Tarsal Ligaments. 
 &VO, 7s. 6d. 
 
 LOUIS C. PARKES, m.d., d.p.h. lond. univ. 
 
 Fellow of the Sanitary Institute, and Member of the Board of Examiners ; Lecturer on Public Health 
 
 at St. George's Hospital Medical School ; Medical Officer of Health for Chelsea. 
 
 I. 
 
 HYGIENE AND PUBLIC HEALTH. Fifth Edition, with numerous 
 Illustrations, crown 8%o, los. 6d. [Now ready. 
 
 [Lewis's Practical Series.] 
 II. 
 INFECTIOUS DISEASES, NOTIFICATION AND PREVEN- 
 tion. Fcap. 8vo, cloth, 2s. 6d ; roan, 4s. 6d. 
 
 JOHN S. PARRY, m.d. 
 Obstetrician to the Philadelphia Hospital, Vice-President of the Obstetrical and Pathological Societies 
 
 of Philadelphia, &c. 
 
 EXTRA-UTERINE PREGNANCY ; Its Causes, Species, Patho- 
 logical Anatomy, Clinical History, Diagnosis, Prognosis and Treatment. 8vo, Ss. 
 
 E. RANDOLPH PEASLEE, m.d., ll.d. 
 
 Late Professor of Gyncecology in the Medical Department of Dartmouth College ; President of New York 
 Academy of Medicine, &c., &c. 
 
 OVARIAN TUMOURS : Their Pathology, Diagnosis, and Treat- 
 ment, especially by Ovariotomy. With Illustrations, roy. 8vo, i6s. 
 
 LESLIE PHILLIPS, m.d. 
 
 Surgeon to tlie Birmingham and Midland Skin and Lock Hospital. 
 
 MEDICATED BATHS IN THE TREATMENT OP SKIN Dis- 
 eases. Crown 8vo, 4s. 6d. 
 
 HENRY G. PIFFARD, a.m., m.d. 
 
 Clinical Professor of Dermatology, University of the City of New York ; Surgeon in Charge of the 
 
 New York Dispensary for Diseases of the Skin, &c. 
 
 A PRACTICAL TREATISE ON DISEASES OF THE SKIN. 
 
 W'ith 50 full page Original Plates and 33 Illustrations in the Text, 410, 
 £2 I2s. 6d. nett. 
 
 G. V. POORE, M.D., F.R.C.P. 
 
 Professor of Medical Jurisprudence, University College ; Assistant Physician to, and Physician in 
 charge of the Throat Department of, University College Hospital. 
 
 LECTURES ON THE PHYSICAL EXAMINATION OF THE 
 
 Mouth and Throat. With an Appendix of Cases. 8vo, 3s. 6d. 
 
20 Catalogue of Works Published by H. K. Lewis. 
 
 SIR RICHARD DOUGLAS POWELL, Bart., m.d. lond., f.r.c.p. 
 
 Physician Extra-ordinary to Her Majesty the Queen; Physician to the Middlesex Hospital; 
 Consulting Physician to the Brompton Hospital. 
 
 THE LTJMLEIAN LECTURES ON THE PRINCIPLES WHICH 
 
 Govern Treatment in Diseases and Disorders of the Heart. Demy 8vo. 
 
 [In preparation. 
 
 BY THE SAME AUTHOR 
 
 DISEASES OP THE LUNGS AND PLEURA, INCLUDING 
 
 Consumption. Fourth Edition, with coloured plates and wood engravings, 
 8vo, i8s. 
 
 TABLE OP PHYSICAL EXAMINATION OP THE LUNGS: 
 
 with Note on International Nomenclature of Physical Signs (reprinted from^ 
 Dr. Powell's " Diseases of the Lungs,"). On one sheet, 6d. 
 
 HERBERT A. POWELL, m.a., m.d., m.ch. oxon., f.r.c.s.e. 
 
