rest; which means, strictly confined to bed-just
as much as if the case were one of broken thigh.
"Digitalis is to be given in mitral disease, but
withheld in aortic disease," is a rule of thumb driven
into the student's mind like a nail into a plank, by
some teachers. Well, as a broad rule it is well
enough; digitalis is usually of service in mitral
disease; but how about aortic disease? When a
fairly hypertrophied left ventricle is struggling
against a contracted aortic orifice, but not quite
successfully; how about digitalis? The system is
suffering from want of arterial blood because the
ventricle is unequal to driving a sufficiency of blood
through the narrow dostium in the normal time to
keep the arteries full. Here digitalis often acts
most potently, indeed furnishes the most brilliant
illustrations of its properties. By increasing the
vigour of the driving power-the ventricular con-
tractions-the normal amount of blood is pumped
into the arteries in the normal time, and tissue
nutrition is improved everywhere; including the
structures of the heart itself.

There is the respiration! Ordinarily we breathe 18 times per minute or thereabouts. There are about 250 inches of "residual" air in the thorax, and the act of respiration takes place normally about 18 times per minute. By such "tidal” air the "residual" air is kept fairly pure. But when the thoratic space is encroached upon either by (a) air in emphysema; (b) connective tissue in cirrhosis; (c) diminution of the calibre of the air tubes from thickening of the bronchial lining membrane; (d) by engorgement of the bloodvessels in mitral disease; then the respiration must be more frequent in order to keep the residual air fairly pure. The stimulus to respiration is the effect of venous blood, laden with carbonic acid, upon the respiratory centre in the medulla.

When there is an excess of carbonic acid in the blood circulating in this centre, then the respiratory efforts are increased in vigour until the excess of carbonic acid is got rid of. Now, when the right ventricle is embarrassed, it is not usually enough to give digitalis to increase the energy of the conOr aortic regurgitation is dilating the left ventri-tractions of the right ventricle. Though, of course, cle too swiftly for hypertrophy to be built up to arrest the dilating process; what is the value of digitalis here? Simply inestimable. It arrests the dilating process; the ventricle recovers its size, and, with that, much of its vigour; the muscle is better nourished, and then that compensatory hypertrophy is built up which often enables the patient to pursue an active life for years.

Certainly, on the other hand, both in aortic stenosis and aortic regurgitation, while the muscular compensation is complete and sufficient, and the patient is fairly well, there is no good end to be attained by giving digitalis. We do not give digitalis because there is valvular disease present; but when the system is suffering in consequence of the said valvular lesion. The digitalis has no influence on the injured valve. But it is of mighty service when the muscular hyperplasia, which compensates the valvular defect to a great extent, is not provided by the powers of nature. By the aid of digitalis the natural powers will often be enabled to surmount the difficulty and secure a muscular growth, or hypertrophy, which is practically com pensatory. Such compensation by muscular hypertrophy is most perfectly seen in aortic stenosis. And on this hangs the good prognosis of aortic stenosis.

It is quite clear that under these circumstances the action of digitalis is powerfully aided (1) by rest, reducing the demand upon the heart; (2) good food to aid in nutrition of the tissues; and (3) iron as a hæmatic. In mitral disease the effect of digitalis upon the right ventricle often leads to most satisfactory results.

Now, when we come to discuss the effects of digitalis upon the right ventricle, there is something more to be considered than the heart merely.

