AV ERY NeWTOM, *• THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES Gift cf Dr. . ..very Newton THE SCHOTT METHODS OF THE TREATMENT OF CHRONIC DISEASES OF THE HEART PRINTERS— UNWIN BROTHERS, LIMITED, LONDON AND WOKING. THE SCHOTT METHODS TKEATMENT OF CHRONIC DISEASES OF THE HEART AN ACCOUNT OF THE NAUHEIM BATHS, AND OF THE THERAPEUTIC EXERCISES ILLUSTRATED W. BEZLY THOENE, M.D., M.E.C.P. FIFTH EDITION. LONDON J, & A . CHURCHILL 7 GREAT MARLBOROUGH STREET 190(3. Biomedical Library PEBFACE TO THE FIFTH EDITION. Since the issue of the fourth edition of this work, it has become desirable to make a statement, which will be found towards the close of Chapter VI., as to the applicability of the methods under consideration to the subjects of aortic regurgita- tion. Evidence which has accumulated and obser- vations which have matured since that date justify the opinions expressed in Chapter VII. as to the treatment of Raynaud's Disease, Graves' Disease, and of certain cases of minor epilepsy. W. BEZLY THORNE. 2, Harley Street, W., June, 1906. eosroa PEEFACE TO THE FOUETE EDITION. Since the publication of the third edition of this work, the views expressed as to the repair of athero- matous and other forms of vascular degeneration have received abundant confirmation. In the present issue will be found two additional short chapters, one on the physiological action of the methods referred to, more especially in relation to the nervous system and to blood-pressure ; and another on the subject of what is commonly called the " after-cure." W. BEZLY THOENE. April, 1902. PEEFACE TO THE THIED EDITION. The clinical experience which has been gained since the former editions of this work were issued has strengthened the conviction that the methods which it was their object to set forth are, as much as ever, deserving of the thoughtful attention of the medical profession. In the third edition old material has been rearranged, and new material introduced, in such a manner as to present two additional chapters, of which one deals more especially with conditions which should influence and modify the details of procedure, while the other offers instances of their application, and calls attention to features scarcely alluded to in the earlier issues, more especially to the institution of vascular repair. At the risk of some redundancy the cases originally reported have been retained in the concluding chapter. W. BEZLY THOENE. August, 1899. PEEFACE TO THE SECOND EDITION. In issuing the second edition of the only volume which, up to the present time, has presented, in concrete form, the system of cardio-therapy which August and Theodor Schott have evolved from prin- ciples first proclaimed by Stokes, I desire to express my thanks for the generous appreciation with which the first edition has been received, alike by friends and strangers in the profession of Medicine, and also the deep satisfaction with which it is now possible to view the in creasing favour which is accorded to a novel, but potent, therapeutic expedient by those whose mission it is to relieve disease and suffering. The few months which have passed since these pages were first given to the medical profession have not diminished the confidence in the methods of which they treat, which then emboldened me to advocate a new departure. Happily, what are known as the Schott Methods promise soon to become an acknow- ledged and accepted medical practice. W. BEZLY THORNE. February, 189G. PEEFACE TO THE FIEST EDITION. In March, 1891, I was enabled, by the courtesy of the Editors of the Lancet, to lay before the medical .profession a paper by Dr. Theodor Schott, in which were explained the principles and practice of the treatment of chronic diseases of the heart by means of mineral baths and exercises, which had been elaborated by him and his deceased brother. As judged by results, it attracted no notice, and the system remained an unknown art in this country. In the early part of the year 1894 I was favoured with a similar opportunity of bringing forward a brief account of my own experience of the Schott system. Since that time I have received so many requests for further and more detailed information that I am encouraged to meet an increasing demand by the publication of the following pages. They do not pretend to offer a complete or exhaustive exposition either of the science and art of the physical treatment of heart affections or of the range of its application. That their scope is mainly limited by my own knowledge and observation is my apology for defects which are only too mani- fest to myself. W. BEZLY THOKNE. March, 1895. CONTENTS. CHAP. I. II. III. IV. VI. VII. VIII. IX. Nauheim and its Waters Baths Therapeutic Movements The Physiological Action of the Baths and Exer cises Conditions which govern the Application of the Methods Conditions to which the Methods are applicable Conditions not primarily Cardiac to which the Methods are applicable ..... The After- Treatment The Exercises, Detailed Description and Illustra tions Illustrative Cases with Diagrams page 11 18 25 32 41 49 87 96 100 126 THE SCHOTT METHODS OF THE TREATMENT OF CHRONIC DISEASES OF THE HEART. CHAPTER I. BAD-NAUHEIM AND ITS WATERS. Situated at the north-eastern extremity of the Taunus range, Nauheim — or, to give it its full name, Bad- jN'auheim, the birthplace and headquarters of the treatment about to be considered — lies mainly on the gentle slope, which, looking south south-east, forms the foot of the Johannesberg. The underground streams which have been brought into requisition for therapeutic drinking and bathing have been tapped in the lowest part of the township — namely, at some little distance on either side of the stream which divides the park into two unequal por- tions ; and it may be said at once that they rise from so great a depth as to preclude the possibility of sub- terranean communication with that small river. The following analyses have been compiled from the observations recorded by Beneke, Prof. Will of Giessen, Doctors August and Theodor Schott, Dr. Uloth, and Prof. Lepsius : — 12 THE SCHOTT METHODS OE THE TREATMENT OF o gfl & < — o '-r — CZ2 . r P3 §j 1 o be ^ - 09 H gS W CO p i . .5 o S3 S ^ ft p-i > H^ >-> to o -% co ^ . CO 2,-! I— I 03.S { H >> H C) 1=1 & _d *o 3 ° CD O o CO rn CO I 03 >TCJ 3-8 -, i* — » i- ° .£ o ° - U 5 * O " 5 K S 5 O fl = o - Ol ,« O 1 - — Tl B^ CO ^ CO — 1- ~ |ljL c. ol CM crs - r"i = 03 01 - X EC BO CC -r co 01 -. — *" v ™ p 1 z »* 1 D 1 ? o 1 1 cp p I 1 1 1 1 co — eq • ~* = - 01 1 •- 1 © ■- 1 - I i 1 ,1, 6 =■ O ' 1 1 1 <=" ■"* co £-••, ■;1-'1 ^Z — ~£"^ 00 '2-' X _■ O i .. 00 J" o ■* t- 1- 10 t» ca cj t- CJ CM O co ~. •* - cj -i c - — o X — — CJ CJ ■Xj CJ © CJ X X /;'-. ~ c~ i~ o ; | -\ r IO 03 rt I © rt = ft s | CI X cp = r CM c 1 -M .- .- 1 -+i s 1 — 5S5o CC H © © ^_, O O O = 3 — ~ H © ^ © ^ Ol _ .1. US •c •*-.• apsi <^N *" 05 — z lO t- c — . t> co X — — CM © O CC -H co o lO t^ CM t- t> — X CO ■m vr CC X t- X o © CJ ao — 01 v. Ol oi :i co BO BO o | :i CO -r CI C O I © rt 1 CC — © U3 o © c- o 1 p p F|H p 9 9 1 p p IS 'C p 1 zr. •* UO © © o — o o o O l-H c ~ h © i CO rH *i-i ^ CO »— < •— < 01 •~1 B cT g o l~ X BO — CO CO CN cr co co -- - - C 10 = c. CO i". X CO X 01 t- BO Ol X ■* ~ 1- 10 1- — . — s * CO CC co co CO — i-. CO o 1 — — ~ — 1 — © CC & 1 t> 3 o 9 M o p o 1 — 7" i p p 1 © © p p B H " ■ r 1 — CO X - 5 CJ 01 01 Ol £ i ~ - u CO r p i. — CO_ CC CO X Ifi CM -# o t~ 10 CO — c C35 X co -r C5 1- lO — ~ cr — X CC © CM O © cj co © 10 CI — OO 10 O ^*< - | c~ ;c C i-H I co O © cc; us cm t~ S 3 X ■* t^ — p 1 © © s - CO - CO p * St J- ; © — rt o o ^ i cf i ^; o © i 3 3 r- •"- ^ BO ,!< Ol — CC 2 x 01 01 -1— CO X CM uo Z t l~- U5 ^-s X i * 2 00 a CO X w i 1 - O to TjH CM OS i~ CO o CM r. c-i — ~. C5 CO 01 f^ o CO "1 * r. io t~ CM CM r oB CO -*< O — — 1 01 - =: OS lO Cl © ^ CM cp r— 1 O ?C >o o ^ o C — ~ p p 1 o c !£ CO © 1 © CO 35 c tIh © CO o o Q C 0) 3 ~ o i i lb pZ-4 rln uo lO CM © - . = CM CO * CO 0^1 X X SSo M< C- l> 1-1 10 f'Z i"o OS — • )c CJ C^l C c3 K >J 9 3 CO 03 (13 — re _J3 t: TJ o cj CO -/. ."S CJ c3 o R /~\ CJ 10 1 g o _ 5 QQ o p 93 O e3 CO 3 r^ — zz ^ = iH ifl fl • Ph fe P CJ X O X o 03 D K? ■f. w e3 o o o o o - - 'o D s o CD o S rt CS P 13 «*-! 02 ° p = o3 PI o „-? " 3 o c P CJ CC? - ! • eg • p 'S > o o CO _ - o 71 CO U3 o — ' :i o CO ... '■; >ffl (N Tj< 1 - O — o CO o o ~ 71 — o O o o o o cq co =r. K - r - - = s ~ ^ ~ «3 »0 CO looooa X X 71 X o DhWOO^NQOOO O (M • — != 3 ^ - «H ° 3 — X b£ n CO o .C w -i-i r ~ p ~Z - „ c Of " -_ o OQ — — — O 1— K O ■* - ^ — *» T3 si o — ,P 3 _z C3 C x _ o o t: P HrijO S c! s l—l *3 ■'"" ~ - X £ g CO 05 CO r-H P © • oo- c5 • £ 5Z ,£» S C fl 5} _, - £* 8th bath. 64 THE SCROTI METHODS OF THE TREATMENT OF in the interval, could scarcely walk ten paces, and spent a great part of each night in a condition of orthopncea. He commenced a course of baths and exercises on the 13th. By the lSth he began to enjoy unbroken nights, had recovered his appetite, and could walk better. On the 23rd of March he com- pleted his treatment, and went into the country in good general health, and able to walk a quarter of a mile at a good pace without discomfort. He returned on the 25th of April somewhat further improved, to apply for the position of a timekeeper in the service of his company. At the commencement of the treat- ment there was audible, at a distance of from six to eight inches from the chest, a loud musical murmur, accompanied by a thrill, which was to be felt over the greater part of the front of the chest wall. On his return it was barely audible at a distance of two inches. It was diastolic in time, and preceded, with- out appreciable interval, by a slight sh-sound. Case 7. Double Aortic Bruit with Mitral Systolic. — This case was reported in the Lancet of March, 1894, as follows, and has been under observation up to the present time (November, 1901): — "A woman, fifty-two years of age at the present time, -and the subject of inveterate lithasmic tendencies, rapidly developed, in the winter of 1891-92 a loud, rasping, basic systolic bruit, which was accompanied by a systolic apex souffle. Her health rapidly failed, and the cardiac condition, involving as it did loss of sleep and appetite and steadily increasing dyspnoea, threatened to bring her life to a close. All ordinary resources having failed to afford relief, I suggested recourse to the ISauheim baths and treatment by exercises, with the practical details of which I was CHRONIC DISEASES OF THE HEART. 65 then unacquainted. The journey, however, appeared to involve such serious risk that I did not venture to authorise it ; but, as Dr. Hermann Weber came to the conclusion that it probably afforded the only remaining chance of life, it was decided to undertake it. "When again seen in the following October, the patient was restored to her former measure of health and pursuing her usual avocations. In May, 1893, CASE 7. Course V. December, 1894 — February, 1895. Rpforp. 1st bath. Before, 28th bath. 66 THE SOHOTT METHODS OF THE TREATMENT OF CASE 7 — continued. Course VI. March to May, 1895. Before, 1st bath. Before, 23rd bath. Course X. October to November, 1896. Before, 1st bath. CHRONIC DISEASES OF THE HEART. 67 CASE 7, Course X. — continued. Before. After. 22nd bath. Course XIII. November, 1897, to January, 1898. Before. 