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 
 
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 CHRONIC DISEASES OF THE HEART. 13 
 
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 14 THE SCIIOTT METHODS OF THE TREATMENT OF 
 
 While, in the winter of 1901-2, spring No. 7 was 
 being provided with new pipes an obstruction, which 
 had been in existence for some forty-six years at a depth 
 of 1 50 metres, was eventually removed; and the spring, 
 having been provided with new pipes, now yields at 
 least half as much more water than before and rises 
 in its jet half a metre higher. The result is that the 
 supply of water for the effervescing flowing baths is 
 to that extent increased in volume and in force, and 
 there is reason to expect that it will be found to be 
 richer than before in carbonic acid gas. In addition, 
 underground storage tanks, encased in non-conducting 
 materials, have been provided for springs 7, 12, and 
 14, with the result that the waters so stored retain 
 approximately their natural temperature, as well as 
 sufficient carbonic acid gas to ensure the retention in 
 solution of their respective salts of iron and calcium. 
 Thus are proA'ided clear and transparent bath waters, 
 intermediate in balneological strength between the 
 waters rendered opaque by the suspended oxides, 
 usually referred to as " thermal," and the clear 
 waters of the actively effervescing and effervescing 
 flowing baths. By the season of 1902 a new house 
 had been completed, and is now devoted exclusively 
 to different systems of pulverisation (systems " Gobel 
 and Wassmuth ") for purposes of inhalation of saline 
 and medicated waters, and provided with chambers 
 for the inhalation of compressed and rarefied air. 
 
 The springs which are used for bathing purposes 
 are No. 12, No. 7, No. 11, and No. 14 ; those employed 
 for drinking purposes, the Kurbrunnen and the Carls- 
 brunnen, the Ludwigsbrunnen and the Schwalheimer- 
 brunnen — mainly the former two. It will be observed 
 that the bathing waters are endowed by nature with 
 temperatures which suit them admirably to the pur-
 
 CHRONIC DISEASES OF THE HEART. 15 
 
 pose. As a matter of fact, it is only in exceptional 
 cases that the waters have to be either artificially 
 heated or cooled by ice. 
 
 A course of baths generally commences with the 
 waters of the great Sprudel (thermal bath), freed 
 from more or less of their natural gas, but, in any 
 case, to such an extent as to induce a deposit of 
 peroxide of iron and calcium carbonate, which, 
 floating in the water, produces an opaque yellow 
 coloration. To these, after a time, in increasing 
 portions, are added one, two, three, or even more litres 
 of Mutterlauge — the uncrystallisable mother-liquor 
 or waste product of the neighbouring works which 
 provide large quantities of salt for the table. It is 
 rich in chloride of calcium and bromine. The 
 smallest quantity, carried to the tongue with the tip 
 of the finger, produces an intense burning suggestive 
 of vesication. The next advance is to the Therm al- 
 Sprudel baths drawn from the storage tanks already 
 referred to (p. 14), the waters of which are inter- 
 mediate in strength between the thermal and Sprudel 
 baths. From them the patient passes on to the Sprudel 
 bath drawn from No. 7 or No. 12, according to the tem- 
 perature desired, containing a residue of natural gas 
 sufficient to retain the whole of the iron in solution, 
 and to coat the body with unbroken relays of globules 
 which, on the bather emerging from the water, are 
 found to have produced, insensibly, a well-marked 
 rubefacience and an agreeable glow of warmth. Then, 
 finally, come the flowing Sprudel baths, probably the 
 most powerful therapeutic baths known, in which 
 the waters of either No. 7, No. 12, or No. 14 
 forcibly enter and, through overflow pipes, leave the 
 receptacle during the whole period of immersion. 
 These, with their constantly rising and simmering
 
 L6 THE SCHOTT METHODS OF THE TREATMENT OF 
 
 globules, emerging from moving water of crystalline 
 clearness, convey the impression of a bath of cham- 
 pagne, and induce a sense of exhilaration not unlike 
 that which is associated with that favourite beverage. 
 No patient, in any case, is allowed to take more 
 than two, or three, or at the outside five, successive 
 baths in as many days, a day of interval always being 
 imposed. Where much infiltration or osteoid deposit 
 has taken place, carefully regulated massage is made 
 to succeed each bath. 
 
 Speaking generally, the effects of the baths are : — 
 To lower the frequency and increase the force of the 
 action of the heart, and to induce a sense of refresh- 
 ment and invigoration which is shortly followed by 
 an agreeable inclination to avail oneself of the hour's 
 rest, in the recumbent position, which is enjoined 
 as the invariable sequel. One of the more remote 
 effects is to cause pain and even swelling of joints, 
 and sometimes of nerve-sheaths, which have been 
 previously affected by the gouty, rheumatic, or 
 so-called rheumatoid processes. Such a condition 
 generally endures for a few days only, but not 
 only may it last longer, but it may be re-induced 
 by each of the succeeding increments of balneo- 
 logical strength above mentioned. On the more 
 permanent influences exercised in the circulatory 
 and respiratory systems I shall enlarge in detail 
 later on. 
 
 The range of morbid conditions which may be 
 relieved by the internal administration and outward 
 use of the Nauheim waters is very wide. They may 
 be divided into those articular and numerous other 
 changes which are dependent on the prolonged pre- 
 sence in the blood-stream of mic acid in excess^ 
 chronic affections of the heart and blood-vessels, with
 
 CHRONIC DISEASES OF THE HEART. 17 
 
 one notable exception ; congestion of the abdominal 
 and pelvic viscera ; and the earlier stages of chronic 
 affections of the congestive or sub-inflammatory 
 order of the spinal nerve structures. 
 
 I propose, however, in this notice, to confine my 
 observations to the systematic use of the saline baths 
 and of the regulated movements of the body in chronic 
 affections of the heart and blood-vessels, according 
 to methods elaborated after years of careful study by 
 Prof. Theodor Schott and his deceased brother 
 Dr. August Schott.
 
 £ B AVERY NEWTON, M, D. 1 . 
 
 CHAPTER II. 
 
 BATHS. 
 
 It has already been stated that the immediate effect 
 of immersion in the Nauheim baths is to reduce the 
 frequency and increase the force of the action of the 
 heart. For example, at a time when my own pulse 
 averaged 74 beats per minute in the recumbent, and 
 84 in the sitting position, the heart and vessels being 
 sound, I found it, on four separate occasions, to have 
 fallen, within two minutes of immersion in a Sprudel 
 bath, to from 60 to 64. In ten minutes it had risen to 
 from 66 to 68, and there remained during the period 
 of immersion, which in no case exceeded fifteen 
 minutes. The exertion of dressing raised it to from 
 76 to 78 ; but, after the prescribed recumbent posi- 
 tion had been assumed, it fell to from 62 to 66, 
 with increased volume, and so remained during the 
 period of repose. It will, therefore, be observed that 
 the influence of the bath was not limited to the period 
 of immersion. 
 
 By way of comparison, the following case may be 
 quoted. A patient, aged forty-six, whose health had 
 been declining for several years, was found to have a 
 pulse of 80 in the recumbent, and of 88 in the sitting 
 position. While he stood it varied from 100 to 104 ;
 
 CHRONIC DISEASES OF THE HEART. 19 
 
 and if he walked ten paces it rose to from 120 to 
 130. The apex was found to beat an inch outside 
 the nipple line. Within two minutes of immersion 
 in his first thermal bath (spring No. 7, divested of 
 the greater part of its carbonic acid gas, temp. 
 90*5° F.) the pulse had fallen to 70, and, judged by 
 the finger, appeared to have doubled in volume ; at 
 the end of four minutes it was 68 ; in six minutes 
 66 ; in eight minutes 68 ; and while standing, after 
 dressing, it was 90. Before he left the bath, after 
 an immersion of ten minutes, the apex beat was 
 found to have receded half an inch in the direction 
 of the mesial line ; and nails and fingers, which had 
 been snow-white up to the junction of the second 
 with the first phalanx, had assumed a healthy flesh 
 tint. 
 
 The immediate effect of the first few baths is to 
 produce a sense of oppression at the prascordium, under 
 the influence of which the patient breathes slowly and 
 deeply for two or three minutes. Kespiration then 
 becomes easy and continues slower by from two to 
 four breaths a minute. 
 