matter

all medical men of much experience have met
with striking illustrations of the almost magical
effects of digitalis in the pulmonary engorgement
of mitral disease; many can also tell where digitalis
failed to afford relief under these circumstances, or
even increased the respiratory embarrassment.
Now, my rule for sometime past has been under
these circumstances of mitral lesion, no
what form with embarrassed respiration, to give
strychnia, a well recognized "respiratory stimulant."
Here, the effect of digitalis upon the right ventricle,
and that of the strychnia upon the respiratory cen-
tre, work together for good with the most satisfac-
tory results. The good effects of this combination
are conclusively demonstrated in those cases
where digitalis given alone, fails to do good; but
where the addition of strychnia at once makes a
striking alteration. Such a case occurred to me
in Nov. 1881. A medical man had a mitral
stenosis, with pulmonary engorgement, and, from
cold, some congestion of the lung basis. Breathing
was hurried; there was orthopnoea; digitalis had
made him worse. Taking in the position on the
line laid down above, I added strychnia to the
digitalis with the most gratifying results. The
breathing quickly fell in rapidity, and the patient.
could sleep without being awakened by violent
dyspnoea, from the respiratory centre being roused
by excess of carbonic acid in the blood circulating
in it. (After the blood has been cleared of car-
bonic acid by violent respiratory efforts, the patient
drops off to sleep again. Such nocturnal dyspnoea
must be distinguished from the more serious mat-
ter of dyspnoea from distension of the right ventri-
cle-a distinction not always made.) Now, under
these circumstances, the addition of strychnia, or
drug of allied character as ammonia to digitalis, is

is high, then digitalis is pre-eminently useful. When albuminuria is present from venous engorgement in heart failure, digitalis will often be followed by its disappearance. As the arteries are filled, the veins are depleted; the albumen which tells of venous congestion, disappears as this state of the veins is relieved; as the arteries are filled the bulk of urine rises.

of great service. Inversely, when there exists any condition of lung, or bronchiæ by which the respiration is embarrassed, or the thoracic space diminished, then digitalis may be added to the cough mixtures with decided advantage. Whenever the breathing is embarrassed and the radial pulse feeble, while the contractions of the heart are vigorous upon auscultation-a condition which tells that the right side of the heart is labouring- The great matter for the practitioner to rememthen digitalis may be given with a respiratory ber about digitalis is, that it increases the energies stimulant, as ammonia, or nux vomica, or both, to of the ventricular contractions; and that the clinithe great relief of patient. Usually that is; of cal indication for its administration is an empty course, if there be anatomical changes which forbid artery. Remember Rosenstein's maxim, "digitalis real relief, then the effects are less palpable. The fills the arteries and empties the veins." With proper relations of digitalis to stimulants of the such views before his mental vision the practitioner respiratory centre is a matter far from being under-will rarely experience any difficulty in deciding stood generally.

The indication, then, for digitalis is not a murmer in the heart; nor a certain form of valvular lesion; nor tumultuous action; nor yet rapidity of action; but, as Rosenstein has put it, whenever it is desirable "to fill the arteries and empty the veins." That is the impression which each student of medicine should form in his mind as to the action of digitalis. If he would do so, the doubts which otherwise may beset his mind in the exigencies of practice will not often embarrass him. Say it is a case of regurgitation; if the arterial system is well filled then digitalis is contra-indicated. But if the wall of the heart be yielding in the latter stages, then surely it ought to be given. In almost all stages of mitral lesion digitalis is indicated. But there is another condition in which digitalis is sometimes given with injurious effects which contrasts with these conditions. The hypertrophied gouty heart often palpitates when there is arteriole spasm, and the larger arteries are tense and full of blood. The resistance offered by this full arterial system to the onward flow of the blood at the cardiac systole is such that the ventricle palpitates in its efforts to contract effectually-such a condition is commonly seen in the "chronic Bright's disease without albuminuria," so well described by Dr. Mahomed. Here digitalis does no good but harm; for the arteries are already full to the risk of apoplexy. Indeed, this last accident has followed the administration of digitalis under these circumstances. The full artery, then, is contraindication. Just as much as an empty artery is an indication for the administration of digitalis,whether the heart be diseased or not.

Digitalis is a diuretic, says another. "Whenever the bulk of urine rises then I know that digitalis is doing good." The bulk of urine, as Traube taught, is the index of arterial fulness. When the arteries are filled the bulk of urine is increased. The rise in the bulk of urine tells in the most unmistakable manner that the action of the drug is filling the arteries. In dropsy, when the bulk of urine is low, and the specific gravity

when to give, or when to withhold the potent digiitalis-potent for good or harm according to the circumstances under which it is prescribed. In cases of cerebral anæmia digitalis may often be prescribed with advantage when it is desirable to raise the blood pressure within the arteries.— Glas. Med. Four., Dec.