1st bath. Before, 28th bath. 68 THE SCHOTT METHODS OF THE TREATMENT OF CASE 7 — continued. Course XVI. October to December, 1898. Before, 1st bath. Before, 28th bath. she returned to Nauheim for a second course, and on her return I was unable to detect either the basic or apex bruit, and the heart was fully competent. In the middle of November a severe access of influenza, unaccompanied by catarrh, and the whole incidence of which appeared to be on the heart and nerve centres, was followed by a return of the bruits and incompetence." A course of exercises was followed by the establishment of a fair measure of compensa- tion, with cardiac competence and a return to rather CHRONIC DISEASES OF THE HEART. 69 more than the former measure of health and activity. A further access of influenza in 1894 necessitated another course of treatment at Nauheim in the summer of that year. From that time the heart has never suffered dilatation or incompetence ; but the lithsemic tendency has never been overcome, and, two or three times a year, has culminated in such severe articular pain, with periosteal inflammation of portions of the cranial bones, the clavicles, the iliac crests, and sacro- iliac synchondroses, that, other remedies failing, the patient has sought and found relief in successive courses of baths and exercises, at one time in Nauheim and at another in London, according to convenience and the season of the year. From the time of their recurrence, above reported, the murmurs have per- sisted and scarcely varied in intensity. Case 8. Apex Systolic Bruit extending to the Left Sternal Margin. — A patient of Dr. J. Lumsden Propert (in conjunction with whom each of the following observations was made), twenty-seven years of age, was a tall man with a chest proportion- ately somewhat narrow, who found himself to be debarred from active exertion by dyspnoea and palpitation. There was a well-marked upheaval of the chest-wall over the right ventricle, with epi- gastric pulsation. A sj^stolic bruit, loudest about midway, was audible from the apex to the sternal margin. The first sound at the base was inaudible. After the fourth bath the bruit was found to be diminished in intensity, but there was marked re- duplication. The first sound to the left of the apex- beat was clean. On the occasion of the tenth bath the first sound at the base had become audible. Fourteen days later (after twenty-second bath) neither bruit nor reduplication was audible at the apex. 70 THE SCIIOTT METHODS OF THE TREATMENT OF Seven days later, the treatment having concluded, there was slight reduplication, but no bruit. The general health had improved, and the patient was able to take long walks without either dyspnoea or palpita- tion. The apex-beat, which before treatment had been in the sixth space and three-quarters of an inch within the nipple-line, was in the fifth space an inch and a quarter within. There remained neither up- heaval nor epigastric pulsation. Dr. Propert reports that the improvement has been maintained. CASE 8. Before, 1st bath. Before, 3rd hatli ! i i CHRONIC DISEASES OF THE HEART. CASE 8— continued. Before, 71 10th bath. Before, 22nd bath. Before, 28th batti. 72 THE SCHOTT METHODS OF THE TREATMENT OF Case 9. Athlete's Heart. — A young man, aged eighteen, with whom there had been difficulties of digestion in infancy and throughout childhood, but who was well grown, was pallid, and expressed him- self as being unable to sustain any ordinary exertion CASE 9. Before treatment. December 5th, 1898. On conclusion of treatment, January 25th, 1899. May 1st, 1899. since, a year before, he had made a cycling tour, in the course of which he had frequently covered ninety miles a day, on irregularly taken and often in- sufficient food and from four to five syphons of aerated water daily. He did not suffer from dyspnoea on exertion. The maximum apex-beat was CHRONIC DISEASES OF THE HEART. 73 one inch within the nipple line. There was upheaval of the whole left mammary region with each pulsa- tion, the frequency of which at the heart was 160 and over, and at the wrist 120. The first sound at the apex was blunt. He derived marked benefit in health, energy, and appearance from a course of baths and exercises under Dr. Schott, at Nauheim. Three months later (December, 1898) he came to London for a further course, as there were signs of relapse. The pulse frequency then was 140 at the heart, and from 130 to 136 at the wrist. The first bath was taken on December 5th. After the second bath the frequency was the same at the heart and wrist — 130. On the conclusion of the course it had fallen to from 110 to 120 ; there was no upheaval of the mammary region, but an exaggerated impulse was to be felt from the apex, one inch within the nipple line, to the sternal margin. The face and lips were ruddy and the general health good. When last seen, on the 1st of May, 1899, he appeared to enjoy perfect health and vigour, and was playing golf almost daily. The pulse remained at 120 at both heart and wrist. It is proposed that a further course of treatment shall be taken at Kauheim in the course of the summer. In similar cases it has been found that two or three years are required for com- plete recovery, and that there is danger of relapse during the period of growth and development. Throughout the course a systolic respiratory bruit, commencing, as regards distribution, one inch outside the nipple-line, and increasing in harshness and inten- sity to within one inch of the spine, and fading above and below the sixth interspace, was audible through- out the inspiratory act. It underwent a gradual diminution of intensity, and on May 1st could be 74 THE SCHOTT METHODS OF THE TREATMENT OF heard only at the angle of the scapula, with the first systole occurring in each inspiration.* Case 10. Myocardial Degeneration with Arterio- Capillary Sclerosis (?) and General Soakage. — A lady, aged fifty-three, a patient of Dr. Forbes Fraser, of Tarporley, who reported that during the two years she had been under his care there had been occasional accesses of faintness and palpitation, sometimes associated with cardiac pain, culminating, in September, 1898, in a severe attack of angina following mental shock. He added that from that time the accesses had been more frequent and severe, and that a very grave attack had taken place in the following November. Dr. Fraser expressed the opinion that the heart was in a state of fatty degene- ration. The patient's father had died of angina pectoris at the age of sixty-eight, her mother's sister and brother had died of sudden failure of the heart. She stated that her brother suffered from heart-pain. Her own account was to the effect that from the age of twenty-one she had been subject to neuralgia and to fronto-occipital headaches, that since a bad confine- ment, six years previously, her ankles had swollen in the evening, and that the last access of syncope had been accompanied by severe pain extending from the nape of the neck to the lowest part of the spine. There had been an attack of pericarditis in 1883. The face and hands were puffy, as were the legs and ankles. The pufliness was of a brawny character, and as a rule there was no pitting until the latter part of the day. The apex-beat was not perceptible in the prone position, but cardiac dulness did not extend beyond the nipple-line. The sounds were distant and of foetal character, the second sound at the apex * At the time of going to press the respiratory bruit had ceased to be audible (August, 1899). CHRONIC DISEASES OF THE HEART. 75 was barely audible, the second at the base relatively accentuated. The bowels acted twice daily, the motions being yellow, and the second either fragmentary or liquid. The pulse was regular in frequency, ninety in the sitting posture, ninety-six on standing up, and fell to ninety-four within the minute ; the pressure was 210 mm. Hg. Treatment by baths and exercises commenced on November 15th, 1898, and throughout the course its effects were marred by a series of disturbing causes. I was dissatisfied with the result, and although Dr. Fraser was struck with the improve- ment which he observed on the patient's return, I strongly urged a second course, which should be con- ducted under conditions of isolation, to guard against all influences calculated to depress the nervous energies. The second course commenced on the 12th of January, 1899, and terminated on the 12th of February following. The patient then went to "West Malvern for a stay of rather more than a fortnight. On the 24th she reported that, although, before treat- ment, she had only been able to crawl about a dozen yards on the level, she could then take the steepest CASE 10. First Course. Before, 1st bath, November loth. 76 THE SCIIOTT METHODS OF THE TREATMENT OF hill without discomfort. I saw her again on the 3rd of March. She was in good health, and the only remaining puffiness was to be found behind the ankles. There was no pitting. The day before leaving West Malvern the patient had walked six miles without discomfort or undue fatigue. The body- weight, which before treatment had been 11 st. 4 \ lbs., was 10 st, 8 lbs. On May loth, Dr. Fraser reported : 4t She remains, as far as I can see, perfectly well." * CASE 10, First Course — continued. Before, Bath, November 16th. Before, Bath, November 17th *^In the course of the treatment the pulse-pressure fell to 180 mm. Hg.,lbut after its conclusion rose again to 210 mm. Hg. CHRONIC DISEASES OE THE HEART. CASE 10, First Course — continued. Before, 77 Bath, November 19th. Before, Uath, November 22nd. Before, Exercises, November 24th. 78 THE SCHOTT METHODS OF THE TREATMENT OF CASE 10, First Course — continued. Before, Bath, November 26th. Before, Bath, November 29th. Before, Exercises, December 1st. CHRONIC DISEASES OF THE HEART. 79 CASE 10, First Course — continued. Before, Bath, December 5th. Before, Bath, December 10th. 80 THE SCHOTT METHODS OF THE TREATMENT OF CASE 10, First Course — continued. Before, Efferv. bath, December 13th. Before, be Exercises, December 15th Before, Efferv. bath, December 17th CHRONIC DISEASES OF THE HEART. 81 CASE 10, First Course — continued. Before, Efferv. bath, December 19th. Before, Exercises, December 21st. Second Course. Before, 1st bath, January 12th, 1899. 82 THE SCIIOTT METHODS OF THE TREATMENT OF CASE 10, Second Course — continued. Before, Bath, January 14th. Before, Bath, January 18th. Before, Efferv. bath, January 23rd. CHRONIC DISEASES OF THE HEART. 83 'CASE 10, Second Course — continual. Before, Eff erv. bath, January 28th. Before, Eff erv. bath, February 3rd. Before, Efferv. bath, February 7th. 84 THE SCHOTT METHODS OF THE TREATMENT OF CASE 10, Second Course — continued^ Before, After, Last bath (efferv.), February 12th. The whole of the sphygmograms which were taken in this case are reproduced with a view to emphasis- ing the importance of isolating patients, during their bathing course, from social, domestic, and business concerns. That end, it need scarcely be pointed out, will, in a great proportion of instances, be best at- tained by resort to a foreign watering-place, such as Nauheim. The pulse-tracings also serve the purpose of testifying to the efficiency of the Schott methods in promoting the repair of degenerated vascular as well as of cardiac tissues. In amplification of the reference to aortic lesion in cases 6 and 7, it is necessary to add that a weight of evidence, which increases year by year, points to aortic regurgitation as being a condition in which baths and exercises yield some of their best results. That such should be the case might be anticipated from what has been adduced to show that, instituting and establishing an improved coronary circulation and consequent myocardial CHRONIC DISEASES OF THE HEART. 