 The effect on the peripheral vessels is to increase 
 their carrying power. A glowing sense of warmth 
 is experienced in the extremities and in the surface 
 of the body generally. The veins are stimulated to 
 a similar activity. In fact, the general arterial 
 capacity, systemic and pulmonary, is increased, and, 
 without loss of blood, the relief of a general bleeding 
 is afforded to an overloaded and labouring heart. 
 
 Such being the results of a carefully graduated and 
 regulated series of immersions in these saline waters, 
 it can scarcely be matter for surprise that in three 
 or four days, especially in cases in which the flow of 
 urine has been scanty, there ensues a free diuresis
 
 20 THE SCHOTT METHODS OF THE TREATMENT OF 
 
 which may continue for days or weeks ; that meta- 
 bolic change becomes accelerated and improved ; that 
 deeply-seated organs, more especially the liver and 
 pelvic viscera, are relieved of congestion and partake 
 in the general impulse to functional health ; and that 
 the heart, relieved of its burden, and contracting 
 fully and without hurry on its contents, derives from 
 an improved coronary circulation materials for the 
 repair of its weakened or damaged tissues. It is sug- 
 gested by Dr. Schott that these effects are produced 
 partly by the cutaneous excitation induced by the 
 mineral and gaseous constituents of the waters, and 
 partly by a more prolonged stimulation of the nerves 
 of sensation excited by imbibition into the superficial 
 layer of the corium. According to this hypothesis, 
 each sensitive nerve branch distributed over the 
 surface that has been immersed, transmits to its 
 parent centre an influence which is centrifugally 
 reflected to the vasomotor system and to the ganglia 
 which control the action of the heart. That the 
 nerve centres are brought under powerful influence 
 is attested by the remarkable trophic changes which 
 may be observed to follow a course of these baths, 
 unaided by the internal use of mineral waters or 
 pharmaceutical remedies, in cases of anaemia, wasting, 
 neurasthenia, and, above all, in cases of osteoarthritis. 
 The rehabilitation of the trophic, and probably of 
 other central nerve tissues, is so lasting that pro- 
 gressive improvement may be observed for three or 
 four months after the completion of the course. It 
 need hardly be pointed out that such a process of 
 general health restoration is a factor of scarcely 
 secondary importance in cases in which the condition 
 of the heart presents the main indication for treat- 
 ment.
 
 CHRONIC DISEASES OF THE HEART. 21 
 
 It is necessary here to state that it is not claimed 
 that these waters are unique in their therapeutic in- 
 fluences ; on the contrary, from the earliest days, Prof. 
 Schott and his brother have insisted that similar, 
 if not indeed identical, effects may be derived 
 from baths artificially prepared so as to resemble 
 the Nauheim waters in their principal mineral ingre- 
 dients. Thus it is recommended that the treatment 
 should commence with a 1 per cent, solution of chloride 
 of sodium, and that the strength should be gradually 
 raised to 2 or 3 per cent. For increasing the cutaneous 
 excitation, chloride of calcium is the salt to be relied 
 on. The initial strength of the bath with regard to 
 that ingredient should be 0-2 per cent., approximately 
 that of No. 7 spring, and, by increasing additions, 
 it may be raised to 0*3 per cent., that is to about the 
 strength of ~No. 12 spring, and eventually to 0-5 per 
 cent. Such varying degrees of concentration may be 
 obtained by the proportional use of common salt, 
 of the crystallised !Nauheim bath salt, and of the 
 mother-lye or calcium chloride. 
 
 For the production of carbonic acid effervescence 
 the action of hydrochloric acid on bicarbonate of 
 soda may be relied on. As a state of chemical purity 
 is not required by the circumstances of the case, the 
 articles of commerce are sufficient for the purpose. 
 Two ways of employing the reagents are suggested, 
 the one calculated to induce slow and gradual, the 
 other rapid and almost immediate, effervescence. 
 In the case of the first, the various salts, including 
 the requisite proportion of bicarbonate of soda, 
 having been dissolved, a bottle containing the acid 
 is laid at the bottom of the bath, and the stopper 
 having been withdrawn it is moved about from time 
 to time. The bath will be ready for use in two or
 
 22 THE SCHOTT METHODS OF THE TREATMENT OF 
 
 three hours. For the more rapid production of 
 effervescence, the stopper of the bottle containing 
 the acid is loosened, but retained in position ; the 
 bottle having then been inverted and* lowered until 
 its mouth is just below the surface of the water, the 
 stopper is withdrawn, and the bottle is moved about 
 so as to diffuse a layer of acid as uniformly as pos- 
 sible over the surface of the bath. By this means 
 the bath will be prepared in about five minutes. It 
 will be useful to employ baths of three degrees of 
 effervescence : 
 
 Mild J lb. NaHCO s to f lb. 
 
 RC1 (25 per cent.). 
 
 Medium 1 lb. NaHC0 3 to l±lb. 
 
 HC1. 
 
 Strong (Sprudel strength) ... 2 lbs. NaHC0 3 to 3 lbs. 
 
 HC1. 
 
 Except in the case of porcelain baths it is desirable 
 to ensure a slight excess of alkali in order to prevent 
 corrosion. 
 
 More convenient, however, for general use are 
 Sandow's acid tablets and packets of alkaline powder, 
 of both of which from four to eight may be brought 
 into use in addition to the other mineral ingredients, 
 according to the measure of effervescence which it 
 may be desired to ensure.* 
 
 The following sphygmographic tracings are 
 borrowed from a paper of Dr. Theodor Schott's, 
 which I was the means of laying before the medical 
 
 * The agent for the sale in England of Dr. Sandow's preparations- 
 is Mr. M. Buchner, of 149. Houndsditch, London, E.G.
 
 CHRONIC DISEASES OE THE HEART. 23 
 
 profession in Britain in 1891,* and afford evidences, 
 which might be indefinitely multiplied, of the 
 invigorating influence which the baths exercise 
 on the heart and the circulation. 
 
 Tracings taken from a patient aged thirty- one, 
 suffering from cardiac weakness. 
 
 ^^^NJ^ 
 
 Fig. 1. 
 Before bathing : Frequency of the pulse, 94. 
 
 Fig. 2. 
 
 After the use of a Nauheim effervescent mineral bath of 87° F. 
 duration fifteen minutes : Frequency of the pulse, 72. 
 
 Tracings taken from a patient aged forty-six, 
 affected with stenosis ostii arteriosi sinistri. Exer- 
 cises were superadded to baths on the ninth day of 
 treatment. 
 
 Fig. 3. 
 
 Before the beginning of the treatment : The pulse could not be counted 
 (more than 150). 
 
 * Lancet, May 23rd and 30th, 1891.
 
 24 
 
 THE SCI10TT METHODS OF TREATMENT. 
 
 Fig. 4. 
 
 Alter the first bath, containing 1 per cent, of salt, temperature 
 89'o° F., duration ten minutes. 
 
 Fig. 5. 
 Eighth day of treatment by baths: Frequency of the pulse, 144. 
 
 Fig. 6. 
 Ninth day of treatment, after half-an-hour's exercises with resistance. 
 
 Fig. 7. 
 Fourteenth day of treatment : Frequency of the pulse, 108. 
 
 Fig. 8. 
 
 After three weeks' treatment : Frequency of the pulse, 108.
 
 CHAPTER III. 
 
 THERAPEUTIC MOVEMENTS. 
 
 The treatment of cardiac affections, as practised by 
 Prof. Schott, is not, however, limited by the therapeutic 
 influences of the baths. As the result of a series of 
 elaborate and prolonged experiments carried out by 
 him and his deceased brother, Dr. August Schott, a 
 system of exercises has been devised which yields 
 results as striking as those of the baths. Their 
 effect is illustrated by the following records, which 
 were made in Nauheim by myself in conjunction with 
 Dr. Hermann, of Charkoff, in August, 1893. The 
 patient was a stout, well-built, fresh-looking man, 
 forty years of age. He brought letters from Pro- 
 fessor von Jiirgensen of Tubingen and from his 
 brother, who is a medical man, both of which 
 described him as having been addicted to alcoholic 
 excesses and being the subject of cor adiposum. 
 Before the exercises the heart sounds were barely 
 audible through a binaural stethoscope, and the apex 
 beat was inappreciable. There was some oedema of 
 the lower extremities. 
 
 Fig. 9. 
 Before exercises.
 
 26 THE SCHOTT METHODS OF THE TREATMENT OF 
 
 Fig. 10. 
 After twenty minutes' exercises. 
 