 THE SURGICAL ASPECT OP TRAUMATIC INSANITY. 
 
 Medium Svo, 2s. 6d. 
 
 D'ARCY POWER, m.a., m.b. oxon., f.r.c.s. eng. 
 
 Assistant Suyg:eoii at St. Bartholomew's Hospital; Surgeon to the Victoria Hospital for Children, 
 
 Chelsea; Examiner in the University of Durham ; Member of the Conjoint Examining Board 
 
 of the Royal College of Physicians (Lond.) and of Surgeons (Eng.). 
 
 THE SURGICAL DISEASES OF CHILDREN AND THEIR 
 
 Treatment by Modern Methods. With Illustrations, crown Svo, los. 6d. 
 
 [Lewis's Practical Series.] 
 
 URBAN PRITCHARD, m.d. edin., f.r.c.s. eng. 
 
 Professor of Aural Surgery at King's College, London ; Aural Surgeon to King's College Hospital ; 
 Senior Surgeon to the Royal Ear Hospital. 
 
 HANDBOOK OP DISEASES OP THE EAR FOR THE USE 
 
 of Students and Practitioners. Third Edition, with Illustrations, crown Svo, 6s. 
 
 [Lewis's Practical Series.] 
 
 CHARLES W. PURDY, m.d. (queen's univ.) 
 
 Professor of Genito-Urinary and Renal Diseases in the Chicago Polyclinic, &c.,&c. 
 
 BRIGHT'S DISEASE AND THE ALLIED AFFECTIONS OP 
 
 the Kidneys. With Illustrations, large Svo, Ss. 6d. 
 
 DR. THEODOR PUSCHMANN. 
 
 Public Professor in Ordinary at the University of Vienna. 
 
 A HISTORY OF MEDICAL EDUCATION FROM THE MOST 
 
 Remote to the Most Recent Times. Translated and edited by Evan H. Hare,. 
 M.A. Oxon., F.R.C.S. Eng., L.S.A. Demy Svo, 21s. 
 
 C. H. RALFE, M.A., m.d. cantab., f.r.c.p, lond. 
 
 Assistant Physician to the London Hospital; Examiner in Medicine to the University of 
 
 Durham, &c., &c. 
 
 A PRACTICAL TREATISE ON DISEASES OP THE KID- 
 
 neys and Urinary Derangements. With Illustrations, crown Svo, los. 6d. 
 
 [Lewis's Practical Series.], 
 
Catalogue of Works Published by H. K. Lewis. 21 
 
 FRANCIS H. RANKIN, m.d. 
 
 President of the New York Medical Society. 
 
 HYGIENE OF CHILDHOOD. Suggestions for the care of 
 
 Children after the Period of Infancy to the completion of Puberty. Crown 8vo, 3s. 
 
 AMBROSE L. RANNEY, a.m., m.d. 
 
 Professor 0/ the Anatomy and Physiology of the Nervous System in the New York Post-Graduate 
 
 Medical School and Hospital, &c. 
 
 THE APPLIED ANATOMY OF THE NERVOUS SYSTEM. 
 
 Second Edition, 238 Illustrations, large 8vo, 21s. 
 
 F. R. COWPER REED, m.a., f.g.s. 
 
 [See Cambridge Natural Science Manuals, page 5. 
 
 H. A. REEVES, f.r.c.s. edin. 
 
 Senior Assistant Surgeon and Teacher of Practical Surgery at the London Hospital; 
 Surgeon to the Royal Orthopadic Hospital. 
 
 BODILY DEFORMITIES AND THEIR TREATMENT: A 
 
 Handbook of Practical Orthopaedics. With Illustrations, crown 8vo, 8s. 6d. 
 
 [Lewis's Practical Series.] 
 
 SIDNEY H. REYNOLDS, m.a. 
 
 [See Cambridge Natural Science Manuals, page 5. 
 