85 repair, they can be relied on to restore compensation in many cases in which all other measures have failed. The proportion of cases in which no re- sponse can be elicited is small, probably less than 10 per cent., and, in such, clinical evidence points to irreparable obstruction of the coronary circula- tion. In aortic, as in other cases, the recession of the area of dulness which occurs under treatment, gives an approximate, but useful, indication of how much enlargement has been due to dilatation as compared to hypertrophy ; and it should be recorded in order to enable the observer to note from time to time whether, and to what extent, re-dilatation, premonitory of failing compensation, may be taking place. Such examples of the effects of the methods under consideration, in similar cases and in others, might be adduced almost indefinitely. The reader is invited, however, to consider them, and especially the sphyg- mographic tracings, by means of which the course of recovery, and in some cases of relapse, is illustrated from a point of view which has not as yet been insisted on, namely, that of vascular repair. As arterial lumen increases, whether in obedience to vasomotor influence or to systolic force, or to both combined, the vascular tunics undergo repair and rejuvenation. Xay, more, patency may be restored to occluded arterioles and capillaries. The process may be watched from day to day and from week to week in the vessels of the face, more especially those of the nose and cheeks, and in the zones of varicose capillaries which often mark the supra- and infra- mammary regions in subjects of atheromatous and 86 THE SCHOTT METHODS OF TREATMENT. other forms of degeneration.* It is reasonable to assume that similar changes take place in the coronary and myocardial circulation, in the great nerve centres, in the lungs and other viscera, and throughout the system generally. The clinical evidence afforded by numerous cases of myocardial degeneration with and without angina, of paresis and paralysis, of asthma, emphysema, and pulmonary consolidation, of albu- minuria, of retinal hemorrhage, and of impairment of mental faculty, confirm the assumptions based on superficial and obvious anatomical changes. Among morbid conditions none yield more readily and com- pletely than those vascular degenerations which have not proceeded to calcification or to irreparable fibrotic change. * This subject is dealt with at greater length in " Cardiovascular Repair." J. & A. Churchill. CHAPTER VII. CONDITIONS NOT PRIMARILY CARDIAC TO WHICH THE METHODS ARE APPLICABLE. In view of what has been said in the preceding chapter it remains to enumerate some of the con- ditions, not primarily or ostensibly cardiac, to which the methods under consideration may be applied with advantage. First in order, and perhaps most obviously, come those which are associated with hyper-acidity of the blood. Such are those in which the sequelre of acute rheumatism, and especially peri-, myo-, and endocardial lesions co-exist with injury to joints and tendons. What has been said of the resolvent, metabolic, and trophic effects of the baths points to them as remedial and restorative agents of the first order of efficacy, especially when their direct effect in contracting the heart and nourishing its tissues is borne in mind. Where myocardial changes have left a legacy of dilatation and feeble action, and the structures entering into the composi- tion of the joints have either escaped injury or undergone effectual resolution, the exercises alone may meet the requirements of the case. The same indications apply to the subjects of acute and chronic gout. Cases of dilatation, weakened heart, or special lesion occurring in the course of osteo- or rheumatoid arthritis stand, however, on 88 THE SCT10TT METHODS OF THE TREATMENT OF different ground. "When the central and trophic influences which, according to Dr. "W. M. Ord and others, play a prominent part in this affection, as well as the measure of neurasthenia and the pro- found cachexia which frequently arise in conjunc- tion with the arthritic changes characteristic of the disease, are taken into consideration, it will be apparent that the treatment by baths is calculated to relieve, at one and the same time, such cardiac troubles as may have arisen, and the other local and general conditions to which allusion has been made. The weakened heart which influenza so often leaves in its train, probably as the result of myocarditis and of altered innervation, is readily amenable to both baths and the exercises. In some such cases murmurs may be detected, mostly basic-systolic. They are probably due to orificial irregularity or dilatation, for they are generally subdued in the first stage of the treatment. Sometimes they recur in the course of the earlier intervals ; but I have not met with any, not previously existent, which have survived a full course (Cases D and E, Ch. X.). The effects of both baths and exercises, whether singly or conjointly employed, are very remarkable in anaemia associated with more or less dilatation, whether chlorotic, gouty, malarial (Case A, Ch. X.), or arising from loss of blood or from chronic intestinal catarrh. In many such cases it is common to see the colour, digestion, spirits, energy, and general health of the patient undergo a notable improvement within three or four days, without the exhibition of either arsenic or iron. A course of four or five weeks, combined with due precaution as to diet, exercise, and general hygiene, is usually sufficient to ensure a return to health. In the two latter classes of CHRONIC DISEASES OF THE HEART. 89 cases, it need not be said that the physical treatment should be combined with measures calculated to arrest the waste which the system has suffered. The effects of both methods, especially when com- bined, have been no less satisfactory in such cases of oedema, anasarca, serous effusion, and albuminuria associated with deficient heart power as, under my observation, have submitted to the treatment. Case I (Ch. X.) is one in point. The Schott methods have brought relief to such cases of asthma, associated with however little cardiac dilatation, as have come under my treatment. I may mention three typical cases : a is a lady of middle age who, on taking a drive, or in any way coming near a horse, experienced the following train of symptoms: — intense injection of the ocular and palpebral conjunctivse, nasal defluxion, hoarseness, and the breathing characteristic of spasmodic asthma. After a week of baths she was able to take a long drive with relative impunity, and, as the course proceeded, the improvement continued, until finally the symptoms were scarcely appreciable. A slightly dilated heart had resumed its normal dimensions within the first week, and the pulse had become uniformly stronger and fuller.* /3 is a lady, thirty-six years of age, who has been liable, with increasing frequency and severity, to accesses of eczema, in- testinal catarrh with abilious stools, bronchitis with profuse muco-purulent expectoration, and asthma with nocturnal exacerbations of great severity. The effects of driving were similar to those experienced by a. When she came under treatment she had not been able to lie down for a fortnight, and could secure only a few snatches of sleep with the aid of the * The benefit has, in this case, been maintained for four years. 90 THE SCHOTT METHODS OF THE TREATMENT OF fumes of a well-known anti-asthmatic powder. The lungs were emphysematous, and the apex beat was two inches outside the nipple line. During the day, any slight exertion induced cardiac dyspnoea and precordial distress. Within three days of com- mencing a course of exercises, all the symptoms had so improved that she could lie down at night and obtain unbroken sleep for two or three hours at a time. At the end of a fortnight the anti-asthmatic inhalations were discontinued. On the conclusion of a course of five weeks (inclusive of the menstrual interval) she enjoyed good nights, could go up and down stairs without the breathing being affected, take long walks, and drive, with scarcely appreciable inconvenience, through the streets of London in hot, dry, and dusty weather. The apex beat had receded two inches and was in the nipple line.* 7 differs from the preceding in having passed the climacteric period by about two years, and in the emphysema being more pronounced. For seven years she had only obtained sleep by being pillowed up and inhaling the fumes of nitre-papers, and outdoor exercise had been limited to slow, rambling walks in the garden of her country residence. The exercises alone were employed. The nocturnal asthmatic exacerbation, from day to day, occurred a little later and lasted a shorter time. In the course of the second week, the nitre-papers were abandoned, and good nights were enjoyed in the recumbent position. On the conclusion of a five weeks' course, the apex beat had receded from an inch without to half an inch within the nipple line. When last heard of, three years later, * This patient has enjoyed better health for three and a half years, but, after an attack of bronchitis, had a course of baths at home. CHRONIC DISEASES OF THE HEART. 91 the patient was taking country walks of about a mile every day, and leading a fairly active life.* I have mentioned these cases with some detail because they seem to open up a prospect of relief to a class of sufferers whose troubles have hitherto, to a great extent, defied treatment. The results recorded are, however, not surprising when considered in the light of what has been shown to take place in the relief of a burdened heart, and the improvement of the capillary circulation. It can scarcely be doubted that the congested and varicose veinlets which en- cumber the alveoli in such cases, share in the general change for the better, and that the circulation through the pulmonary circuit is quickened, and the aeration of the blood proportionately facilitated, by the in- creasing systemic arterial and capillary capacity and activity. Briefly, it may be assumed that the fol- lowing changes combine to relieve asthmatic sub- jects : relief of veinlets in the bronchioles and alveoli ; increase of breathing capacity consequent on cardiac shrinkage ; elimination of toxins by diuresis and diaphoresis ; direct and reflex influences, improved digestion, and subsidence of gastric dilatation ; the effects on the general health of better rest at night and of increased ability to take outdoor exercise. Be that as it may, it needs no argument to show that an asthmatic patient is in better case when strong and well - contracting heart - muscles propel the blood-stream through channels which offer a reduced, and perhaps no more than a normal resist- ance. In this connection I may state that con- valescence from acute bronchitis and from pneumonia * Each of these three patients, showing signs of relapse, under- went, after about a year's interval, a course of artificially-prepared baths, with satisfactory results. 