 Fig. 11. 
 After thirty-five minutes' exercises. 
 
 Fig. 12. 
 After forty-five minutes* exercises. 
 
 The following diagram (Fig. 13) gives, on a reduced 
 
 B® 
 
 D — --= 
 
 Fig. 13. 
 
 a, left nipple ; b, right nipple ; c, fossa jugularis ; n, upper level of 
 hepatic dulness ; e, ensiform cartilage ; t d, total diminution of 
 area of cardiac dulness : x, '.•'., positions of apex beat.
 
 CHRONIC DISEASES OF THE HEART. 27 
 
 scale, the tracings of the area of cardiac dulness which 
 were taken before, and at the conclusion of, the same 
 exercises. 
 
 These exercises have been denominated by their in- 
 ventors " Widerstandsgymnastik," or gymnastic with 
 resistance. They may perhaps be more conveniently 
 termed resisted movements or exercises. They consist 
 of movements calculated to bring into successive and 
 regulated action almost every collective system of 
 voluntary muscles which is comprised in the human 
 frame. Each succeeding movement is resisted by an 
 attendant to such an extent as to oppose without 
 arresting it. They consist of slowly-conducted flexion 
 and extension, adduction and abduction, and rotation, 
 in orderly succession, of the arms, the trunk, and the 
 lower extremities. Each movement must be slowly 
 and evenly made with a definite and uniform effort on 
 the part of the patient. The office of the attendant is 
 not limited to resisting the movements with equally 
 uniform, but slightly inferior, force, but it is his duty 
 to impose a short interval between each movement, to 
 enjoin slow and regular breathing, and, more espe- 
 cially, by observing the rate of breathing and its force 
 as indicated by the alas nasi, to ensure that no undue 
 strain is placed on the heart and lungs. He is also 
 charged to guard the patient from perspiration and 
 the slightest approach to palpitation of the heart. 
 Either of these indications must be the signal for an 
 interval of repose, during which the part being exer- 
 cised is either left to hang at rest, or is supported by 
 the hand of the attendant, who, under no circum- 
 stances, is allowed to grasp or in any manner constrict 
 any portion of the patient's body. As the course pro- 
 ceeds, the energy of the movements, and consequently 
 the force of the resistance, are gradually increased-
 
 28 THE SCHOTT METHODS OF THE TREATMENT OF 
 
 The results are in general very noteworthy. It is by 
 no means uncommon, in cases of dilatation, to see 
 the oblique long diameter of the heart's area of dul- 
 ness diminish by from three-quarters of an inch to an 
 inch and a quarter, and, perhaps more surprising still, 
 to observe a diminution by as many as two inches, in 
 vertical measurement, of a liver which at first extended 
 to the umbilical level ; and to hear the patient, at the 
 conclusion of what cannot be described as an ordeal, 
 volunteer the statement that a load has been removed 
 from the praecordium, that he breathes easier and 
 more deeply, and experiences a sense of general 
 relief. 
 
 It is not suggested that the whole of such a gain is 
 permanent, for in the time that intervenes before the 
 next day's exercises or bath, as the case may be, the 
 dilated and congested organs may have tended to 
 their former dimensions, but, be it well observed, 
 they do not in most cases wholly relapse. On the 
 contrary, each contraction ensures a proportional per- 
 manent gain, until, at the end of a few weeks, the 
 attenuated and dilated heart and the congested liver 
 may have recovered either their normal dimensions, 
 or, at any rate, such contraction and compensatory 
 power in the one case, and resolution in the other, as 
 constitute them practically sound. 
 
 The resources of Prof. Schott and his brother did 
 not come to an end with the conception of this system 
 of physical treatment. With a view to enabling phy- 
 sicians and patients to maintain treatment of the same 
 kind without dependence on a second person, they 
 devised a method in the practice of which the patient 
 is instructed, himself, to supply the necessary resist- 
 ance or its equivalent, and by the aid of these self- 
 resisted movements he is able to carry on and, from
 
 CHROXIC DISEASES OF THE HEART. 29 
 
 time to time if need be, resume a therapeutic process 
 of unquestionable value. 
 
 In the course of his memorable lectures on surgical 
 pathology, Sir James Paget quoted the profound 
 observation of Treviranus that " each single part of 
 the body, in respect of its nutrition, stands to the 
 whole body in the relation of an excreted substance." 
 In view of what may be achieved by means of the 
 Schott system of therapeutic exercises, we may 
 go further, and say that each part of the body, 
 through its motor nerves, is capable of exercising 
 a health- sustaining, and in some cases a health- 
 restoring, influence on the heart and circulatory 
 system, and consecutively on the entire organ- 
 ism. It has been shown that, even in health,, 
 the heart may present, under the alternating influ- 
 ences of exercise and repose, very appreciable varia- 
 tions in size ; and Stokes, long ago, insisted that 
 exertion, under suitable conditions, may promote the 
 health of a damaged heart. On the other hand, 
 there are not wanting examples of hearts that have 
 been morbidly dilated, and to that extent damaged, 
 either temporarily or permanently, by strains dispro- 
 portionate to their strength. Drs. August and Theodor 
 Schott enjoy the distinction, and are entitled to the 
 credit, of having brought the physiological relations- 
 of exercise, function, and repair into obedience to a 
 therapeutic system which yields results in the treat- 
 ment of diseases of the heart hitherto unknown 
 and unlooked for. Such service brings honour 
 to their profession and deserves the gratitude of 
 mankind. 
 
 What has been said of the influence of the baths- 
 applies equally to the therapeutic exercises, except 
 that retardation of the pulse is not so rapidly effected.
 
 30 THE SCHOTT METHODS OF THE TREATMENT OF 
 
 even though its force and volume be manifestly in- 
 creased ; and that, in the nature of things, it would 
 not be desirable to prolong immersion beyond fifteen 
 or, even in cases of exceptional tolerance, twenty 
 minutes ; while, on the other hand, there are few 
 patients who may not be kept under exercise for half 
 an hour, and some can undergo an hour's treatment 
 without fatigue. There are, therefore, in matters of 
 secondary detail, differences between the baths and 
 the exercises, and it rests with the physician to 
 decide whether one should be brought into requisi- 
 tion to the exclusion of the other, or both be em- 
 ployed at suitable times and intervals. 
 
 As with the baths so with the exercises, therefore, 
 the following immediate results may be looked for in 
 the majority of patients afflicted with a damaged or 
 weakened heart : retardation of the pulse and in- 
 crease of its volume ; contraction of the heart, gene- 
 rally first on the right side (it is rare for the left 
 ventricle not to share in the contraction); slower and 
 deeper breathing, with a sense of lightness and relief 
 in the chest ; a better colour of the lips and improved 
 facial aspect ; and, where that organ is congested, a 
 notable diminution in the dimensions of the liver. 
 Systematic administration of the exercises is generally 
 followed in a few days by marked, and often long 
 maintained, diuresis. 
 
 In the course of the first few movements a bruit, 
 due to stenosis, may be observed to become accen- 
 tuated ; before the series has been completed mur- 
 murs, resulting from valvular incompetence other 
 than that caused by actual lesion, may be diminished, 
 then modified to duplication, and finally obliterated ; 
 heart sounds which were barely to be heard may 
 become distinctly audible ; and an apex beat that
 
 CHRONIC DISEASES OF THE HEART. 31 
 
 could not, under any circumstances, be detected may 
 become appreciable to the touch. 
 
 The increase of the general arterial capacity is not 
 less striking in the case of the exercises than of the 
 baths. Within a few minutes the size of radial 
 artery, as gauged by the touch, may seem to have 
 doubled, and, before the series of movements has 
 been completed, cheeks and fingers that were cold 
 and either white or bluish-red, glow with warmth 
 and healthy colour. The motor nerves, called into 
 orderly, regulated, and, above all, not exhausting 
 activity, seem to exercise centripetal and reflex 
 influences similar to those which are brought into 
 action by the baths through the nerves of sensation. 
 The increased capacity of the vessels, clown to the 
 smallest capillaries, enables the heart so to contract 
 as to empty its cavities at each stroke ; while, at the 
 same time, the ganglia, which control its action, 
 seem to enforce a tonic contraction, which, renewed 
 and maintained from day to day, leads to the establish- 
 ment of a better habit of both function and repair.
 
 CHAPTER IV. 
 