 SAMUEL RIDEAL, d.sc. lond., f.i.c, f.c.s. 
 
 Fellow of University College, London. 
 I. 
 
 PRACTICAL ORGANIC CHEMISTRY; The Detection and 
 
 Properties of some of the more important Organic Compounds. Second edition, 
 i2mo, 2s. 6d. [Now ready. 
 
 II. 
 PRACTICAL CHEMISTRY FOR MEDICAL STUDENTS, re- 
 quired at the First Examination of the Conjoint Examining Board in England. 
 Fcap 8vo, 2S. 
 
 J. JAMES RIDGE, m.d. 
 Medical Officer of Health, Enfield. 
 
 ALCOHOL AND PUBLIC HEALTH. Second Edition, crown 8vo, 2s. 
 
 E. A. RIDSDALE. 
 
 Associate of the Royal School of Mines. 
 
 COSMIC EVOLUTION ; being Speculations on the Origin of our 
 
 Environment. Fcap. Svo, 3s. 
 
22 Catalogue of Works Published by H. K. Lewis. 
 
 SYDNEY RINGER, m.d., f.r.s. 
 
 Holme Professor of Clinical Medicine in University College; Physician to University College Hospital, 
 
 HARRINGTON SAINSBURY, m.d., f.r.c.p. 
 
 Physician to the Royal Free Hospital and the City of London Hospital for Diseases of the Chest, 
 
 Victoria Park. 
 
 A HANDBOOK OP THERAPEUTICS. Thirteenth Edition, thoroughly 
 revised, 8vo, i6s. [Now ready. 
 
 SYDNEY RINGER, m.d., f.r.s. 
 
 ON THE TEMPERATURE OP THE BODY AS A MEANS 
 
 of Diagnosis and Prognosis in Phthisis. Second Edition, small 8vo, 2s. 6d. 
 
 R. LAWTON ROBERTS, m.d. lond., d.p.h. camb., m.r.c.s. eng. 
 
 Honorary Life Member of, and Lecturer and Examiner to, the St. John Ambulance Association. 
 
 I. 
 
 ILLUSTRATED LECTURES ON AMBULANCE WORK. 
 
 Fifth Edition, copiously Illustrated, crown 8vo, 2S. 6d. 
 
 ILLUSTRATED LECTURES ON NURSING- AND HYGIENE. 
 
 Second Edition, with Illustrations, crown 8vo, 2S. 6d. 
 
 FREDERICK T. ROBERTS, m.d., b.sc, f.r.c.p. 
 
 Professor of the Principles and Practice of Medicine in University College; Physician to University 
 College Hospital ; Consulting Physician to Brompton Consumption Hospital, &c. 
 
 THE THEORY AND PRACTICE OP MEDICINE. Ninth Edition, 
 with Illustrations, large 8vo, 21s. 
 
 II. 
 THE OPPICINAL MATERIA MEDICA. Second Edition, entirely 
 rewritten in accordance with the latest British Pharmacopoeia, fcap. 8vo, 7s. 6d. 
 
 III. 
 NOTES ON THE ADDITIONS MADE TO THE BRITISH 
 Pharmacopoeia, i8go. Fcap. 8vo, is. 
 
 A. D. ROCKWELL, a.m., m.d. 
 
 Formerly Professor of Elictro-Therapeutics in the New York Post Graduate Medical School and 
 Hospital ; Fellow of the New York Academy of Medicine, &c. 
 
 THE MEDICAL AND SURGICAL USES OP ELECTRICITY. 
 
 New Edition, illustrated with 200 Engravings, large 8vo, i8s. nett. 
 
 [yiist Puhlishcd. 
 
 H. D. ROLLESTON, m.d., f.r.c.p. 
 
 [See Cambridge Natural Science Manuals, page 5. 
 
 D. B. ST. JOHN ROOSA, m.d. 
 
 Consulting Surgeon to the Brooklyn Eye and Ear Hospital, &c. 
 