92 THE SCHOTT METHODS OF THE TREATMENT OE may be favourably influenced by recourse to either method, more especially as regards the drying up of moist exudations. A considerable proportion of other subjects of cardiac dilatation are also affected with frequently recurring distension of the stomach, or with chronic dilatation of that organ. These conditions generally subside pari passu with the improvement in the state of the heart without special treatment. The changes in the general circulation, and more especially in the peripheral vessels and the capillaries, which lead to habitual coldness of the extremities with a deep bluish-red colour of the hands, which gives place to a white hue on pressure, but returns the moment the pressure is relaxed, and not infrequently similarly affect the colour of the cheeks and of the tip of the nose, yield equally well to both baths and exercises where these conditions have not become hopelessly confirmed. Many such cases have been apparently cured. In one an habitual headache, which, with occasional variations of intensity and a few complete intervals, had existed for about seven years, was effectually relieved. The patient was a lady twenty- two years of age. One in whom the treatment produced only partial and temporary relief, and no permanent benefit, was over thirty years of age and also the subject of habitual headache with occasional accesses of acute hemicrania. A man seventy-four years of age, who for four months had been troubled with habitual headache associated with the evacuation of uric acid crystals and accesses of lumbago, was relieved of the headache in four days. The exercises were persevered with for a month, and the apex beat, which had been found an inch outside, receded to a point half an inch within, the nipple line. CHRONIC DISEASES OF THE HEART. 93 Of women who had habitually suffered acutely during the first hours of the menstrual period, a large proportion have reported that they were unconscious of discomfort during the initial stage of the first menstrual period which occurred after either exercises or baths had been commenced. In most of those cases of which I have been able to obtain subsequent information, the relief has been permanent. The structural changes occurring in the heart and vessels, which are generally designated atheromatous, and which have been regarded as due to the irreparable decay of nature, yield, as already stated, in a manner which is nothing less than surprising to the influences of the baths, but it is only in comparatively early cases that repair can be expected to be carried to the point of completion by one course. Very satisfactory results have been observed in patients who had advanced to the age of seventy-four and upwards. But it has to be borne in mind that subjects of that disease, as of most other affections of the organs of circulation, are the victims of chronic self-poisoning originating in the alimentary canal. It, therefore, follows that dependence must not be placed on physical treatment alone, and that diet and gastro-intestinal antisepsis, as well as measures calculated to ensure effectual elimi- nation, must be regarded as indispensable adjuvants ; and it may be stated in this connection that of all internal remedies for cardiac affections generally, aneurysm not excepted, water is perhaps the most powerful and important. It should not be taken in considerable quantities in such relation to meals as to effect injurious dilution of the gastric juice. In power to free the blood, by means of renal excretion, of those toxic ingredients which induce chronic con- traction of arterioles and capillaries, and eventually 94 THE SCHOTT METHODS OF THE TREATMENT OF degeneration of structure, and to lower intra-arterial pressure, it stands far in advance of pharmaceutical preparations, which, nevertheless, and more especial^ the alkaline iodides and various preparations of mer- cury, may often be usefully employed. What has been said on the subject of vascular repair and the restoration of patency to obsolescent and obsolete vessels has a special application to Raynaud's disease. Many cases of that affection have been under treatment and observation. In all relief, in the greater number cure has been effected. But in them, perhaps more than in many other conditions, measures of hygiene and pharmaceutic treatment should be applied. Of the latter, the prolonged and repeated exhibition of the salts of calcium, the merits of which have been so strongly enforced by Prof. A. E. Wright and Dr. G. W. Ross, is perhaps the most impor- tant. In nearly all such cases undue peripheral resistance and myocardial malnutrition have led to some measure of cardiac dilatation both of which yield readily to baths and exercises. In Graves' Disease these methods have at- tained a measure of success surpassing that of other systems of treatment. But it should be borne in mind that subjects of that affection not only can bear, but in many instances spontaneously ask for baths of a lower temperature than generally rules in other cases. For complete relief, however, they generally require two or three courses, as well as strict enforcement, in diet and hygiene, of all precautions which tend to obviate autotoxis, a condition which is becoming more and more widely recognised to be a prime cause of affections of both the nervous and circulatory systems. CHRONIC DISEASES OF THE HEART. 95 The number of cases characterised by brief accesses of vertigo or of momentary unconscious- ness, with failure of power in the lower extremities, accompanied first by pallor and then by flushing or lividity is perhaps greater than is generally recognised. They are, in fact, examples of minor epilepsy of circulatory origin. Many such occur quite apart from established bradycardia, and can, therefore, scarcely be grouped with what is known as the Stokes- Adams syndrome, though they may not be fundamentally diverse. They may gene- rally be completely relieved by recourse to these methods, combined with the correction of those conditions which predispose to defects of circula- tion. This brief notice of what may be called the second- ary or indirect results of a treatment which is more especially directed to the heart, would be incomplete if I were not to allude to its psychological influence. Xo one can have observed the subjects of cardiac inefficiency, especially those who are affected by either simple dilatation, or by that condition asso- ciated with valvular lesion and failure of com- pensation, without being struck with the nerve- tension and mental suffering which they endure. Intolerance of sound, irritability, difficulty of mental concentration, lessened power of work, depression amounting, in some cases, to despondency, and night alarm, are of common occurrence. With the rehabilita- tion of the heart and vessels which these methods of physical treatment are so successful in inducing, all such nerve-suffering vanishes like a dream, and the spirits rise to a plane of hope and energy which is surprising alike to the patient and the physician (Cases C and D, Oh. X.). CHAPTEE VIII. THE AFTER-TREATMENT. From what has been said on the physiological action of the baths and exercises, and as to the con- ditions which should govern their application (Chaps. IV. and V.), it will be apparent that the processes of action and reaction, and the metabolic and nutritional changes which have been initiated, impose a first charge on the energies of the nervous system. It is, therefore, not surprising that the subject of a success- ful course of treatment will, on its conclusion, express surprise that, along with improvement in all other respects, there remains a liability to a sense of lassi- tude ensuing on all kinds of mental and physical exertion. But where the margin of energy stored in the nervous system has been small, the physiological actions referred to have required the expenditure of all, or nearly all, of that store, and the patient may be by no means fitted to return at once to the cares and duties of everyday life, in spite of repair of cardio- vascular structures and the restoration of compensation which have been effected. Even if that sense of languor be scarcely apparent, an interval of relative repose is imperatively demanded. It is indicated, firstly because what may be called a working capital of nerve energy equal to all the demands of ordinary life, without risk of overdraft, must be laid up in CHRONIC DISEASES OF THE HEART. 97 reserve ; and also because the general musculature has for a considerable period, to be measured by months or even years, been undergoing progressive deterioration in consequence of the limits to physical exercise which have been imposed by the disablement of the circulatory, and, in a secondary sense, of the respiratory mechanisms. In order, therefore, that fatigue may be endured, not only without exhaustion, but under conditions which will ensure healthy repair of daily waste and progressive improvement of the physical condition, it is in the highest degree desirable that an interval of not less than two or three weeks, according to circumstances, should be devoted to health culture under carefully devised hygienic conditions. Such is what is commonly called the " after-cure." A well-devised after-cure involves consideration, therefore, of where the patient should go and how he should regulate his life. The primary condition is isolation from domestic and business responsibilities and the avoidance of all unnecessary mental concen- tration. It is obvious that the domestic hearth and the place of business should, above all others, be avoided, that correspondence should be brought to an irreducible minimum, and that study and the decision of anxious or important questions should be deferred. Pure air and sunshine are the next considerations. An open space with a long vista, but sheltered from the colder winds, and with a southern exposure, will ensure those conditions. At the height of summer there should be shelter from the noonday sun, and an altitude of from 1,000 to 3,000 feet above the sea-level is generally desirable. The question of altitude is important in cases in which anaamia has been a prominent symptom, on account of the favourable influence it exercises on the proliferation of the red 7 98 THE SCHOTT METHODS OF THE TREATMENT OF corpuscles of the blood. On the other hand, it may be little less than disastrous to send a patient who is the subject of persistent and irreducible high blood- pressure, especially if there be even slight albuminuria, to a high station. A sense of cerebral congestion and distressing dyspnoea, often referred to as cardiac asthma, would almost certainly ensue, and speedily efface the benefits of the preceding treatment. It is within my knowledge that no more than 800 or 900 feet of elevation may have that undesirable effect. The same precaution applies to cases in which emphy- sema, especially of the senile atrophous variety, enters as a factor into the general morbid condition. In all such cases a plain, at the outside not more than 300 feet above sea-level, sheltered from cold winds, as well as a southern exposure, are indicated. It should be borne in mind that a situation at an altitude of from 500 to 1,000 feet fully open on two or three sides may be infinitely preferable to one twice as high, if the latter be so enclosed by hills or mountains as to interfere with the free circulation and renewal of the air ; also that, at any altitude, the conformation of a rocky or other water-holding subsoil may be such as to involve the presence of stagnant underground water so near to the surface as to cause the exhalation of gases of almost paludal noxiousness. The after-cure is pre-eminently the opportunity for that physical culture which the changes effected in the heart and vessels render profitable as well as possible ; and, on exercise carefully regulated and gradually and cautiously increased, should be expended all those vital energies which are no longer exacted by the reactions of the treatment, and are carefully withheld from mental pre-occupation and concentration. It is at this juncture that the hill- CHRONIC DISEASES OF THE HEART. 