 THE PHYSIOLOGICAL ACTION OF THE BATHS AND 
 EXERCISES. 
 
 It may be well, now, to gather together in brief 
 summary the effects of these simple but remarkable 
 therapeutic agents, and I am favoured with per- 
 mission to do so by quoting the f ollowiug lines from an 
 article by Sir Philip C. Smyly, which appeared in the 
 Dublin Journal of Medical Science (September, 1894): — 
 " Take for example, the four following phe- 
 nomena : — 
 
 1. The colour before 
 the movements is a pur- 
 ple-blue in the cheeks 
 and hands and feet. 
 
 2. The forehead, neck, 
 and ears, etc., are a waxy 
 white. 
 
 3. The pulse is rapid. 
 
 4. The area of dulness 
 over the heart is large. 
 
 1. The colour after 
 twenty minutes or so 
 becomes red, and the 
 blue gradually disappears 
 from the hands and feet. 
 
 2. The forehead, neck, 
 and ears, etc., become 
 pink. 
 
 3. The pulse slows and 
 becomes full. 
 
 4. The area of dulness 
 diminishes at times as 
 much as an inch or more 
 in diameter.
 
 CHRONIC DISEASES OF THE HEART. 33 
 
 These results are due to : — 
 
 1. Increased arterial circulation, due to "the 
 
 diminution of peripheral resistance." * 
 
 2. Diminished venous congestion, due to larger 
 
 quantity of red blood in the arteries. 
 
 3. Diminished work for the heart, due to the 
 
 free circulation of the blood in the arteries. 
 
 there will ever be a feeling against this 
 
 treatment until it is clearly seen and believed to be 
 true : — 
 
 1. That the movements relieve the back pressure 
 
 on the heart. 
 
 2. That the diminution in the size of the heart 
 
 is due to the absence of excess of blood in 
 its cavity. 
 
 3. That this is attained by there being more 
 
 room in the arteries. 
 
 4. That the heart muscle gains strength by 
 
 having room to contract. 
 
 5. That the contraction being more complete, it 
 
 takes a longer time, thus making the pulse 
 slower, and, at the same time, fuller. 
 
 6. Being able to send on more blood it is ready 
 
 to receive more, and thus removes venous 
 congestion. 
 
 7. The strength gained by the heart is due to 
 
 the freedom to contract fully." 
 
 Various suggestions and arguments have from time 
 to time been advanced to show that the diminution of 
 the cardiac dulness, referred to as following on the 
 
 * " Mechano-Therapy," A. Symons. Eccles. Pract. Aug., 1894, 
 p. 114.
 
 34 THE SCHOTT METHODS OF THE TREATMENT OF 
 
 administration of both baths and exercises, either is 
 imaginary, or, if not imaginary, indicative of no 
 actual change in the volume of the heart itself. It 
 has, for example, been asserted that belief in such 
 modifications of the area of dulness must either be 
 due to the influence of preconceived ideas or to defec- 
 tive methods of procedure. Such suggestions have, 
 however, emanated from those whose practical ac- 
 quaintance with the treatment has been very limited, 
 and is contradicted by so overwhelming a consensus 
 of opinion on the part of those who have made 
 observations as extensive as they have been pains- 
 taking, that they need not be further alluded to. 
 
 A more plausible objection is that the diminution 
 of the area of percussion-dulness must be attributed 
 to an increase of pulmonary inflation, and of conse- 
 quent overlapping of the heart. That such is not the 
 case is shown by the fact that the position of the 
 diaphragm either remains unchanged, or if it move, 
 does so in an upward direction. Moreover, the inter- 
 position of a cushion of breathing lung of increased 
 superficies and depth might be expected to muffle tne 
 force of the impact of the apex against the chest wall. 
 The fact that migration in the direction of the mesial 
 line is generally accompanied by accentuation, and 
 in no case by diminution, of the impulse would 
 appear to be of itself a sufficient answer. 
 
 The same reasons traverse the theory that the effect 
 of baths and exercises is to induce rotation of the 
 heart on the basal vessels as a centre, in such a 
 manner as to cause it to present a smaller area to 
 percussion, apart from any actual change of bulk or 
 outline. It is to be observed that no evidence, either 
 actual or presumptive, has been adduced in support 
 of that suggestion; whereas the results of clinical
 
 w 
 
 H 
 
 Cm 
 
 To follow page 34,
 
 Piatt I.
 
 CHRONIC DISEASES OF THE HEART. 35 
 
 observation combine to contradict it. The descent 
 of the apical portion of the heart could only take 
 place in conjunction with a lowering of the average 
 level of the diaphragm, and a corresponding rise of 
 that part of the basal portion of the heart which is 
 situated to the right of the great vessels. ~No such 
 changes have ever been observed to take place. On 
 the other hand, it is quite true that the subsidence of 
 gastric dilatation may cause the heart to assume a 
 lower and more normal position in the thorax ; but, as 
 could be shown by numerous records, the several 
 regions of the heart, under those circumstances, main- 
 tain their relative positions to the vertical middle 
 line of the chest. Happily, however, demonstration 
 of the therapeutic value of these methods is not 
 dependent on the measure of accuracy which may 
 characterise either the theories or the clinical obser- 
 vations of those who carry them into practice. Their 
 warranty is to be found in the life and health of those 
 who have put them to the test, and who not long ago 
 would have found themselves condemned to bear the 
 burden of life on a downward course, with but par- 
 tial and temporary alleviation, until the melancholy 
 end had been reached. 
 
 Before leaving the subject of the cardiac dulness, 
 it may be well to call attention, to the following 
 photographic reproductions of radiograms on a re- 
 duced scale. Those given in Plate I. are placed at my 
 disposal by Prof. Schott. They were taken from a 
 man, forty-four years of age, who, after rheumatic fever 
 and in conjunction with alcoholic excesses, was found 
 to be the subject of mitral insufficiency, dilatation of 
 both ventricles (mainly of the right), commencing 
 arterio-sclerosis, and angina pectoris. A course of 
 exercises brought relief of all his symptoms. Measure- 
 ment of the radiograms of natural size give the fol-
 
 36 THE SCHOTT METHODS OF THE TREATMENT OF 
 
 lowing results as following half-an-hour's resisted 
 exercises : — 
 
 
 Before. 
 
 After. 
 
 At the level of the third rib 
 
 . 15-6 
 
 14-2 centimetres. 
 
 Between the mamillae 
 
 . 19-9 
 
 18-2 
 
 It is interesting to observe that, before the adminis- 
 tration of the exercises, the leaden discs fixed to the 
 mamilhe rose and fell, as the result of dyspnoea, to 
 such a degree as to produce an oval shadow, whereas 
 after their administration the movement was so 
 much reduced that the same discs show a nearly 
 circular outline. It is also noteworthy that, after the 
 exercises, the diaphragm is found to have risen on 
 both sides of the heart, and that there is no evidence 
 of rotation of that organ on the basal vessels. 
 
 The accompanying tracings on paper fixed to the 
 fluorescent screen were made by Mr. Harris, of Cran- 
 brook, and myself, in June, 1898, with the assistance 
 of Mr. Wilson Noble. (See Plate III.) 
 
 The physiological influence of the baths and exer- 
 cises on the organism is very complex, but for the 
 purposes of this notice, which are mainly clinical, 
 they may be considered from three points of view, 
 namely, as they relate more especially to the heart, 
 the vessels, and cell activity or metabolism. On 
 clinical, as well as theoretic grounds, however, it 
 must be premised that, in the more or less co-ordinate 
 action of all three the nervous system plays a primary 
 and, in some respects, predominant part. What may 
 therefore be regarded as the normal influence of 
 these methods of physical treatment may for that 
 reason be favoured, obstructed, or altogether pre- 
 vented by the condition of the nervous system, more 
 especially as regards the store of energy which may 
 be available for response to the various stimuli which
 
 PLATE III. 
 
 The black lines were traced on transparent paper placed on the screen 
 before, and the red lines after, the administration of seven lightly-resisted 
 movements. The patient was between 50 and 60 years of age, was the 
 subject of winter bronchitis, and had a weak and dilated heart. 
 
 £ N/ 
 
 To face fugc :Sli.
 