 A PRACTICAL TREATISE ON THE DISEASES OP THE 
 
 Ear. Including a Sketch of Aural Anatomy and Physiology. Seventh Edition, 
 Illustrated, large 8vo, 25s. 
 
Catalogue of Works Published by H. K. Lewis, 23 
 
 ROBSON ROOSE, m.d., ll.d., f.c.s. 
 
 Fellow of the Royal Collegio/ Physicians in Edinburgh, &c. 
 I. 
 
 GOUT, AND ITS RELATIONS TO DISEASES OE THE 
 
 Liver and Kidneys. Seventh Edition, crown 8vo, 4s. 6d. 
 
 II. 
 NERVE PROSTRATION AND OTHER FUNCTIONAL Dis- 
 orders of Daily Life. Second Edition, demy 8vo, 18s. 
 
 III. 
 
 LEPROSY AND ITS PREVENTION : as Illustrated by Nor- 
 
 wegian Experience. Crown Svo, 3s. 6d. 
 
 "WILLIAM ROSE, m.e., b.s. lond., f.r.c.s. 
 
 Professor of Surgery in King's College, London, and Surgeon to King's College Hospital. 
 
 HARELIP AND CLEFT PALATE. With Illustrations, demy Svo, 6s. 
 
 BERNARD ROTH, f.r.c.s. 
 
 Orthopadic Surgeon to the Royal Alexandra Children's Hospital, Brighton, &c. 
 
 THE TREATMENT OF LATERAL CURVATURE OF THE 
 
 Spine. Second edition, with Photographic and other Illustrations, demy Svo. 
 
 [In preparation. 
 
 W. H. O. SANKEY, m.d. lond., f.r.c.p. 
 Late Lectwrer on Mental Diseases, University College, London, etc. 
 
 LECTURES ON MENTAL DISEASE. Second Edition, with coloured 
 Plates, Svo, 12s. 6d. 
 
 JOHN SAVORY. 
 
 Member of the Society of Apothecaries, London. 
 
 COMPENDIUM OF DOMESTIC MEDICINE AND COM- 
 
 panion to the Medicine Chest: Intended as a source of easy reference lor 
 Clergymen, Master Mariners, and Travellers ; and for Families resident at a 
 distance from professional assistance. Tenth Edition, sm. Svo, 5s. 
 
 DR. C. SCHIMMELBUSCH. 
 
 Privat-docent and Assistant Surgeon in Prof. i\ Bergmann's University Clinic at Berlin. 
 
 THE ASEPTIC TREATMENT OF WOUNDS. With a Preface by^ 
 Professor Bergmann. Translated from the Second German Edition by A. T 
 Rake, M.B., B.S. Lond., F.R.C.S. Eng., Registrar and Pathologist to the Eas 
 London Hospital for Children. With Illustrations, crown Svo, 5s. 
 
 E. SCHMIEGELOW, m.d. 
 
 Consulting Physician in Laryngology to the Mtinicipal Hospital and Director of the Oto-Laryngologica 
 Department in the Polyclinic at Copenhagen. 
 
 ASTHMA : Especially in its Relation to Nasal Disease. 
 
 Demy Svo, 4s. 6d. 
 
24 Catalogue of Works Published by H. K. Lewis. 
 
 DR. B. S. SCHULTZE. 
 
 Professor of Gynecology ; Director of the Lying-in Hospital, and of the Gynecological Clinic at Jena. 
 
 THE PATHOLOGY AND TREATMENT OP DISPLACE- 
 
 ments of the Uterus. Translated by J. J. Macan, M.A., M.R.C.S., and edited 
 by A. V. Macan, M.B., M.Ch., Master of the Rotunda Lying-in Hospital, Dublin. 
 With I20 Illustrations, medium 8vo, 12s. 6d. 
 
 A. C. SEWARD, M.A., F.G.s. 
 
 [See Cambridge Natural Science Manuals, page 5. 
 