99 climbing of Oertel may, in suitable cases, be advan- tageously introduced. But its indiscriminate employ- ment may be fraught with mischief, especially in those cases in which the liability to dyspnoea and palpitation are associated with valvular lesions. In such cases walking should be practised mainly on the level, and no attempt should ever be made to establish " second wind " in the face of the symptoms referred to. It is better to enjoin for the first days four or five short walks, with intervals of repose, rather than two long ones, as well as a period of rest before and after meals This last precaution has a special im- portance in cases of angina. The question of diet is referred to elsewhere (Chapters VII. and IX.). CHAPTER IX. THE EXERCISES. " Movements without design weaken the heart ; movements with design, on the contrary, strengthen the heart." — Theo. Schott. [For the illustrations contained in this ehaj)ter I am indebted to the joint labours oj one of my assistants and of Mr. Prenderpast Parker, the artist.— W. B. T.] Ix approaching the subject of the movements which have been shown to exercise therapeutic influences over the heart and blood-vessels, which place the drugs hitherto relied on completely in the shade and relegate them to the position of occasional auxiliaries, it cannot be too clearly stated that we have not to do with "gymnastics" in the sense in which that word is usually employed in the English language. They do, doubtless, in the end, promote the development of the muscles generally, but that is not their primary object. It should be dis- tinctly understood that they are designed to pro- duce regulated movement with little exertion and no fatigue. The person who administers them, who may be called the "operator," should strictly observe and enforce the following rules : — 1. Each movement is to be performed slowly and evenly, that is, at an uniform rate. 2. No movement is to be repeated twice in succes- sion in the same limb or group of muscles. CHRONIC DISEASES OF THE HEART. 101 3. Each single or combined movement is to be followed by an interval of rest. 4. The movements are not to be allowed to accele- rate the patient's breathiDg, and the operator must watch the face for the slightest indications of : (a) dila- tation of the ala3 nasi ; (b) drawing of the corners of the mouth ; (c) duskiness or pallor of the cheeks and lips ; (d) yawning ; (e) sweating ; and (f) palpitation. 5. The appearance of either of the above signs of distress should be the signal for immediately interrupt- ing the movement in process of execution, and for either supporting the limb which is being moved, or allowing it to subside into a state of rest. 6. The patient must be directed to breathe regu- larly and uninterruptedly, and should he find any difficulty in doing so, or for any reason show a ten- dency to hold his breath, he must be instructed to continue counting, in a whisper, during the progress of each movement. 7. No limb or portion of the body of the patient is to be so constricted as to compress the vessels and check the flow of blood. If the physiological significance of such general rules be apprehended, it will become apparent that the precise geometrical outline of one or more of the limited number of movements which the different parts of the body are capable of performing, is of altogether secondary importance as compared with the conditions under which they are executed. So- called Swedish movements, which are of unquestion- able value in certain cases, cannot, however exactly practised, be regarded as " Schott " movements unless administered in conformity with the fundamental physiological conditions which have been indicated. Moreover, movements which are enforced by me- chanical appliances, and therefore without adaptation 102 THE SCIIOTT METHODS OF THE TREATMENT OF of speed, force, and duration of interval, to the immediate effect on the patient, cannot fulfil the conditions essential to cardiac therapy. The following are the movements : — ~No. 1. — The arms are to be extended in front of the body on a level with the shoulder joints, the Fig. 16. palms of the hands meeting in front of the chest (Fig. 16). The operator places his hands on the outer surface of the patient's wrists in such a manner that the ulnar side of the patient's wrist rests in the fork between his own thumb and forefinger. He places one foot in front of the other so that he may lean forward, without overbalancing himself, while the CHRONIC DISEASES OF THE HEART. 103 patient's arms are carried outwards until they are in line with each other, and with the transverse diameter of the chest. The operator then places his hands, with a similar disposition of the thumb and forefinger, on the palmar surfaces of the patient's wrist, and Fig. 17. offers resistance while the arms and hands are being brought back to the position from which they started Fig. 17). No. 2. — The arm and hand of one side at a time are extended in the depending position, with the palm of the hand directed forwards, and the opera- tor, standing at the patient's side, places his open hand on the palmar surface of the patient's wrist, the 104 THE SCHOTT METHODS OF THE TREATMENT OF thumb only being on the dorsal surface (Fig. 18). The patient then flexes the forearm, without move- ment of the upper arm, until the fingers come into contact with the shoulder. The operator then places Fig. 18. Fig. 19. the palmar surface of his own hand on the dorsal surface of the wrist, and maintains it there while the flexed arm is being extended to the position from which the movement commenced (Fig. 19). No. 3. — The arms are extended vertically in the depending position, with the palms of the hands turned forwards. After they have been raised out- wards until the thumbs meet over the head, they are CHRONIC DISEASES OF THE HEART. 105 brought back to the original position. The operator faces the patient, and resists the upward movement Fig. 20. Fig. 21. on the radial side of the wrist (Fig. 20), and the downward movement on the ulnar side (Fig. 21). ^No. 4. — The hands, with fingers flexed from the end of the first phalanx in such a manner that the second phalanges of the respective fingers of the two hands are in apposition with their fellows of the opposite side, are pressed together in front of the lower part of the abdomen. The thumbs are extended, and lie within 106 THE SCHOTT METHODS OF THE TREATMENT OF the three sides of a rectangle formed by the flexed forefingers, and touch each other at their tips (Fig. 22). The arms are then raised until the hands are on a level with the vertex of the head. Eesistance is offered by placing the hands on the radial surface of the wrists. The movement is then reversed. Fig. Fig. 23. Before the return movement is performed the oj3era- tor changes the position of his hands so as to receive the wrists in the fork between his thumb and fore- finger, the palmar surface of his fingers being applied to the palmar surface of the patient's wrists (Fig. 23). No. 5. — The extended arms are placed in the depending position, with the palms of the hands CHRONIC DISEASES OF THE HEART. 107 resting against the thighs. They are then raised in parallel planes until vertically extended. The move- ment is then reversed. The operator faces the patient, and in order that he may maintain an uniform and effect ual resistance, the relation of his hands to the patient's wrists must pass through the Fig. 24. following changes : In the first position the fork between his thumb and forefinger must be applied to the radial part of the wrist (Fig. 24). As the arms rise to an angle of 45° to the body, his fingers glide round the wrist until they are lightly folded round the radial surface of the wrists. Before the reverse movement commences he receives the 108 THE SCFTOTT METHODS OF THE TREATMENT OF ulnar aspect of the wrist in the fork between his thumb and forefinger (Fig. 25). While the arras are descending his thumbs move outwards, and at the same time, the fingers glide round the dorsal surface of the wrist in a direction opposite to that which his thumb is taking, in such a manner, and at Fig. 2n. Fig. 26. such a rate, that, when the patient's arms are on a level with the shoulders, the ulnar aspect of the wrist rests on a reversed fork formed by the radial aspect of operator's forefingers, and the thumb pushed out to a right angle with the somewhat flexed fingers (Fig. 26). As the hands descend towards CHRONIC DISEASES OF THE HEART. 109 the thigh the tips of the operator's fingers gradually glide round to the ulnar aspect of the wrist, so as to resist the downward and backward movement of the arms. This is the operator's pons asinorunt, but it should be mastered. No. 6. — The trunk is flexed forward, without the knees being bent, and then brought back to the erect Fig. 27. Fig. 28. positioD. The operator stands at the patient's side with one hand over the upper third of the sternum, and the other supporting the mid-lumbar region (Fig. 27). The reverse movement is resisted by placing one hand over the junction of the cervical and dorsal portions of the spine (Fig. 28). 110 THE SCHOTT METHODS OF THE TREATMENT OF ~No. 7. — The trunk is rotated, without movement of the feet, as far as it can be carried to one side, say to the right, then to the left, and lastly brought back to face forwards as at starting. The movements are resisted by one hand being placed in front of, and a little above, the advancing axilla, while the other is Fig. 29. placed over the receding shoulder (Fig. 29). The operator must, to a limited extent, move round the patient when the second stage of the rotation is being performed, and will be able to do so most evenly and securely by carrying one foot round behind the other, CHEOXIC DISEASES OF THE HEAET. Ill somewhat as is done in performing the skating il out- side edge backwards," before shifting the position of the other. ~No. 8. — The trunk is flexed laterally, first to one side, secondly completely over to the other, and thirdly brought back to the erect position. The Fig. 30. operator stands in front of the patient. When the movement is to the right, his left hand is pressed against the right side of the chest in the axilla, while the right firmly supports the opposite hip, and vice versa (Fig. 30). 112 THE SCHOTT METHODS OF THE TREATMENT OF No. 9. — This movement is identical with No. 2, with the exception that while it is being executed the fists are kept firmly clenched. No. 10. — The arms are flexed in succession as in movement No. 2, with this difference, that the Fig. 31. palmar surface is turned outwards and the fist is firmly clenched (Fig. 31). No. 11. — The arm is extended in the depending position, the palm of the hand lying against the thigh, and then makes a complete revolution from CHRONIC DISEASES OF THE HEART. Hi the shoulder joint, forwards and upwards, until it is vertically raised alongside of the ear. Before it descends backwards, the palm of the hand should be turned outwards (Fig. 32). The operator stands at the patient's side with his fingers folded round the Fig. 3± radial side of the wrist. His other hand must be ready to receive the wrist when it reaches the vertical position, and to maintain the resistance until the arm has descended to the position from which it started. This movement is performed by one arm at a time. 114 THE SCHOTT METHODS OF THE TREATMENT OF No. 12. — The arms are extended vertically in the depending position, the palms of the hands resting' against the thighs. They are then moved upwards and backwards in parallel planes as far as it is possible Fig. 33. to do so without bending the trunk forwards. The upward movement is resisted with the fork of the hand on the ulnar aspect of the wrist, the down- ward by folding the fingers round the radial surface (Fig. 33). CHRONIC DISEASES OF THE HEART. 