 CHRONIC DISEASES OF THE HEART. 37 
 
 are brought to bear on it. It has always been recog- 
 nised by those conversant with these methods that 
 they induce an almost immediate increase in the 
 energy of the cardiac systole ; and, at one time, it 
 was the prevalent belief that that result was the 
 immediate and only cause of the increase of the 
 volume of the pulse and of the general arterio- 
 dilatation which are constantly observed to ensue. 
 That view was confirmed by the defects of mano- 
 metric appliances, at the time available, which led to 
 the opinion that the height of the wave in the radial 
 artery, as indicated on the dial, was the measure of 
 the mean blood-pressure. Arterio-dilatation came, 
 therefore, to be regarded as the direct result of an 
 increase of the systolic vis a tergo. But in the 
 earlier editions of this work I pointed out that the 
 tendency to syncope which is observed in some cases 
 when exercises are administered to the subjects of an 
 impediment to the rapid filling of the left heart, more 
 than suggested that a process of vaso-dilatation is 
 initiated independently of the increase of cardiac 
 systole, synchronous with, if not anterior to it, al- 
 though under normal conditions co-ordinate with it. 
 On those grounds I felt justified in advocating the 
 application of the Schott methods to, at least, early 
 cases of aneurysm, especially of the arch of the aorta. 
 Since the introduction of the more reliable instruments 
 of Hill and Barnard, Dr. George Oliver, Potain, 
 Gaertner and others, the occurrence of synchronous 
 or antecedent vaso-dilatation has been brought within 
 the cognisance of several observers, and has received 
 a lucid exposition at the hands, among others, of 
 Dr. J. McGregor Robertson.* 
 
 In considering the influence of therapeutic baths 
 
 * Edinburgh Medical Journal, June and July, 1901.
 
 38 THE SCHOTT METHODS OF THE TREATMENT OF 
 
 and exercises on the circulatory apparatus it is, there- 
 fore, necessary to take into account both increase of 
 cardiac systole and an effort, more or less successful 
 under varying conditions, in the direction of arterio- 
 dilatation ; and, in conjunction with those phenomena, 
 deviations from normal structure and healthy innerva- 
 tion which may interfere with either or both of those 
 physiological reactions. 
 
 Taking it, therefore, as established that both baths 
 and exercises, administered under conditions adapted 
 to each individual case, induce synchronously, or 
 almost synchronously, both arterio-dilatation and a 
 development of the energy of the cardiac muscle, it 
 is necessary to take into consideration the influence of 
 those results on the hydrostatic pressure of the blood ; 
 and the factors which determine that condition may 
 be said to be : The responsive capacity (a) of the 
 nerve mechanism to peripheral stimulation conveyed 
 respectively by cutaneous and muscular excitation (b) 
 of the vascular tunics themselves, and (c) of the myo- 
 cardium to alternations of innervation. These, in their 
 turn, are liable to be influenced by (1) the energy 
 actually in store in the nervous system, (2) the 
 integrity of the vascular tunics especially as bearing 
 on their resilience and elasticity, and (3) the integrity 
 of the myo-cardium as an effective contractile mechan- 
 ism. If those postulates may be accepted it follows 
 that the physiological effect of both baths and exer- 
 cises may be either promoted, delayed, or prevented 
 by the state of the nervous system at the time of 
 administration ; that if the measure of arterio-dilata- 
 tion be in excess of the increase of cardiac energy the 
 blood-pressure will fall ; that if the increment of 
 cardiac energy be in excess of the measure of arterio- 
 dilatation, it will rise ; that, if they be exactly co-
 
 CHRONIC DISEASES OF THE HEART. 39 
 
 ordinated, arterio-dilatation and increase of cardiac 
 energy being exactly balanced, the blood-pressnre will 
 remain unchanged. 
 
 The clinical importance of such considerations could 
 not well be exaggerated, and the successful application 
 of the physical methods of cardiac therapy depends 
 largely on a careful estimate of their respective 
 influences, especially in the earlier stages of treat- 
 ment when the several powers inherent in the 
 organism have reached a point of depression which 
 renders response feeble and tardy, or structural 
 change may have reached the point of partial, 
 temporary, or permanent inhibition. 
 
 If the blood-pressure be unduly lowered, failure 
 of re-action, sense of exhaustion, and depression of 
 spirits will ensue. If, on the other hand, it be un- 
 duly raised, palpitation, headache, and sleeplessness, 
 either singly or in conjunction, may be expected. 
 
 Where such results are due to temporary inco- 
 ordination or weakness of the organism they may 
 often be met, in the one case by rest, food, and heart- 
 stimulants such as digitalis and strychnine ; in the 
 other by vaso-dilators, with or without heart-stimu- 
 lants according to the circumstances of the case, and 
 judicious stimulation of the emunctories, especially of 
 the liver and kidneys. 
 
 It will scarcely be necessary to point out that, other 
 things being equal, the younger the subject, and the 
 less impaired, at any age, the cardio-vascular tissues, 
 the more certain will be the normal physiological re- 
 actions ; and that in proportion as the heart, the 
 blood-vessels, either or both, may have undergone 
 structural change, the forethought and ingenuity of 
 the physician will be taxed to adapt means to the 
 desired end, especially until such time as a certain
 
 40 THE SCHOTT METHODS OF TREATMENT. 
 
 measure of structural change has been effected by the 
 processes of elimination and improved metabolism 
 which these methods are calculated, in many cases, 
 to effect with a rapidity which has not hitherto been 
 attained by other means.
 
 CHAPTEB Y. 
 
 CONDITIONS WHICH GOVERN THE APPLICATION 
 OF THE METHODS. 
 
 Speaking generally, the baths, as compared with the 
 exercises, offer special advantages for the treatment 
 of failure of compensation and of cardio-vascular 
 degeneration, whether or no there be co-existing 
 valvular lesions. But it should be pointed out that 
 in some extreme cases in which either the cardiac 
 condition itself or some dependent, or independently 
 occurring, complication forbids the removal of the 
 patient from his bed, the exercises, modified, if need 
 be, to meet the requirements of the case, may prove 
 to be of value in preparing the patient to undergo 
 treatment by baths, more especially if they should 
 not be easy of access. The exercises, therefore, may 
 be at once brought into use, with or without the 
 more powerful influences of the baths, to meet either 
 failure of compensation or the general condition of 
 those in whom degeneration has not made such 
 advances as must in the nature of things be 
 irreparable. The combined application of the two 
 methods may, in some instances, be expected to yield 
 results which could not be obtained by means of 
 either if employed alone. 
 
 Apart, however, from such general considerations 
 there are conditions, some of which it would be 
 difficult accurately to define, which determine the
 
 42 THE SCHOTT METHODS OF THE TREATMENT OF 
 
 tolerance of either method or of both, and which 
 must be taken into account by the medical attendant 
 in order that the greatest attainable benefit may be 
 secured for the patient. Physiologico-pathological 
 conditions may give valuable indications. For 
 example, distension and labour of the right heart 
 dictate precaution with regard to such measures as 
 are calculated to accelerate the return of the venous 
 blood. The laboured breathing and sense of con- 
 striction in the direction of the epigastrium, which 
 commonly follow the early immersions, and esjDecially 
 the first, are probably, in some degree at least, 
 associated with the effort which is being made to 
 restore due correlation of the pulmonic and systemic 
 circulations. It will therefore be readily understood 
 that, wherever an impediment lies between the two 
 circulations, care and judgment must be exercised ; 
 and it is hardly necessary to observe that such a 
 condition exists in cases of bronchial catarrh, asthma, 
 emphysema, and pulmonary consolidation whatever 
 its cause, as well as where changes have affected the 
 competence or sufficiency of the tricuspid and pul- 
 monic valvular structures. Moreover, the impediment 
 may act backwards, from the left heart, more espe- 
 cially in defect of the aortic valve mechanism. 
 Again, rigidity of the coronary vessels resisting the 
 impulse of an increasing systolic force and of a 
 general stimulus to arterial expansion, may give rise 
 to distress of the anginous order. The exceptional 
 conditions of the cerebral vessels, both arterial and 
 venous, in relation to contractility and adaptability 
 to variations of pressure and volume, constitute a 
 factor which must be taken into consideration with 
 respect to functional disturbance and, in cases of 
 deterioration of structure, to temporary congestion.
 
