underlying cause, treatment will be vain. As soon, however, as the fact is recognized that the source of the trouble is a circulatory disturbance, then the application of the proper remedy will very rapidly afford relief.

The transference of intravascular pressure from the arterial to the venous side of the circulation necessarily results in diminished secretion of all the glandular organs involved in the process of digestion; the salivary, gastric, intestinal, pancreatic and hepatic secretions being diminished, there results a host of symptoms depending upon this impairment of secretion. A deficiency of bile intensifies the results of the diminished flow from the gastric glands, hence there are putrefaction, accumulation of gases, constipation, foul-smelling stools, epigastric pains, sero-mucous diarrhea, jaundice and a number of other symptoms, due to chronic catarrhal conditions of the entire gastro-intestinal canal and all of the glandular organs connected therewith. As a result of such persistent turgescence of the liver and spleen, we may have contraction of the connective tissues and subsequent destruction of the secreting cells, but this is not usually the common result in cardiac congestion; more frequently the hypertrophy is permanent.

In those very common cases where we have contracted kidneys associated with heart disease, most generally both the cardiac and kidney disease is due to the same cause, i. e., artero-sclerosis.

The rationale of jaundice in such cases should receive special mention, the congestion of the bile ducts extending into the ductus communis choledicus, producing complete obstruction and consequent jaundice. The skin has a greenish hue in such cases, due to combination of the congested skin with the yellow, due to bile pigment serving to produce this peculiar appearance.

It is astonishing to the uninitiated to see how rapidly all these symptoms will disappear upon the administration of sufficient doses of digitalis to overcome the obstruction of the circulation by stimulating the left ventricle to efficient contraction.

The action of the kidneys also affords a very sensitive test as to

arterial pressure. There are no organs in the body whose secretion is more rapidly influenced by the activity of the circulation than the kidneys.

The venous congestion resulting from heart disease acts mechanically upon the renal cells by facilitating the press of albuminous transudation; therefore, diminished amount of urine of normal or high specific gravity, with a small amount of albumin, is very significant of heart disease, because such condition of the urine is not found in any independent form of kidney disease of serious extent. Under the careful administration of digitalis or other heart tonics, the urine will very rapidly increase in quantity, the albumin will disappear, and what was supposed to have been a very serious renal disease will prove to have been dependent altogether upon cardiac causes.

Menorrhagia is not infrequently another result dependent upon disturbed circulation, due to cardiac weakness, and instead of treating the uterus in such cases, the trouble will be remedied by prompt attention to the central cause, namely, the heart.

The brain is another organ affected by cardiac weakness, resulting in defective aortic pressure, hence we may have sharp apoplectic or epileptiform seizures and attacks of threatened or actual syncope, tinnitus aurium, flashes of light across the field of vision, flushing of an ordinarily pale face. These are symptoms of cardiac weakness of common occurrence, especially in aortic regurgitation. Such symptoms attended usually by an apparently full and bounding pulse are often referred to cerebral congestion, treated by leeches or venesection, producing a weakening of the heart, the debilitated condition of which was the sole cause of symptoms mentioned. It is only by rectifying the central lesion, as far as possible, that we may expect to remedy the peripheral phenomena dependent upon it.

It is hardly necessary for me to say that no originality whatever is claimed for these remarks. It has been my intention only to emphasize the significance and importance of the subject. I cheerfully acknowledge my indebtedness to two works by an eminent author, viz. Dr. Geo. Wm. Balfour, of Edinburgh, in his "Clinical

Lectures on Diseases of the Heart," and on the "Senile Heart." Both of these works have been a source of inspiration to me in practice and in the teaching of clinical medicine.

DISCUSSION.