 JOHN SHAW, M.D. LOND., M.R.C.P. 
 
 Obstetric Physician to the North-West London Hospital. 
 
 ANTISEPTICS IN OBSTETRIC NURSING. A Textbook for 
 
 Nurses on the Application of Antiseptics to Gynaecology and Midwifery. 
 Coloured plate and woodcuts, 8vo, 3s. 6d. 
 
 G. E. SHUTTLE WORTH, b.a., m.d. 
 
 Late Medical Superintendent, Royal Albert Asylum for Idiots and Imbeciles of the Northern Counties, 
 Lancaster ; formerly Assistant Medical Officer, Earlswood Asylum. 
 
 MENTALLY-DEFICIENT CHILDREN THEIR TREATMENT 
 
 and Training. With Illustrations, crown 8vo, 4s. 
 
 A. J. C. SKENE, M.D. 
 
 Professor of Gynecology in the Long Island College Hospital, Brooklyn, New York. 
 
 TREATISE ON THE DISEASES OP WOMEN, POR THE 
 
 Use of Students and Practitioners. Third Edition, with coloured plates and 290 
 engravings, large 8vo, 28s. 
 
 FRANCIS W. SMITH, m.b., b.s. 
 
 THE SALINE WATERS OP LEAMINGTON. Second Edition, with 
 Illustrations, crown 8vo, is. 7iett. 
 
 J. LEWIS SMITH, M.D. 
 
 Ffiysician to the New York Foundling Asylum ; Clinical Professor of Diseases of Children in Bellevue 
 
 Hospital Medical College. 
 
 A TREATISE ON THE MEDICAL AND SURGICAL Dis- 
 eases of Infancy and Childhood. Eighth Edition, with 273 Illustrations and 
 four plates, large 8vo, 21s. [jfust published. 
 
 E. HUGH SNELL, m.d., b.sc. lond. 
 
 Diplomate in Public Health of the University of Cambridge ; Medical Officer of Health to the City 
 of Coventry ; late London County Council Medical Officer to the Blackwall Tunnel. 
 
 COMPRESSED AIR ILLNESS, OR SO-CALLED CAISSON 
 
 Disease. With Illustrations, demy 8vo, los. 6d. 
 
Catalogue of Works Published by H. K. Lewis. 25 
 
 JOHN KENT SPENDER, m.d. lond. 
 
 Physician to the Royal Mineral Water Hospital, Bath. 
 
 THE EARLY SYMPTOMS AND THE EARLY TREATMENT 
 
 of OSTEO-ARTHRITIS, commonly called Rheumatoid Arthritis, with special 
 reference to the Bath Thermal Waters. Sm. 8vo, 2s. 6d. 
 
 LOUIS STARR, m.d. 
 Physician to the Children's Hospital, Philadelphia, &c. 
 
 HYGIENE OP THE NURSERY. Including the General Regimen 
 
 and Feeding of Infants and Children ; Massage, and the Domestic Management 
 of the Ordinary Emergencies of Early Life. Sixth Edition, with Illustrations, 
 crown 8vo, 3s. 6d. ijfust ready. 
 
 JAMES STARTIN, m.b., m.r.c.s. 
 
 Senior Surgeon to the London Skin Hospital. 
 
 LECTURES ON THE PARASITIC DISEASES OF THE SKIN. 
 
 Vegetoid and Animal. With Illustrations, crown 8vo, 2S. 6d. 
 
 JOHN LINDSAY STEVEN, m.d. 
 
 Assistant Physician and Pathologist, Glasgow Royal Infirmary ; Physician for Out-patients, 
 Royal Hospital for Sick Children, Glasgow, &c. 
 
 THE PATHOLOGY OP MEDIASTINAL TUMOURS. With 
 special reference to Diagnosis. With Plates, 8vo, 4s. 6d. 
 