 CHRONIC DISEASES OF THE HEART. 43 
 
 They also have an important bearing on cerebral 
 anosmia and reparative nutrition, in relation to the 
 power of sustained mental concentration, excitement, 
 depression, and mental conditions generally,* as well 
 as to the repair of lesions. It must not, however, be 
 assumed that such conditions as have been enumerated 
 contra-indicate treatment by the methods under con- 
 sideration. On the contrary, they invite its applica- 
 tion, but only with such careful adaptation and 
 modification as may be indicated in each individual 
 case. 
 
 It remains to take into account the phenomena 
 of physiological reaction, due regard to which is one 
 of the fundamental conditions of successf ul treatment. 
 The temperatures which have been indicated as suit- 
 able for the baths are all below the normal of the 
 human body. It will therefore be understood that it 
 is not the object, and should not be the effect, of the 
 immersion to exercise an influence on the circulation 
 by the exposure of the surface to a heat-communi- 
 cating medium. On the contrary, it is sought to 
 induce and establish therapeutic changes by a 
 course which is precisely the opposite. Indeed it 
 may be said that there is a difference of degree only, 
 and not of kind, between the plunge which a hardy 
 bather takes into freezing water and the careful 
 immersion of a patient in a bath of a temperature a 
 few degrees below that of the body. The question 
 is : In what degree will a subject presenting, amoug 
 other indications, certain morbid conditions, ex- 
 hibit the physiological reactions which determine 
 whether exposure to a cool medium shall be a source 
 
 * In this connection the reader may be referred to communica- 
 tions made to the Lancet by Dr. Maurice Craig and the writer, 
 under the heading of "Blood Pressure in the Insane." June 25th 
 and July 16th, 1898.
 
 44 THE SCHOTT METHODS OF THE TREATMENT OF 
 
 of injury or of well-being ? The reply depends 
 largely on the reserve of power which may at the 
 time be latent in the sanguiferous organs and in the 
 nervous system. Of the two the latter is probably 
 the more important as regards the immediate result ; 
 while the state of the former, more especially with 
 reference to tissue change, which may be irreparable, 
 will largely determine the ultimate issue. 
 
 It has been suggested, in the course of discussions 
 which have from time to time arisen on this subject, 
 that the mineral and gaseous constituents of waters 
 used for balneological purposes are inert as regards 
 the human organism, and can in no way affect the 
 result of immersion. That proposition is so distinctly 
 traversed by balneological experts, as well as by 
 universal experience, more especially as to the differ- 
 ence between fresh and sea water bathing, that it 
 may be dismissed without further comment. The 
 rubefacience they induce bears testimony to the 
 influence which carbonic effervescing waters are 
 capable of exercising on superficial vessels and 
 nerves, and it can scarcely be doubted that such 
 mineral constituents as the chlorides of sodium and 
 calcium produce, to a minor and less apparent extent, 
 a similar cutaneous excitation.* 
 
 A careful estimate of the patient's power of reac- 
 tion, made with due allowance for such modifying 
 local conditions as may exist, will determine, among 
 other things, the temperature and mineral strength 
 of the bath, the duration of the immersion and of 
 the period of rest which must follow it, the number 
 of baths which are to be taken in immediate succes- 
 
 * Since the above was written, Dr. Wilfrid Edgecombe and Dr. 
 William Bain have published observations on the subject. (Lancet, 
 June 10th, 1899, p. 1554.)
 
 CHRONIC DISEASES OF THE HEART. 45 
 
 sion, as well as, later, the shortening or prolongation 
 of the course, and the conditions under which the 
 " after-cure " should be taken. The same considera- 
 tion will, in the administration of the remedial 
 exercises, determine the measure of resistance to 
 be offered, the number of movements to be admin- 
 istered, the intervals to be interposed between each, 
 the posture in which they should be executed, and 
 whether one or more should be omitted in deference 
 to such local conditions as renal or uterine displace- 
 ment and ovarian congestion. It is obvious that the 
 height to which the upper extremities should be 
 raised must be made to bear some relation to the 
 ability of the right heart to receive blood returning 
 with increased volume and pressure from the uplifted 
 arms. 
 
 In order to guard against injury and to ensure 
 success, it is, therefore, necessary that the mind of 
 the medical attendant should be specially directed to 
 the phenomena of action and reaction. The effects 
 of the immersion are to produce contraction of the 
 cutaneous vessels and, in some cases, a consequent 
 sense of cold, followed, after an interval which varies 
 in different individuals and classes of cases, by dilata- 
 tion of those vessels, an afflux of arterial blood, a 
 glow of warmth, and a rise of general temperature of 
 from one-half to one degree Fahrenheit. But it has 
 to be borne in mind that the due sequence of reaction 
 on action demands the exercise of a certain office on 
 the part of the nervous system which can only be 
 performed at the expense of a measure of energy 
 already in store. The importance of these considera- 
 tions will be appreciated when it is remembered that 
 a large proportion of the subjects of chronic affec- 
 tions of the heart are also in greater or less degree
 
 46 THE SCI10TT METHODS OF THE TREATMENT OF 
 
 neurasthenic. It may also be suggested that the 
 stimulus which the therapeutic measures in question 
 are calculated to convey to the heart must be consi- 
 dered in relation to the peripheral vessels, which in 
 so many cases are the seat of degenerative changes 
 involving a loss of conductivity. These may or may 
 not in the end be susceptible to a process of repair, 
 but for the time being render them incapable of 
 transmitting an increased supply of blood, and may, 
 therefore, contribute to such a rise of intra-arterial 
 pressure as would be a source of discomfort or even 
 of danger to the patient. A sudden increase of 
 arterio-capillary capacity, on the other hand, may be 
 a cause of embarrassment to a myocardium which is 
 prevented by structural changes, whether intrinsic 
 or extrinsic, from making an adequate systolic re- 
 sponse. In the former case, flushing, headache, 
 excitement, or insomnia may ensue ; in the latter, 
 a sense of faintness or actual syncope. It cannot, 
 however, be too emphatically stated that the avoid- 
 ance of such drawbacks is within the capacity of the 
 physician who is experienced in the practice of these 
 methods, and that it should be his constant preoccu- 
 pation to forestall their occurrence. 
 
 A good reaction is followed not only by a glow of 
 warmth, but also by a sense of general comfort and 
 of mental composure, which a period of rest in the 
 recumbent position of not less than an hour's duration 
 should increase and confirm. Indeed it may be desir- 
 able to prolong the period of recumbent rest. The 
 experiments of Dr. George Oliver on man, confirmed 
 by those of Mr. Leonard Hill on animals, show 
 that, in the asthenic condition, radial enlargement 
 is favoured by recumbency, as a consequence of 
 the blood not being retained in the legs and the
 
 CHRONIC DISEASES OF THE HEART. 17 
 
 splanchnic area by gravitation. The importance of 
 the part which the maintenance of a good reaction 
 and of the uniform distribution of the blood may 
 play in relieving an incompetent or dilated heart, is 
 manifest. 
 
 Frequently the reaction glow takes place within 
 two or three minutes of immersion. It may not occur 
 until the patient lies down to rest. If it should be 
 delayed beyond a few minutes from that time, it may 
 be desirable to promote it by placing warm bottles 
 near to the extremities, or one or more blankets over 
 the body, and perhaps also by the administration of 
 some warm stimulating fluid. Should such measures 
 not be attended with success, the baths immediately 
 succeeding should be modified as already suggested, 
 and at the same time it would be advisable to 
 inquire into the patient's manner of life in so far as 
 it might affect the expenditure of nervous and mus- 
 cular energy. Among definite symptoms of reaction- 
 failure may be enumerated : a sense of cold through- 
 out the immersion and persisting after it, yawning, 
 and the occurrence of nervous rigor, such as is occa- 
 sionally observed in and after parturition. They are 
 important indications to the medical attendant of the 
 direction in which the treatment should be modified, 
 but they need by no means be accepted as proof that 
 it is inapplicable. Indeed, reaction is a function 
 which can be cultivated into steady and vigorous 
 growth, and become confirmed into an endowment 
 of infinite value to the patient, especially if he be 
 gouty, rheumatic, or subject to frequent chills. 
 
 Enough has been said to show that the practice of 
 these methods should not be lightly undertaken. 
 Their safe and beneficial administration requires a 
 careful adjustment of means to an end, and close
 
 48 THE SCHOTT METHODS OF TREATMENT. 
 
 attention to matters of detail. The novice who sets 
 himself to test their value and to pronounce judg- 
 ment on their efficacy, by experimenting on a few 
 cases, and lighting on such as have been referred to 
 in this chapter, is likely to encounter something more 
 than discouragement, and to come to conclusions as 
 unfavourable as they would be unfounded. It is 
 obvious that to commit such treatment to nurses, 
 however well trained, apart from the exercise of 
 efficient medical direction and supervision, would not 
 be in accordance with recognised medical ethics on 
 the subject of the employment of unqualified assist- 
 ance. That it should be carried out by unqualified 
 persons on their own responsibility would be a grave 
 abuse.
 