115 iNo. 13. — The patient stands with one hand resting on a chair or table, while the thigh of the opposite side is flexed on the trunk to the extreme limit, and then extended until the feet are side by side. The Fig. 34. leg should hang downwards from the knee-joint. The upward movement is resisted by a hand placed immediately above the knee (Fig. 34). The return 116 THE SCHOTT METHODS OE THE TREATMENT OE may be resisted by a hand placed below the lower part of the thigh or under the sole of the foot. No. 14. — The patient, supporting himself with Eig. 35. one hand, as in the last movement, bends the whole extended lower extremities in succession, first for- CHRONIC DISEASES OF THE HEART. 117 wards to the extreme limit of movement, then back- wards to the same degree, and finally brings the one foot alongside of the other. The forward movements Fig. 36. are resisted in front of and above the ankle (Figs. 35, 36), the backward movements behind. 118 THE SCHOTT METHODS OF THE TREATMENT OF No. 15. — The patient, supported in front by a chair or table, stands on either foot in succession, Fig. 37. while the leg of the other side is flexed on the thigh. The upward movement is resisted by pressure on the heel (Fig. 37), the return movement above the instep. No. 16. — The patient, resting one hand on a chair and standing on the foot of the same side, raises the CHRONIC DISEASES OF THE HEART. 119 extended lower extremities in succession, outwards from the hip joint, and then reverses the movement. Fig. 38. The operator resists by means of one hand placed above the ankle (Fig. 38). No. 17. — The arms, extended horizontally out- wards, are rotated from the shoulder-joint to the extreme limits, forwards and backwards. The move- 120 THE.SCHOTT METHODS OF THE TREATMENT OF ments may be resisted by the operator grasping the ulnar edge of the metacarpal portion of the hand Fig. 39. (Fig. 39), or by closing his thumb and forefinger in a ring round the wrist. No. 18. — The hands, in succession, are first ex- tended, then flexed on the forearm to the extreme limits, and lastly brought into line with the arm. Fig. 40. The operator's one hand supports the wrist, while the other resists the movements at the metacarpo- phalangeal junction, first on the dorsal, secondly on the palmar, and thirdly again on the dorsal surface (Fig. 40). ' CHRONIC DISEASES OF THE HEART. 121 No. 19. — The feet, in succession, are flexed and extended to the extreme limits, and then brought back to their natural position. The movements are resisted in the dorsal and plantar surfaces, at about Fig. 41. Fig. 42. the level of the metatarso-phalangeal joints (Figs. 41, 42). Such being the mechanical details of the thera- peutic movements, it is not surprising that, on making acquaintance with them, the patient asks, with scarcely veiled scepticism, why a wash in the " waters of Jordan" should not be equally effectual. No question could be more apposite, no allusion more appropriate. Many days have not passed before results too manifest to be mistaken offer an un- equivocal reply. At the same time, no greater mis- take could be made than to assume that the mastery of mechanical details is a sufficient equipment for either the physician or the operator, for in no two cases is their expert and judicious application likely to be precisely similar. In the first place it should be understood that there 122 THE SCHOTT METHODS OF THE TREATMENT OF is no magic in the exact sequence which has been adopted in the foregoing description. Many patients are, at the beginning, nnable to perform the full series without experiencing what is always to be avoided — namely, fatigue or distress as exhibited by one or more of the symptoms which have been enumerated. Others cannot with advantage submit at once to movements of some special parts, such as the trunk or lower extremities. Some who are confined to bed cannot, in the nature of things, execute a portion of the exercises. In all such re- spects it devolves on the medical adviser to instruct the operator. The time to be occupied by the several movements, the duration of the interval of rest, and the measure of resistance to be offered, are points on which his judgment should be expressed. For that reason he should always be present when the first exercises are administered, and, in many cases, it will be advisable for him to conduct a few move- ments himself, aud then, having gauged the patient's powers and capacity, to administer them to the assistant in order that his estimate of the required rate of movement and degree of resistance may be placed beyond the possibility of misapprehension. It needs not to be said that the medical attendant should, in all cases, submit the patient to an exhaus- tive preliminary examination. More especially is this the case where there exists any impediment to the rapid filling of the expanding arteries and capillaries. Should, for example, the pulmonary circuit be obstructed, as it is in cases of emphysema and asthma, and with rigidity or stenosis of the aortic orifice, syncope may be easily induced. In presence of such conditions, the resistance should be limited to feather weight, the movements slowly executed, and the intervals prolonged to allow the heart and vessels CHRONIC DISEASES OF THE HEABT. 123 time for the adjustment of their mutual relations to the changes which are being rapidly effected in the flow and distribution of the blood. It may even be desir- able to enforce the recumbent position lest the pres- sure in the cerebral vessels be unduly lowered bv the imperative requirements of the increasing vascular capacity. If the right side of the heart be overloaded, a down-grade should not. at first, be given to the brachial veins by raising the arms above the level of the shoulders. Briefly, the system under consideration brings such powerful influences to bear on the whole circulation, that, in applica- tion, it requires to be adapted to the exact condition of each individual. As with other potent remedies, the "rule of thumb" may easily convert a thera- peutic agent into an instrument of mischief. Xo less care should be taken in the selection, instruction, and supervision of operators. They should be in- telligent, light of hand, endowed with powers of observation, and trained to use them. The choice of women is not limited. Trained nurses who possess a knowledge of elementary anatomy and physiology, and whose faculties have been cultivated by hospital service, abound in our country ; but suitable men are not easilv found, \\ith regard to treatment, although the physical method relegates pharmaceutical remedies to the rank of auxiliaries, their influence is, in some instances, of material value in correcting a special defect of health or in raising the general tone of the system. The patient's daily life often needs regulation, more especially in regard to exercise, fresh air, and the avoidance of undue fatigue, excitement, anxiety, mental distivs-. and all other depressing conditions. Diet, however, is a matter of scarcely secondary importance. The con- dition into which most patients have fallen, and the 124 THE SCHOTT METHODS OF THE TREATMENT OF acceleration of tissue change which the bath and exercises alike induce, demand a liberal supply of muscle-forming nourishment, comprising, generally, animal food, though not of necessity butchers' meat, three times daily. If there be a class of subjects with regard to whom the adjustment of the dietary claims exceptional care, it is that numerous one in which a tendency to the excessive deposit of adipose tissue is the accompaniment of ansemia or of some other dyscrasia. With them, the substitution of animal food for a considerable proportion of the fats and carbohydrates in common use, is a measure of great importance. A judiciously devised "thinning," but not "lowering," diet lightens the corporeal burden, gives free play to the muscles, and strengthens the heart to an extent which can hardly be accounted for by the mere removal of superincumbent fat. It should be added that those who have had the widest experience of the Schott methods attach no import- ance whatever to special limitation of the quantity of fluids ingested, and that graduated mountain climb- ing, as recommended by Oertel, should only be resorted to towards the end of the treatment or after it has been brought to a satisfactory conclusion. It then forms the rational complement of the treat- ment. Physical exercise, practised by means of mechanical appliances, forms no part of the system, and introduces principles which are not only foreign to its conception but essentially opposed to it. It now remains to be said that exercises with " self- imposed resistance " are often found to be of value as an after-treatment, more especially as they are within the competence of everyone who has become acquainted with the movements, and involve no risk of injury by over-exertion. " Selbst-hemmungs-gym- nastik" or self-restraining gymnastics, were devised CHRONIC DISEASES OF THE HEART. 125 to enable patients to be, if one may so express it, their own operators. The restraint or resistance is effected by that hardening of the muscles of the limbs, or groups of muscles, which execute the movements, of which the condition of the forearm produced by firmly clenching the fist is an example. After a little practice the patient can induce that condition at will, and maintain it throughout the several move- ments, especially those of the arms and legs. It would be unbecoming to close these observations without offering a tribute of admiration to the in- dustry and genius which August and Theodor Schott have displayed in devising and elaborating means at once so simple and so effectual for the relief of a large measure of disablement and disease, and, at the same time, acknowledging the generous spirit in which they have, consistently with the most honourable profes- sional ethics, made every effort to bestow the fruit of their labours on the medical profession at large for the benefit of suffering mankind. CHAPTER X. ILLUSTRATIVE CASES. A., a lady, aged twenty-seven, had resided for four years in one of the semi-tropical States of America. Had suffered frequent accesses of tertian fever, which throughout the summer of 1893 had continued in unbroken series. Presented intense anaemia, dyspnoea on exertion, and sallow complexion. Suffered con- tinuous headache and chronic intestinal catarrh, to which she had been liable for years. At the termina- tion of the course the anaemia was completely relieved. The headache and dyspnoea were relieved by the end of the first week. The intestinal catarrh was pharma- ceutical!)- treated and relieved, but showed a tendencj- to return on slight provocation. Three years after the completion of the course the improvement was found to have been maintained. Note. — Areas of cardiac dulness and apex beats indicated by red lines and crosses, respectively, refer to observations made after either baths or exercises. DIAGRAM A. (UN. A A andA 1 A 1 , areas of cardiac dulness before and after first exer- cises (1 to 13). B B and B 1 B 1 , areas of cardiac dulness before and after last series of exercises at end of third week. C C, area of cardiac dulness on termination of four weeks' course. R .X.and L.N. right and left nipples. S S, mid-sternal line. Tefiuefage 12i>. DIAGRAM B. 6 | IN. A. A. area of cardiac dulness before first exercises. A A 1 , the same after twenty minutes' exercises. P> B, the same after completion of the course, thirty-one days later. C C, the same eighty days after completion of the course. X A and X . positions of apex beat at corresponding stages. R.N. and L.N., right and left nipples. S S, mid-sternal line. Tofaafugt 127. CHRONIC DISEASES OF THE HEART. 