 LEWIS A. STIMSON, b.a., m.d. 
 
 Surgeon to the New York, Bellevue, and Hudson Street Hospitals; Professor of Surgery in the 
 University of the City of New York, &c. 
 
 AND 
 
 JOHN ROGERS, Jun., b.a., m.d. 
 
 Assistant Demonstrator in the College of Physicians and Surgeons, New York, &c. 
 
 MANUAL OP OPERATIVE SURGERY. Third Edition, with- 
 numerous Illustrations, post 8vo, 12s. 6d. iiett. [Now ready.. 
 
 JAMES STOCKEN, l.d.s. eng. 
 
 Late Dental Surgeon to the National Dental Hospital. 
 
 DENTAL MATERIA MEDICA AND THERAPEUTICS. 
 
 Fourth edition, revised by Leslie M. Stocken, L.R.C.P., M.R.C.S., L.D.S., 
 and J. O. Butcher, L.D.S. Eng., Assistant Dental Surgeon to Guy's HospitaL 
 Fcap. 8vo, 4s. 
 
 ADOLF STRUMPELL. 
 
 Professor and Director of the Medical Clinique at Erlangen. 
 
 TEXT-BOOK OP MEDICINE POR STUDENTS AND 
 
 Practitioners. Second Edition translated from the German by Dr. H. F. Vickery 
 and Dr. P. C. Knapp, with Editorial Notes by Dr. F. C. Shattuck, Visiting 
 Physician to the Massachusetts General Hospital, &c. With 119 Illustrations,, 
 imp. 8vo, 28s. 
 
26 Catalogue of Works Published by H. K. Lewis. 
 
 JUKES DE STYRAP, m.r.c.p.i., etc. 
 
 Physician-Extraordinary , late Physician in Ordinary, to the Salop Infirmary ; Consulting Physician 
 to the South Salop and Montgomeryshire Infirmaries, etc. 
 
 I. 
 
 THE YOUNG- PRACTITIONER: WITH PRACTICAL HINTS 
 
 and Instructive Suggestions, as Subsidiary Aids, for his Guidance on Entering 
 into Private Practice. Demy Svo, 7s. 6d. 7iett. 
 
 II. 
 A CODE OP MEDICAL ETHICS: "WITH GENERAL AND 
 
 Special Rules for the Guidance of the Faculty and the Public in the Complex 
 Relations of Professional Life. Fourth Edition, demy Svo, 3s. 6d. nett. 
 
 III. 
 MEDICO-CHIRURGICAL TARIFFS, Fifth Edition, revised and en- 
 larged, fcap. 4to, 2S. nett. 
 
 IV. 
 
 THE YOUNG PRACTITIONER : HIS CODE AND TARIFF. 
 
 Being the above three works in one volume. Demy Svo, los. 6d. nett. 
 
 C. W. SUCKLING, M.D.LOND., m.r.c.p. 
 
 Professor of Materia Medica and Therapeutics at the Queen's College, Physician to the Queen's 
 Hospital, Birmingham, etc. 
 
 I. 
 
 ON THE DIAGNOSIS OF DISEASES OF THE BRAIN, 
 
 Spinal Cord, and Nerves. With Illustrations, crown Svo, 8s. 6d. 
 
 II. 
 ON THE TREATMENT OF DISEASES OF THE NERVOUS 
 
 System. Crown Svo, 7s. 6d. 
 
 J. BLAND SUTTON, f.r.c.s. 
 
 Assistant Surgeon to the Middlesex Hospital ; Examiner in Anatomy for the Fellouiship to the Royal 
 
 College of Surgeons, England. 
 
 LIGAMENTS: THEIR NATURE AND MORPHOLOGY. 
 
 Second Edition, with numerous Illustrations, post Svo, 4s. 6d. [Now ready. 
 
 HENRY R. SWANZY, a.m., m.b., f.r.c.s.i. 
 