 CHAPTER VI. 
 
 CONDITIONS TO WHICH THE METHODS ARE 
 APPLICABLE. 
 
 The value of therapeutic measures which are capable 
 of promptly relieving an over-burdened and labouring 
 heart, without recourse to either general bleeding or 
 dependence on drugs the use of which may sooner 
 or later be attended with toxic or, to say the least, 
 undesired effects, is so obvious that it does not stand 
 in need of elaboration. Once it is recognised that the 
 circulation, arterial, capillary, and venous, systemic 
 and pulmonary, may thereby be stimulated to healthy 
 activity and normal function, and that such health- 
 restoring effects may, under careful and judicious 
 direction, be maintained, progressively increased, and 
 eventually confirmed without injury or drawback to 
 the patient, it must be apparent that they may be 
 applied with advantage to the greater proportion of 
 the affections of the circulatory system, as well as to 
 the relief of troubles which are not commonly con- 
 sidered to be exclusively cardiac in their origin and 
 incidence. 
 
 Prof. Schott affirms that benefit may be expected 
 to accrue in all cases of chronic heart disease, whether 
 of valvular or parietal incidence, except where the 
 myocardium has reached an advanced state of de- 
 generation, or the vessels are the seat of advanced 
 .arterio- sclerosis. I have myself been witness of
 
 50 THE SCHOTT METHODS OF THE TREATMENT OF 
 
 improvement amounting to practical or actual cure in 
 cases presenting the physical signs usually regarded 
 as indicative of the following affections : stenosis of 
 either the aortic or the mitral orifice ; stenosis of 
 both ; incompetence of either or both, with attendant 
 dilatation ; dilatation consequent on myocarditis, on 
 habitual haemorrhage and on constitutional anaemia ; 
 fatty heart ; weakened heart ; congenital mitral 
 insufficiency ; patent foramen ovale ; and angina 
 pectoris of apparently both neurotic and organic 
 causation. It is reasonable to assume that measures 
 calculated to diminish peripheral resistance, and to 
 promote the nutrition and repair of the cardio- 
 vascular tissues, must be applicable to, at least, the 
 early stages of aneurysm of the heart and great 
 vessels. 
 
 The diagnostic and prognostic value of the exer- 
 cises must not be overlooked. Familiarity with 
 the effects which they may be expected to produce 
 on healthy and on weakened walls enables the 
 physician to detect early stages of dilatation, the 
 existence of which it might otherwise be difficult or 
 impossible to recognise. More pronounced dilatation 
 may be readily differentiated from parietal hyper- 
 trophy, superincumbent fat, and pericardial effusion 
 or infiltration. The measure of contraction induced 
 by a few exercises readily discloses whether an 
 abnormal area of dulness is to be attributed to dila- 
 tation or to a substantial mass of unyielding tissue. 
 As regards prognosis, valuable information may be 
 derived from the rate at which preecordial dulness is 
 reduced, and, after a few days, by ascertaining, before 
 the bath or exercises, as the case may be, the amount 
 of more than temporary contraction which has been 
 secured. Lastly, an unsuspected valvular lesion may
 
 CHRONIC DISEASES OF THE HEART. 51 
 
 be betrayed by the development of a bruit while the 
 movements are in progress. 
 
 A question of no secondary importance is : May 
 such recovery of heart-power and efficiency, together 
 with the improvement in the general health which 
 is contemporaneously effected by the systems under 
 consideration, be so enduring as to justify, in the 
 greater number of instances, the return of the patient 
 to the cares and labours of an active life ? From my 
 own observation, and from the testimony of other 
 observers, I am able to reply that such is the 
 case. 
 
 In confirmation of these propositions it may be 
 useful to adduce the evidence of cases illustrative of 
 the effects of treatment in different descriptions of 
 cardio-vascular affection. In so doing it should be 
 premised that, whatever may be the histological con- 
 dition of what is sometimes denominated "weakened 
 heart," it cannot long persist without involving at 
 least some appreciable degree of dilatation, dependent, 
 probably, on softening of structure and loss of resili- 
 ence. The cases are arranged according to physical 
 signs rather than pathological conditions, which, in 
 some cases at least, must in the present state of our 
 knowledge, be matters of inference rather than of 
 certainty. 
 
 Case 1. Weakened Heart. — A lady aged fifty-seven 
 had had fifteen accesses of influenza in about five 
 years, three of which had occurred within the last 
 twelve months. She complained of dyspnoea on 
 exertion and on assuming the recumbent position, 
 which, once set up, often persisted throughout the 
 day or night. The area of dulness was increased 
 to the right and left, and a feeble apex-beat could
 
 52 THE SCHOTT METHODS OF THE TREATMENT OF 
 
 CASE 1. 
 
 Before treatment. Hg. 168 mm.* 
 
 After 4th bath. Hg. 140 mm. 
 
 After 18th bath. Hg. 144 mm. 
 
 After 28th bath. Hg. 150 mm. 
 
 One month after treatment. Hg. 160 mm. 
 
 * The pressure, in this and the following cases, was taken with 
 Hill & Barnard's larger sphygmometer.
 
 CHRONIC DISEASES OF THE HEART. 53 
 
 be felt in the anterior axillary line. The heart- 
 sounds were foetal in character, and a systolic 
 " whiff " was audible at the apex. She had twenty- 
 eight baths, and her weakness was so great that, 
 during the greater part of the course, she kept her 
 bed in the intervals between the baths, which 
 were mostly taken on alternate days. The pulse- 
 pressure, which at the commencement averaged 
 170 mm. Hg., came down to about 140. The area of 
 dulness and the position of the apex- beat returned to 
 normal, and, after a stay of nearly three weeks at 
 Crowborough, the patient returned to London in 
 fairly good health, and was able, with care not to 
 overtax her strength, to lead an ordinary life. In 
 this case the chest was marked with cutaneous 
 angiomatous macules, the significance of which has 
 been alluded to elsewhere.* 
 
 Case 2. Angina sine Dolor e. — A country clergy- 
 man, an old sportsman, seen in October, 1896, then 
 fifty-six years of age. He could not walk more 
 than from 150 to 200 yards without being arrested 
 by precordial distress and a sense of impending 
 death. He had had several accesses of syncope, 
 and, three weeks before coming to London, had 
 fallen unconscious after dinner while being as- 
 sisted upstairs by two of his sons to his bedroom on 
 the first floor. On reaching the room he fainted 
 again. The bowels acted once daily, the stools being 
 consistent and yellow. He suffered from a gnawing 
 sense of hunger before meals. On his coming to 
 London I visited him with one of my bath assistants, 
 and endeavoured to administer two of the arm 
 movements with the lightest resistance ; while he 
 
 * " Cardio -vascular Repair." J. & A. Churchill.
 
 54 THE SCHOTT METHODS OF THE TREATMENT OF 
 
 CASE 2. 
 
 Before and after exercises (2nd day). 
 
 One hour after last bath.
 
 CHRONIC DISEASES OF THE HEART. 55 
 
 was executing the second he fell into our arms, and 
 we laid him unconscious on the sofa. As soon as he 
 regained consciousness we administered slight move- 
 ments of the hands and fingers, while he remained in 
 the recumbent position. These and others I ordered 
 to be repeated for three days still in the same 
 position. On the fourth day I was present when he 
 had his first mineral bath ; it was followed by a good 
 reaction. In three weeks' time he could not be 
 restrained from the enjoyment of walking three and 
 four miles daily. After a course of twenty-eight 
 baths he returned home, and about Christmas time 
 started on a visit to friends in India. In June, 1897, 
 a mutual friend informed me that he was in perfect 
 health, and on the Saturday preceding he had made 
 ninety-eight at the village cricket-match, and on the 
 following day had taken four services single-handed. 
 I heard of him again in July, 1901. He was in 
 excellent health, and fulfilling all his clerical duties, 
 as well as leading the active life of a country 
 gentleman.* 
 
 Case 3. Angina cum Dolor e. — F., set. sixty-three, 
 proprietor of a business in the West-end of London, 
 first seen on the 13th of May, 1898, had suffered 
 for more than five months from acute pain, extend- 
 ing from the preecordium to the left arm, which 
 supervened on all but the smallest exertions. He 
 could not carve at table without bringing it on. 
 Most mornings he had been obliged to stand still 
 for some minutes in the course of a walk of a few 
 hundred yards taken to catch an omnibus, and had 
 been able to proceed at a slow pace only after in- 
 haling amyl nitrite and swallowing a nitro-glycerine 
 
 * This is Case III. reported in " Cardio-vascular Repair."
 