127 B., aged sixty-five, had rarely smoked less t than twenty cigars a day during a thirty years' residence in India, and was found to be unduly stout, with pale and drawn face, and light bluish lips. He could not walk a hundred yards without stopping to recover his breath, nor ascend a flight of stairs without resting, supported on the banister, for the same purpose. He was dieted to reduce his weight and correct gastric fermentation, and treated by exercises. Before the completion of the course his aspect and expression had changed, and his face and lips became ruddy ; he walked daily to and from his club, a distance of five miles in all, and there played billiards for two or three hours, and could run up stairs without becoming breathless. In weight he lost a pound a week for six weeks. Nine months after the conclusion of the treatment, he was fishing and shooting in Norway, and now smokes, on an average, six small cigars a day. Two years after the commencement of the treatment, the patient was found to be relapsing. A second course of treatment, consisting mainly of baths, yielded equally satisfactory results. 128 THE SCHOTT METHODS OF THE TREATMENT OF C.j aged fifty, had presented symptoms of cardiac failure for at least twenty } T ears, and had been liable for four years to accesses of partial syncope, associated with gastric distension and intense vertigo. The treatment by exercises commenced a few days after recovery from the last such attack. On the conclu- sion of the course, the patient summarised the change in her condition as follows : " Before the treatment my sensations frequently forced upon me the appre- hension of impending death, my digestion was bad, and every exertion of mind and body seemed to be too tiring to be endured. Xow I walk for at least an hour twice daily. I can eat and drink anything in reason, and I am a stranger to fatigue and depression of spirits." Four months after the completion of the treatment the improvement was more than maintained. The patient had crossed a mountain pass at an altitude of more than 7,000 feet, in a snowstorm, without the breathing being affected, or experiencing any incon- venience. A year later there had been no recurrence of the symptoms. DIAGRAM C. A A and A 1 A 1 , areas of dulness before and after exercises. (Pulse reduced from 84 to 76.) B B, area of dulness after twelfth exercises (the fourth after an in- terval of fourteen days, necessitated by the menstrual period). C C, the same after twenty-fifth and last exercises. Cx, situation of apex beat on that occasion (not having been appre- ciable when previous observations -were recorded). R.N. and L.N., right and left nipples. S S. mid-sternal line. To fact page 128. © A A and A 1 A 1 , areas of cardiac dulness before and after first exer- cises. (Pulse reduced from 108 to 104.) B B, area of cardiac dulness twenty hours after completion of the course. (Pulse 84, after going up and down two flights of stairs.) X A 1 , Ax, and Bx, positions of apex beat at corresponding stages, R.N. and L..X., right and left nipples. S S, mid-sternal line. Tofjcefagi 189. CHRONIC DISEASES OF THE HEART. 129 J)., aged eighteen, 5 ft. 10 in. in height, had a first access of influenza in 1890, and a second in 1892. The latter was followed by loss of ocular accommoda- tion, as well as cardiac weakness and vertigo which became so severe, about three weeks after the termina- tion of the febrile state, that he was obliged to take to his bed, and there lay with a basin at his side, because an incautious movement of the head, or even the auto- matic fixing of the eyes on a crack in the ceiling, except while wearing convex lenses, brought on an attack of retching. From that time forward he was debarred from participation in all games and sports, as any exertion beyond a leisurely walk brought on palpitation, precordial pain, and dyspnoea. On the 28th of February, 1894, he commenced a course of exercises which extended to the 24th of March, in- clusive, after which he returned to the country. A month later I received the following report : — In active pursuits he is now on a level with other young men of his age. His tutor reports that in power of application, and in memory, he is twice the man he was ; but the most remarkable change is in his spirits, for, whereas the word " beastly " used to be freely scattered through his letters, everything in life is now said to be "awfully jolly." After the lapse of a year the patient was in good health and leading an active life. Eighteen months later the patient was reported to be in good health and to be leading an active life. In the winter and spring of 1895 — 6 he played foot- ball and rowed in " College eights," subsequently to suffering an access of influenza. Tachycardia (pulse 110 — 120) and a measure of dilatation of the right side of the heart ensued. A course of baths restored him to a state of health which has since been maintained. 9 130 THE SCHOTT METHODS OF THE TREATMENT OF E. — The following case is published by permission of Dr. James Harper, with whom I saw the patient six weeks after the termination of the acute stage of influenza. She was twenty years of age, and had not gained in strength or power of movement from the time of leaving her bed. She was found to be very anaemic, somewhat wasted, and could only move from one room to another adjoining, at the cost of dyspnoea and precordial pain. A well-marked systolic bruit was audible at the base. I administered exercises very slowly, with gentle resistance, and long intervals, for the space of fifteen minutes in all. The areas of dulness were traced by Dr. Harper, who also recorded the following observations : — Dec. 12, 1898. Before exercises. P. 96, murmur distinctly audible. After ., P. 84, ,, scarcely „ „ 14, ,, Before ,, ,, fairly marked. After 20 m. „ ,, scarcely audible. „ 18, „ Before „ P. 84-120 „ audible. (very variable). After 20 m.„ P. 84, „ not audible. ., 28, „ „ „ „ P. 92, no bruit, Jan. 1, 1894. Before „ P. 132, ., After 24 in. „ P. 84, >» **> >> ii ii ii *« "■*> ii „ 9, „ „£-houi's„ P. 96, „ 12, ,, Before exercises, P. 96, „ After the completion of the course the patient travelled by rail from Victoria station to South Kensington, whence she walked about three-quarters of a mile. She presented the appearance, and en- joyed the sensations, of perfect health. The pulse was 88, and I could discover no bruit. Up to June, 189-8, the patient had remained in excellent health. DIAGRAM E. 5lN. A A and A 1 A 1 , areas of cardiac dulness before and after fifteen minutes' exercises, with gentle resistance. 13 B, the same at the conclusion of a course extending over thirty- one days. R.N. and L.X., right and left nipples. S S, mid-sternal line. To face f age 130. DIAGRAM F. *C' xcB A' b . : XB *A £j 2riN. Si in. A A and A 1 A 1 areas of dulness before and after first exercises. B B and B 1 B 1 areas of dulness on seventh day before and after exercises. C C and C 1 C 1 . areas of dulness before and after exercises after an interval of twenty-six days. D I), area of dulness eighty-five days after conclusion of treatment, li.js. and L.r> . right and left nipples. mid-sternal line. X A, X B, etc., positions of apex beat at stages corresponding to letters A, B, C, and D. x A', x B\ etc., positions of apex beat at stages corresponding to letters A , U , and C 1 . T j fact frige 131. CHRONIC DISEASES OF THE HEART. 131 P., aged sixty-seven, had been known for four years to present symptoms of aortic stenosis, but had good compensation and led an active life. He came under observation again on March 8, 1894, some weeks after suffering from symptoms which suggested an attack of influenza. His face was drawn and anxious, and he complained of dyspnoea on exertion, and of great loss of mental and physical energy. On auscultation the basic-systolic bruit was found to have become louder, and to it was superadded a well- marked apex -systolic murmur. The first exercises reduced the pulse from 60 to 50, and increased its force and volume. After seven days (B) he left London much improved, both murmurs being audible but reduced in intensity. Eesumed the treatment after an interval of twenty-six days (C), enjoying at the time good general health and complete freedom from dyspnoea. The first exercises of this series reduced the pulse from 72 to 44. In ten more days the treatment was brought to a conclusion by the necessity of leaving London again. By that time the apex bruit had been superseded by a sound which, but for a slight lack of definition, was healthy. Eighty-five days later the area dulness was found to be as indicated by D. The basic bruit was reduced to its old intensity ; the apex sound remained as when last observed. The pulse was 52. The general condition left nothing to be desired. The greater part of the members of this patient's family have, in health, a pulse of about 50. Symptoms of relapse were observed in November, 1895, following in- fluenza, and were effectually relieved by a second course consisting mainly of baths. This patient died suddenly of heart failure in 1897. 132 THE SCHOTT METHODS OF THE TREATMENT OF G., aged fifty- nine, who had for many years been the subject of heart troubles associated with a loud apex-systolic bruit, and exophthalmos, was found on December 3rd, 1893, to be suffering from acute pulmonary apoplexy. The pulse was bigeminous, two beats corresponding to each complete respiratory act. He was at once instructed to practise the arm exercises with self-imposed restraint, and ordered digitalis and strychnia. On the 7th, he was moving about the drawing-room, and commenced a course of exercises resisted by a trained operator. On the 12th, he went to his office and was from home for three and a-half hours. He has since been from time to time under treatment for oedema of the lower extremities, but continued to lead an active professional life until July, 1895, when a serious illness supervened. At the present time the patient is convalescent. The heart is fairly competent and there is no oedema. Note. — This patient died of steadily increasing heart failure with general anasarca, in 1897. DIAGRAM G. 6b IN. December 7th. A A, before exercises. B 13, after twenty minutes. C C, before exercises. D 1), before exercises, after being out three and a-half hours and returning in a gale. D 1), after half-an-hour's exercises. E E, before exercises, and after six and a-half hours' absence from home on professional duty. „ 25th. F F, before exez'cises. January 3rd. <; (*. three hours after exercises. E.N. and L.N., right and left nipples. S S, mid-sternal line. 9th. 12th. 14th. To face page 132. DIAGRAM H. o 6t IN. A A and A l A 1 , areas of cardiac dulness before and after first exercises. A x and A 1 x , apex beats before and after. B B, area of cardiac dulness on completion of course twenty-eight days later. B x, apex beat. K.N, and L.N'., right and left nipples. S S, mid-sternal line. To face page 133. CHRONIC DISEASES OF THE HEART. 