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. 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P . c • ^ P . - ?. 1 ****** -ll^H 2 3 9 „ .. . -H'S * 5m c 2 ° -JJ pH (y -rT'P C — bC -t? f- © - XO -XCF-nOX 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 Unwin Brothers. 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