 Examiner in Ophtlwlmology to the University of Dublin; Surgeon to theNational Eye and Ear 
 Infirmary, and Ophthalmic Surgeon to the Adelaide Hospital, Dublin. 
 
 A HANDBOOK OF THE DISEASES OF THE EYE AND 
 
 their Treatment. Sixth Edition, illustrated with wood-engravings, colour tests, 
 &c., small Svo, 12s. 6d. [Now ready. 
 
 EUGENE S. TALBOT, m.d., d.d.s. 
 
 Professor of Dental Surgery in the Woman's Medical College ; Lecturer on Dental Pathology and 
 Surgery in Rush Medical College, Chicago. 
 
 IRREGULARITIES OF THE TEETH AND THEIR TREAT- 
 
 ment. With 152 Illustrations, royal Svo, los. 6d. 
 
Catalogue of Wo7-ks Published by H. K. Lewis. 27 
 
 ALBERT TAYLOR. 
 
 Associate Sanitary Institute ; Demonstrator to the Students of the Sanitary Institute ; Chief Sanitary 
 Inspector to the Vestry of St. George, Hanover Square, &c. 
 
 THE SANITARY INSPECTOR'S HANDBOOK. Second Edition, 
 with Illustrations, crown 8vo, 5s. [Now ready. 
 
 H. COUPLAND TAYLOR, m.d. 
 
 Fellow of the Royal Meteorological Society. 
 
 WANDERINGS IN SEARCH OF HEALTH, OR MEDICAL 
 
 and Meteorological Notes on Various Foreign Health Resorts. With Illustra- 
 tions, crown 8vo, 6s. 
 
 J. C. THOROWGOOD, m.d. 
 
 Assistant Physician to the City of London Hospital for Diseases of the Chest. 
 
 THE CLIMATIC TREATMENT OP CONSUMPTION AND 
 
 Chronic Lung Diseases. Third Edition, post 8vo, 3s. 6d. 
 
 D. HACK TUKE, m.d., ll.d. 
 
 Fellow of the Royal College of Physicians, London. 
 
 THE INSANE IN THE UNITED STATES AND CANADA. 
 
 Demy Svo, 7s. 6d. 
 
 DR. R. ULTZMANN. 
 
 ON STERILITY AND IMPOTENCE IN MAN. Translated from the 
 German with notes and additions by Arthur Cooper, L.R.C.P., M.R.C.S., Surgeon 
 to the Westminster General Dispensary. With Illustrations, fcap. Svo, 2s. 6d. 
 
 W. H. VAN BUREN, m.d., ll.d. 
 
 Professor of Surgery in the Bellevuc Hospital Medical College. 
 
 DISEASES OP THE RECTUM : And the Surgery of the Lower 
 
 Bowel. Second Edition, with Illustrations, Svo, 14s. 
 
 ALFRED VOGEL, m.d. 
 Professor of Clinical Medicine in the University of Dorp at, Russia. 
 
 A PRACTICAL TREATISE ON THE DISEASES OP CHIL- 
 
 dren. Third Edition, translated and edited by H. Raphael, M.D., from the 
 Eighth German Edition, illustrated by six lithographic plates, part coloured, 
 royal Svo, iSs. 
 
 A. DUNBAR WALKER, m.d., cm. 
 
 THE PARENT'S MEDICAL NOTE BOOK. Oblong post 8vo 
 cloth, IS. 6d. 
 
28 Catalogue of Wo7-ks Published by H. K. L,ewts. 
 
 A. J. "WALL, M.D. LOND. 
 
 Fellow of the Royal College of Surgeons of England ; of the Medical Staff of H. M. Indian Army 
 
 (Retired List). 
 
 ASIATIC CHOLERA : its History, Pathology, and Modern 
 
 Treatment. Demy 8vo, 6s. 
 
 JOHN RICHARD WARDELL, m.d. edin., f.r.c.p. lond. 
 