CIRRHOSIS OF THE LIVER.

CLINIC, BY JAMES TYSON, M.D., PHILADELPHIA.

I have recently been showing you some cases of disease of the liver, and to-day I bring before you another of the same class. Our patient is 38 years old, is a tin-roofer by trade, and was admitted to the house September 27. He had always been healthy, but for the last four or five years has been what might be called a hard drinker, frequently going on sprees. For six weeks previous to his admission he had been drinking steadily. On the morning of the day on which he was admitted, he had a very profuse hemorrhage from the nose, and that night he had a second hemorrhage, which was checked only by packing the nostrils with tannic acid. He also had some nausea and loss of appetite. The second day after his admission (September 29), he noticed his limbs were swelling, but an examination of his urine revealed nothing abnormal. About the same time his abdomen began to enlarge. You can all see to what extent this enlargement has taken place, and by placing my hand on one side of the abdomen, and gently tapping the other side, I get distinct fluctuation, showing distinctly the presence of fluid. what conditions will cause the presence of fluid in the abdominal cavity? First, we have obstructive disease of the heart, which, by overloading the venous system, causes the watery elements of the blood to exude through the walls of the vessels. An examination of this man's heart fails to reveal any lesion; so we can exclude this. In the second place, it may be caused by renal dis

Now,

ease.

But if there be any disorder of the kidney of sufficient gravity to produce the amount of ascites present in this man, it would undoubtedly produce albuminuria; and we have failed to find any albumen in this man's urine. Excluding these two, then, narrows it down to the third-i. e., some interference with the portal circulation. Let us examine the liver and see if we can detect any alteration in it.

Having the patient on his back, percussing in the mammillary line, we find that dulness begins at the fifth rib and extends to the edge of the ribs. In the line of the ensiform cartilage there is tympany all the way from it to the umbilicus. In the mid-axillary line, dulness begins at the seventh in terspace, and passes without interruption into the dulness occasioned by the ascites. In percussing the liver you will find it to be more easily mapped out by having the patient lie on the left side and draw up his thighs towards his abdomen; and I will now percuss him in that position. Going back to the mammillary line, we find dulness begins at the sixth rib and is replaced by tympany at the eighth rib. In the mid-axillary line dulness begins at the seventh rib and is replaced by tympany at the tenth rib. Posteriorly, dulness begins with the tenth rib and merges into that of the lumbar muscles. By this examination you perceive the liver is smaller than normal.

may generally, with very good reason, be attributed to congenital syphilis.

Let us pause to consider briefly the morbid anatomy of the affection. In this case the cirrhosis is evidently due to alcohol. In the excessive use of this substance the liver is the first organ to suffer organically, because the alcohol reaches it immediately after its absorption, in a comparatively unaltered state, and diluted only by the secretions of the stomach. Acting as an irritant, if long continued it soon excites an overgrowth of the conective tissue along the ramifications of the portal vein. The first product is a round-celled embryonic tissue, by the presence of which the bulk of the liver is actually increased; but, organizing into fibrillated connective tissue, it has the property of all such new-formed tissue, it contracts, and compresses the proper parenchyma of the organ,―that is, the cells, and destroys them. When the circlets formed by the smaller branches of the portal vein are involved, the areas included in them are compressed and forced to rise upward, forming grain-like elevations, whence the term "granular liver." When branches of medium size are involved, larger areas of liver-substance are compressed, and elevations, of which many correspond in size to the hob-nail, are produced, and there results the so-called "hob nail" liver; and when still larger branches of the portal vein are involved, we have even larger bulging areas, and a “lobulated" appearance results.

As to the treatment, I am confident that small degrees of interstitial hepatitis may be removed by appropriate measures; and even where the overgrowth of interstitial tissue is decided, the process may be so modified that the liver will be able to perform its offices. Most important, however, is the removal of the cause; and where this is the excessive use of alcohol it must be discontinued if any results are to be expected.