 56 THE SCIIOTT METHODS OF THE TREATMENT OF 
 
 CASE 3. 
 
 Before and after 1st bath. 
 
 Before and after exercises, ten days later, 
 with acute coryza (influenza ?). 
 
 Before and after the last (28th) bath.
 
 CHRONIC DISEASES OF THE HEART, 57 
 
 tabloid. He had been under medical treatment, and 
 advised to dispose of his business. After nine days 
 of preliminary treatment, in the course of which the 
 pulse-pressure fell from 170 mm. Hg. to 130, he 
 commenced a course of baths and exercises. On the 
 27th he reported that he had taken neither tabloid 
 nor inhalation for seven days. Two or three times 
 during the remainder of the treatment recourse was 
 had to those remedies. On July 21st he presented 
 himself, after a stay in the neighbourhood of Malvern, 
 and stated that, a few days after his arrival there, he 
 had walked without discomfort to the top of the 
 Worcestershire Beacon and back, that he had resumed 
 his usual business occupations, and only on rare 
 occasions experienced any reminder of the old sensa- 
 tions. In the January following I saw him two or 
 three times with Dr. Wightwick, in the course of a 
 severe attack of influenza. He made a good recovery, 
 and has since reported himself as being " very well.'' 
 Throughout the treatment, and on his return from the 
 country, the pulse-pressure was found to range from 
 130 to 136 mm. Hg. 
 
 Case 4. Angina cum Dolore. — A man, aged fifty- 
 eight, was examined in September, 1898, by Dr. 
 Lauder Brunton, who favours me with permission to 
 quote as follows from his notes, which were headed 
 "Atheroma:" — "Complains of albumen in urine, 
 from a trace to a cloud. For twenty years has been 
 subject to ' gout.' Acute nephritis fifteen years ago. 
 Attacks, more like rheumatism than gout, lasting 
 three or four months at a time, and presenting no 
 redness and but little swelling. Apex half an inch 
 outside the nipple-line. Loud systolic murmur, subsid-
 
 58 THE SCHOTT METHODS OF THE TREATMENT OF 
 
 ing after recumbent position has been assumed. 
 Urine pale, clear, acid, 1013, thin cloud of albumen." 
 On the 4th of February, 1899, I found the apex- 
 beat half an inch outside the nipple-line. There 
 was no bruit, the pulse was 108 (sitting position), 
 pressure 210 mm. Hg. No albumen. He reported — 
 " August 11th last, rose early to catch a train, having 
 sat up late the previous night. While driving to 
 
 CASE 4. 
 
 February 4th. 
 
 March 17th. 
 
 April 5th. 
 
 the station, a burning pain came on in the region of 
 the heart, and remained very severe for five or six 
 minutes. At the end of the journey, under the 
 influence of some annoyance, the pain became very 
 severe for about ten minutes. The next day, went 
 out after luncheon and shot twelve brace of grouse ; 
 but, after walking about fifty yards up a hill, the pain 
 came on again very severely for ten minutes. Ever
 
 CHRONIC DISEASES OF THE HEART. 59 
 
 since has been subject to a ' catching ' feeling and 
 some burning whenever exertion is made, and cannot 
 walk a hundred yards without bringing it on." 
 
 In conjunction with a course of baths and exercises, 
 he took small doses of iodides, with sodium bicarbonate 
 and liquor bismuthi, and for six consecutive nights 
 gr. i of calomel. By the 17th of March he could 
 walk for one and a half hours without discomfort. He 
 was last seen on the 5th of April, after a fortnight's 
 after-cure at West Malvern, and reported that he had 
 been able to walk to the top of the Worcestershire 
 Beacon without pain or fatigue, but that on one or 
 two occasions he had experienced a suspicion of the 
 old sensations on attempting to take a brisk walk 
 immediately after breakfast. 
 
 In the following tables that referring to the fre- 
 quency of the pulse gives, in the first column, the 
 frequency in the sitting posture, and the second and 
 third the frequency as counted in the quarters 
 of a minute immediately following the act of 
 standing up. 
 
 
 Frequency. 
 
 
 
 
 
 1st 2nd 3rd 
 
 Pressure. 
 
 Body-weight 
 
 
 |m. J m. \ m. 
 
 
 
 st. lbs. 
 
 Feb. 4. 
 
 27 27 27 
 
 210 mm 
 
 Hg. 
 
 13 13 
 
 16. 
 
 16 19 19 
 
 170 „ 
 
 V 
 
 13 10 
 
 27. 
 
 18 19 18 
 
 160 „ 
 
 ,, 
 
 13 8h 
 
 March 10. 
 
 18 19 19 
 
 170 „ 
 
 J! 
 
 13 6| 
 
 „ 17. 
 
 16 18 17 
 
 170 „ 
 
 . 
 
 13 6i 
 
 April 5. 
 
 16 18 17 
 
 160 ,. 
 
 ?) 
 
 13 U 
 
 Case 5. Apex- Systolic Bruit in Mitral Area. — 
 A. man, aged forty (patient of Dr. Lucas, Bury St. 
 Edmunds), had had acute rheumatism in childhood, 
 and twice in manhood. Dr. Lucas had attended 
 for endocardial mischief. For the last six months 
 has been rapidly declining in health and strength,
 
 60 THE SCROTI METHODS OF THE TREATMENT OF 
 
 1st bath, October 22nd, 1897. 
 Before, 
 
 3rd bath, October 25th. 
 Before, 
 
 Exercises, October 28th.
 
 CHRONIC DISEASES OF THE HEART. 
 
 CASE 5. — continued. 
 Before, 
 
 61 
 
 9th bath, November 2nd. 
 Before, 
 
 After, 
 
 15th bath, November loth. 
 Before, 
 
 28th bath, November 28th,
 
 62 THE SCIIOTT METHODS OF THE TREATMENT OF 
 
 with increasing dyspnoea, which now supervenes on 
 the slightest exertion. He entered the room with 
 difficulty, supported by a companion, and with severe 
 dyspnoea and a dusky face. On the 27th of November, 
 1897, he commenced a course of baths and exercises, 
 on the conclusion of which, on the 11th of November, 
 he went to "West Malvern. Shortly before he was to 
 have left that place he was taken with acute bron- 
 chitis, and, as soon as he was able to travel, returned 
 to Bury St. Edmunds. Before the course of treat- 
 ment the apex-beat was If in. outside the nipple- 
 line, and at the conclusion, \ in. On the loth of 
 June in the following year, 1 was favoured by Dr. 
 
 Lucas with the following report: — "When 
 
 returned from Malvern he was suffering considerably 
 from dyspnoea, and his heart appeared to be more 
 irregular. I kept him in bed for a month, and since 
 then he has been better all round. His cardiac 
 dulness is the same as when you last examined him. 
 His heart has undoubtedly maintained the improve- 
 ment which it had undergone from the treatment. 
 He is able to attend to his business, under restrictions. 
 A few weeks ago he underwent one of the severest 
 conceivable of mental shocks. I quite expected that 
 it would have had a very bad effect, but up to the 
 present he does not seem to be any the worse." 
 
 Case 6. Traumatic Lesion of Aortic Valves. — An 
 omnibus driver, aged forty-eight, reported, on the 
 10th of February, 1899, that until six weeks pre- 
 viously he had been in good health, when, on leaving 
 the box after making a great effort to hold up both 
 of his horses, which had slipped at the same moment, 
 he found that he could scarcely walk for shortness 
 of breath. He had remained under medical treatment
 
 CHRONIC DISEASES OF THE HEART. 63 
 
 CASE 6. 
 Before, 
 
 1st bath. 
 Before, 
 
 After, 
 
 Bl 
 
 7th bath. 
 Before. 
 
 IflMU 
 
 After, 
 
 L>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 
 
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