133 H., aged sixteen, is reported to have had carditis in the course of scarlet fever, at the age of five, followed by haamato-albuminuria and oedema. Whoop- ing cough, at the age of six, was followed by chorea of moderate intensity, which lasted for a year. A cond attack, lasting four months, occurred at these age of seven. When first seen he was under treat- ment by Mr. Barwell for spinal curvature. He had a loud systolic-apex bruit, with a well-marked and diffused thrill, and epigastric pulsation perceptible to sight as well as touch. His parents had been advised to remove him from school, and not to allow him to leave the house otherwise than in an invalid chair or pony-chaise. After the exercises on the twenty-first day of treatment he trotted about a hundred and twenty yards and then walked fifty. Before doing so the pulse was 66, and the respirations were 20 ; after- wards they were respectively 86 and 19. He expe- rienced no fatigue, and showed no signs of distress. At the conclusion of a course extending over twenty- eight days he trotted two hundred yards. Before doing so the pulse was 66, and the respirations were 16 ; afterwards they were 80 and 18 respec- tively. He was, at that time, taking walks of one and two hours' duration without fatigue, and, generally, leading an active life, though debarred from running more than a few paces, and from joining in out-door games. The areas of dulness before, and at the conclusion of, the treatment were verified by Mr. Barwell, who also noted a much diminished apex mpulse and complete absence of thrill and epigastric pulsation. The bruit had diminished, but was still well marked. 134 THE SCHOTT METHODS OF THE TREATMENT OF I. — I am enabled, by the courtesy of Sir Philip C. Smyly, to quote in extenso the following case from his article alreacty alluded to : — * Miss X., set. seventeen, had been ailing for some time. Oct. 20th, 1893. — She had an attack of faintness, and swelling of the feet and ankles. Feb. 24th, 1894. — She came under my care. She was very low and weak ; anaemic ; hands and feet oedematous and very blue ; general anasarca ; ascites well marked, and fluid in both pleurae. The area of the heart dulness was well defined to the right side of the sternum, but could not be outlined below or to the left side on account of the dulness from the pleural effusion. The skin was white and waxy on the forehead, ears, and neck. The cheeks were a dark purple-blue. After a very careful examination the diagnosis arrived at was — Dilated heart with patent foramen ovale (possibly) ; obstructed arterial circulation, with venous congestion of all the organs. No albumen in the urine. Began the resisted move- ments for twenty minutes every morning about 11 o'clock, and massage by an experienced masseuse every evening. The colour improved every day, area of dulness diminished, and the pulse became fuller and less frequent. The blue colour improved to a dark red. March 8th. — In the daily report it was noted : — " She did some additional exercises with more strength. Her pulse was considerably stronger. Her nose bled slightly. She passed a cheerful day." 11th. — " Marked improvement in the pulse. Her colour keeps good all day ; very little blue at any time." * Dublin Journal of Medical science, September, J 894. CHRONIC DISEASES OF THE HEART 135 17th. — Eemarked the healthier appearance of the forehead, ears, and neck. (From the 20th of March until the 11th of April the movements were omitted — unavoidably — though the massage was continued.) 21st. — " Not a good night — restless and dreaming. Appetite very poor." April 5th. — " Her colour was very dark with much blue in the morning; got right in the afternoon. Urine very scanty." 6th. — " Swelling of the abdomen greatly in- creased. Only eleven ounces of urine in twenty-four hours." 11th. — Pain in the right side. Movements begun again, but very slightly, owing to great distress in breathing. Urine, eleven ounces. 1 2th. — Pain worse. Much swelling ; could not lie down in bed. Urine, thirteen ounces. Daily exer- cises and steady improvement. 20th. — "Better. Urine, thirty-one ounces in twenty-four hours." 22nd. — " The heart rhythm was normal for the first time." 25th. — " The menses showed for the first time since October, and continued slightly for five or six days." 26th. — The patient was moved from one house to another. On being lifted into the carriage she became breathless and very blue. Towards evening she breathed better, but could not lie down. She got little or no sleep, and had to be supported sitting up all night. 28th. — The whole of the right pleura was full. Distress of the breathing rapidly increasing. Assisted by Dr. Cruise, I tapped the chest and drew off sixty- two ounces of fluid, clear and yellow. She coughed 136 THE SCHOTT METHODS OF THE TREATMENT OF up a quantity of thin mucus during the afternoon. Temperature 100°. At 10 o'clock, p.m., the tempera- ture was 99 = . She could lie down in bed with only two pillows. May 4th. — Consultation with Dr. Cruise. She was very much improved. Movements were resumed. 11th. — " Was very cheerful all day. Colour a little high, but no blue." 21st. — Left Dublin, 7 p.m., for Holyhead. Next day to London, and on Wednesday had a consultation with Dr. Bezly Thome. 26th. — Arrived at Nauheini better than when she left Dublin. 28th.— Had her first bath. June 1st. — Pulse before the bath, 116 ; after, 110. 8th. — Dr. Schott showed the patient's mother "that the water had gone down a hand's breadth over her stomach." 20th. — Began the gymnastics. From standing during the examination, and the marking out the area of dulness, her pulse was 114; after the exercises it fell to 88, and then rose to 96, and then to 104. 21st. — I saw the patient at Nauheim with Dr. Th. Schott. I could not find any sign of fluid either in the chest or in the peritoneum. No oedema ; and the heart's action normal. July 6th. — Dr. Schott reports the heart very well. 29th. — Dr. Bezly Thorne saw the patient in London, and reports — " Wonderf ully improved. Cannot detect any wrong sound in her heart." 30th. — Dr. Cruise and I very carefully examined the patient together, and found the heart's action normal, and no swelling anywhere. She returned home to all appearance quite well. At an early part of this case it was mentioned that it appeared possible, from the extreme cyanosis, that CHRONIC DISEASES OF THE HEART. 137 some patency of the foramen existed. It is, however, quite possible that this may have been remedied by the contraction of the dilated heart, and consequent valvular closure of the foramen. " 93, Merrion Square, " August 9th, 1894. " Dear Sir Philip, "Having read your paper on the treatment of enlarged heart by movements of the system of the brothers Schott, I beg to add a short note, which, if you wish, you can publish. " As you know, I saw your patient in the most critical portion of her illness, and learned, for the first time, what can be done by these movements, and in confirmation of what you succeeded in accomplishing in a young girl, I now beg to report my own ex- perience of the treatment in a very aged patient. " Within the last month I met Dr. O'Donoghoe, of Baldoyle, in relation to the case of a very aged gentle- man, who was suffering extreme distress of breathing and loss of sleep from a weak dilated heart. " In addition to the administration of iron and digitalis, and stimulation by a small blister, I used the resisted movements of the arms, and I showed them to Dr. O'D., who fully appreciated their object and value. He and some of the patient's family have still continued them, and the patient is totally changed for the better — sleeps well, has recovered his appetite, and physically shows increased impulse and diminished area of cardiac dulness. 1 ' I remain, my dear Sir Philip, "Yours most faithfully, "F. R. Cbtttse." 10 138 THE SCHOTT METHODS OF TREATMENT. On the 19th of September Sir Philip reported: — "X. is wonderful — riding, driving, and boating." He draws attention to the following points, which this case brings into prominence : 1. The importance of the movements without the baths, followed by such an improvement that the patient was able to undertake the journey to Nau- heim. 2. The value of the ISauheim baths in removing the ascites and pleural effusion. 3. The interesting observation that the symptoms returned when the movements were discontinued for some weeks, though massage was continued regularly. In November, 1895, I carefully examined this patient. The cardiac sounds and area of dulness were normal. She was in excellent health, had gained a stone in weight, and was leading an active life. Still later information (May, 1898) showed the patient to be in excellent health. ^Y. B. T. INDEX Altitude, 97 Anaemia, 88, 97 Analyses of waters, 12, 13 Aneurysm, 50 Angina, 99 Angina cum dolore, 55, 57 Angina sine dolore, 53 Anginous distress in the batli, 42 Animal food, 124 Antisepsis, gastrointestinal, 93 Aortic disease with mitral, 64 Aortic regurgitation, 84 Aortic stenosis, 122 Aortic valves, lesion of, 62 Artificially prepared baths, 21, 22 Asthma, 89, 90, 91 Atheroma, 85, 93 Athlete's heart, 72 Bath waters, 12, 13, 22 Blood-pressure, 38, 39, 98 Bodv, weight diminution of, 59 Bronchitis, 91 Carbonic acid, 21, 22 Cold extremities, 92 Contra-indications which are only apparent, 43 Cutaneous excitation, 44, 46 Degeneration, myocardial, 74 Diagnostic value of exercises, 50 Diaphragm, level of, 35 Diet, 93, 124 Dilatation, diagnosis of early stages, 50 Disturbing causes interfering with treatment, 75-81 Diuresis, 19, 30 Dysmenorrhooa, 93 Dyspnoea, 98 Effervescence, production of, 21, 22 Exercises, description of, 100 Exercises, diagnostic value of, 50 in obstruction of pul- monary circuit, 122 influence of, 30 resistance in administer- ing, 122 with self-imposed resist- ance, 124 Fluids, limitation of, 124 Gastric dilatation, 92 Graves' disease, 94 Hands, pale or blue, 31, 92 Headache, 39, 92 Heart, contraction of the, 30 Hypertrophy, differential dia- gnosis of, 50 Inflation of lungs. 34 Influenza, 51 cardiac sequelae of, 51, 88, 129, 130 Irresponsible treatment, 48 Isolation, benefit of, 75, 84 Kidneys, effect of baths on, 20 effects of exercises on, 30 Mechanical appliances, 124 Minor Epilepsy 95 140 IXDEX Mitral disease, 59 Mitral, aortic disease with, 64 Mountain climbing, 124 Murmurs, changes in, 30, 130 Myocardial degeneration, 74 Myocardial Malnutrition, 94 Nervous system, influence upon reaction, 38, 45, 75 (Edema, 89, 134, 13(5 Oertel treatment, 99, 122 Pneumonia, 91 Prognostic value of exercises, 50 Psychological influence <>f Schott methods, 95 Pulse, influence of baths on, 18, 19, 23, 24 influence of exercises on, 25, 26, 32 pressure, diminution of, 53, 59, 75, 76 Raynaud's Dissase, 94 Reaction, 43, 46, 47 Recumbent position, 46, 123 Repetition of treatment, 64-69 Resistance, measure of, 45, 122 Respiration, effects of baths on, 19 Respiratory bruit, 73 Restorative influence of exer- cises on syncope, 55 Rheumatism, sequela? of. 87 Rheumatoid arthritis, 87, 88 Right heart, affection of : C>9 Smoker's heart, 127 Sprudel bath, 15, 16 spring, 12 Stokes- Adams Syndrome, 95 Syncope, 37, 46 precautions against, 122 restorative influences of exercises on, 55, of ex- tremities, 19 Syndrome, 95 Systolic bruit, right heart, 69 Temperatures of natural baths, 12, 13, 43 Trophic influence of baths, 20 Uric acid pains, 69 Urine, increased flow of, 20, 30 Vascular capacity, increase of, 20, 31 repair, 84 system, effects on, 1 9, 25. 26, 31, 32, 85, 86, 91 Warmth in delayed reaction, 47 Water, drinking of, 93 Widerstandsgymnastik, 27 Unwin Brothers. 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