 Late Consulting Physician to the General Hospital Tunbridge Wells. 
 
 CONTRIBUTIONS TO PATHOLOGY AND THE PRACTICE 
 
 of Medicine. Medium 8vo, 2is. 
 
 "W. SPENCER WATSON, b.m. lond., f.r.c.s. eng. 
 
 Surgeon to the Throat Department of the Great Northern Hospital ; Senior Surgeon to the Royal South 
 
 London Ophthalmic Hospital. 
 I. 
 
 DISEASES OP THE NOSE AND ITS ACCESSORY CAVITIES. 
 
 Second Edition, with Illustrations, demy 8vo, 12s. 6d. 
 
 II. 
 THE ANATOMY AND DISEASES OP THE LACHRYMAL 
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Catalogue of Works Published by H. K. Lewis. 29 
 
 L. R. ^A^ILBERFORCE, m.a. 
 
 AND 
 
 T. C. FITZPATRICK, m.a. 
 
 Demonstrators at the Cavendish Laboratory , Cambridge. 
 
 A LABORATORY NOTE-BOOK OF ELEMENTARY PRAC- 
 
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 BERTRAM C. A. WINDLE, d.sc, m.d., m.a. duel. 
 
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30 Catalogue of Woi-ks Published by H. K. Levm. 
 
 HENRT V/OODS, b.a., f.g.s. 
 
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 A. S. V/OODAA^ARD, m.a. 
 
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Catalogue of Works Published by Ht K. Lewis. 31 
 
 LEWIS'S PRACTICAL SERIES. 
 
 Under this title a Series of Monographs is published, embracing the various branches of Medicine 
 and Surgery. The volumes are written by well known Hospital Physicians and Surgeons, recognised 
 as authorities in the subjects of which they treat. The works are of a thoroughly practical nature, 
 calculated to meet the requirements of the practitioner and student and to present the most recent 
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 DISEASES OF THE NERVOUS SYSTEM: A Handbook for Students and 
 
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 THE TREATMENT OF PULMONARY CONSUMPTION. By VINCENT D. HARRIS, 
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 HYGIENE AND PUBLIC HEALTH. By LOUIS C. PARKES, M.D., D.P.H. Lond. 
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 MANUAL OF OPHTHALMIC PRACTICE. By C. HIGGENS, F.R.C.S., Ophthalmic 
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 London Hospital, &c. With Illustrations, cr. 8vo, los. 6d. 
 
 DENTAL SURGERY FOR MEDICAL PRACTITIONERS AND STUDENTS 
 
 of Medicine. By ASHLEY W. BARRETT, M.B. Lond., M.R.C.S., L.D.S., Consulting Dental 
 Surgeon to the London Hospital. Third edition, with Illustrations, cr. 8vo, 3s. 6d. 
 
 PRACTICAL DEFORMITIES AND THEIR TREATMENT. A Handbook of 
 
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32 Catalogue of Works Published by H. K. Lewis. 
 
 THE NEW SYDENHAM SOCIETY'S PUBLICATIONS. 
 
 President :—linii^\ Power, Esq., M.B., F.R.C.S. 
 
 Honorary Secretary : — Jonathan Hutchinson, Esq., F.R.S. 
 
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 ANNUAL SUBSCRIPTION, ONE GUINEA. 
 
 The Society issues translations of recent standard works by continental authors on subjects of 
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 Amongst the works issued are " Binz's Pharmacology," " Sir William Gull's Collected Works," 
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 logy," " Henoch's Diseases of Children," " Spiegelberg's Midwifery," " Hirsch's Historical and 
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 PERIODICAL WORKS PUBLISHED BY H. K. LEWIS. 
 
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 *^* Mr. Lewis is in constant communication with the leading publishing firms 
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 Mr. Lewis's publications can be procured of all Booksellers in any part of the 
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 London : Printed by H. K. Lewis, 136 Gower Street, W.C. 
 
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