DR. H. W. CROUSE, Victoria: There are three remedies that I should like to mention, one of which gave me marked results in the treatment of a little child three years of age, suffering with mitral regurgitation, who was sent to the coast from Denver, Colorado, to die. The child had been attacked with rheumatism several months before, and had developed a cardiac lesion, secondary to rheumatism. He had been treated with the usual remedies, the final ones being the use of digitalin and strychnia. After observing the case for a matter of a week, permitting the treatment to be carried out as outlined by his previous physician, Dr. Whitney, of Denver, I decided upon the use of tincture of nerium oleander as put up by Merck. Whittaker advises the use of this tincture in two-drop doses in a five-year-old child, three times per day. I gave it in an aqueous solution with a minute dose of nitro-glycerine. The result was that in about two weeks the intense dropsical condition had markedly improved, the gastric irritation had practically disappeared, and the impoverished systemic stage was shown to be changing through the improvement in the appearance of the hair and skin. Strychnia was used, as a tonic, in the proper doses. Compensation was allowed to take place, and the child in a few weeks was seemingly convalescent. Instead of being compelled to carry it about on a pillow and to worry with it through the night, it was sleeping regularly, with a hearty appetite, stools improved and a general condition of well-being. In order to prove that the treatment was the one which had given the benefit, not climate, I stopped the use of the nerium oleander for a week, and the faulty conditions previously existing returned rapidly. The oleander was recommenced, and the case again improved. This test was carried out two or three times. I have been convinced in handling heart cases that digitalin and digitoxin are two remedies not to be relied upon. It is difficult to state, as Merck remarks in his “Archives," when we have a specimen of the drug that is not inert. In other words, that, while prepared the same way each time, frequently an inert alkaloid will be secured in either form. The two other remedies that I wish to call your attention to are the fluid extract of cactus grandiflora and the tincture of convallaria majalis. These latter two, used in adult doses, where we have mitral regurgitation, cardiac hypertrophy, hepatic enlargement and interstitial changes in the kidneys, will give you good results; provided that you use them in an aqueous solution, ten drops of each per dose, accom

panied by the hundredth of a grain of nitro-glycerine, given every three or four hours, at first, for a few days, lengthening out the interval gradually, then stopping for a day or two, and recommencing the drugs at the point you left off. It is essential, of course, to accompany any of these cardiac remedies with the proper hepatic stimulant. The mild chloride of mercury or hydrargyri pilulæ mass are the proper remedies. The case which I have mentioned to you permitted, through the use of nerium oleander, time for proper compensation to take place in the heart. I believe that with all of these cases diet is an essential feature; also that we should utilize the milk diet, either skimmed, buttermilk or the plain sweet milk, instead of any other food. In conditions where we have acute cardiac dilatation-practically a cardiac apoplectic condition existing-the old phlebotomy method of free bleeding will give us marked results, the cyanotic condition will be relieved, the difficult respiration will improve, and the unconsciousness will disappear. In other words, if we will but return at times to the treatment pursued by our fathers we will secure results that can not be obtained in any other way. I have called the attention of several men who have been treating cases of cardiac lesion, and have told them about the use of the nerium oleander. If you will take the “Twentieth Century Practice of Medicine," and read Whittaker upon the treatment of valvular lesions, the full data will be secured to prepare you to handle this remedy properly. All to whom I have called the attention of this remedy have been pleased with it. This preparation requires some carbolic acid to preserve it, say two drops to every three-ounce mixture. You can secure the product from Merck.

DR. FRANK PASCHAL, San Antonio: Did Dr. Crouse think of the possibility that the change from the high altitude of Denver, Colorado, to the sea level might not have influenced the condition of the heart as much as the remedy that he employed?

DR. CROUSE: I thought so at first, doctor, until I had come in contact with several other mitral cases that had developed upon the coast. In these cases I tried the nerium oleander in the proper doses, and, at the expiration of a few weeks, had secured as good results as in the first case in which I had used it. I believe by the tests that I gave tincture of nerium oleander in the first case—in other words, taking the patient off the remedy for a week and returning him to it, then testing it again, and finding that when the drug had been stopped that the case declined, and when recommend that improvement took place-proves conclusively the merit of the remedy. Fifteen cases to my knowledge have been treated by this remedy so far in Victoria, in all of which good results have been secured.

DR. W. B. COLLINS, Lovelady: I want to say that in this condition it has become a routine practice with me to employ digitalis, combined with bitartrate potash. I also employ reconstructive tonics, etc. Digitalis, in my judgment, gives as good or better results upon the heart in this condition than any other drug at our command.

DR. H. A. WEST, in closing, said: I have very little to say in closing the discussion upon this subject, except a few words in regard to the use of digitalis. In my opinion, this drug is superior to any other in cases where there is a failure of cardiac compensation. The man who understands how to use this great remedy truly has the sword of the Lord and of Gideon in his hand. With proper administration, in sufficient doses, and with a pure and fresh drug the results are sure to follow. I remember on one occasion where I consulted Dr. Janeway, of New York, upon this subject in a case in my own family, in which, of course, I was deeply interested. His statement confirmed the opinion I have just given as to the superiority of digitalis over all of its congeners. It should be borne in mind that the digitalis leaves found in many drug stores are in many instances inert. By the use of the fresh English leaves in preparing the infusion, or the prescription of Squibb's tincture or of Merck's digitalin in proper doses, you are sure to get good results. Merck's digitalin has an important place where the stomach is irritable, and can be used in much larger doses than that ordinarily laid down in the text-books. I have given this hypodermically in doses of as much as one-thirtieth of a grain, and with good results.