Now, what diseases are there in which the liver is smaller than in health? I can recall but one,— cirrhosis, or interstitial hepatitis. Let us now take up this man's symptoms, and see wherein they accord with the phenomena of this affection. The first thing that he noticed was the hemorrhage from the nose, and I called your attention to this symptom. What was the cause of it? It was entirely mechanical. The blocking up of the portal system causes engorgement of the veins all over the body, and the hemorrhage from the nose was simply an effort of nature to relieve the engorgement. Hemorrhage iuto the stomach and intestines is a more frequent symptom, and is even more directly accounted for. Next there is the ascites. We have seen that the liver is smaller than normal, and this contraction must necessarily compress the vessels which pass through its sub-in a small quantity of water after meals. Along with stance. As a result of this, the current of the blood is retarded, and the serum exudes through the vessel-walls, producing the ascites.

The remedy for the removal of the hyperplastic connective tissue is pre-eminently iodide of potassium. It is best given in moderate doses while fasting, and in a large quantity of water. Two and a half grains in a tumblerful of water and on an empty stomach will do more good than five grains

this, the bowels must be kept active with salines. If there be any specific taint, one-thirty-second to one-twenty-fourth of a grain of bichloride of mercury may be given along with the iodide, three times a day. In malarial cases iron and arsenic are indicated. Counter-irritation over the region

of the liver may be produced by an ointment made of equal parts of mercurial and belladonna oint

Let us for a few moments consider the etiology of the disease. It is an error to regard the use of alcohol as the only cause of cirrhosis. In the vast majority of cases it doubtless is the cause; but I have seen cirrhosis in childreen two or three years of age and in young men of twenty; and Dr. Har-ments. ley, in his recent work on the liver, refers to such cases (p. 307). The use of liquor, syphilis, and a prolonged exposure to malarial influences will produce it. When seen in very young subjects, it

In this patient the treatment has been five grains iodide of potassium, largely diluted, three times a day, fasting, and his bowels have been kept freely open by the administration of salines. He has greatly improved under this treat

ment, and says that he is very much better. There "I do not claim that we can perfectly cure aneurism

is still, however, some fluid in the peritoneal sac, which had much better be removed by tapping; and I had intended to tap him in your presence, but he objects to the operation, and I will not insist upon it. He will improve much more slowly than if this water were taken away.-Medical Times.

by iodide-of-potassium, or by anything else, yet I am quite certain that at the present day we possess no other remedial agent or mode of treatment which so surely gives relief, and so frequently prolongs life, as the iodide-of-potassium."-Louisville Med. News.

HYSTERO-TRACHELORRHAPHY.-Dr. Herrick, of DISEASES OF THE HEART.-BALFOUR-In lec- Grand Rapids, Mich., gives the following in the ture ix, on the variation and vanishing of cardiac Obstetric Gazette:-In 1880 I reported for the murmers, Dr. Balfour offers a good deal of sound Philadelphia Medical and Surgical Reporter, vol. advice to practitioners, many of whom, he very XLII, No. 3, a "modification of Emmet's operajustly remarks, are not at all aware how frequently tion" which had for its object the doing away of complete restoration to health may follow after sutures through the uterine mucous membrane, perfect developement of regurgitation through claiming that they were unnecessary, as good union either, or even through both valves. The curious could be had without them, thus saving the patient phenomenon of variation in the same murmur, much pain, and the operator no little trouble; which may completely disappear one day to be and making professional assistance not absolutely present again the next, and the failure to appreciate necessary, as the patient could be operated upon its significance, have sometimes led to erroneous without being etherized. As the introduction of and embarrassing statements of opinion of the sutures is the most tedious step of the operation, most contradictory nature. Ferceiving the great it is also the most painful to the patient, and is the desirability, therefore, of avoiding this confusion, only part requiring special skill. The modification Dr. Balfour gives directions for conducting a thor- in brief is as follows: The lacerated edges of the ough examination of the heart in such a manner cervix are denuded as usual, care being taken as shall prevent all possibility of deception being that they are properly coaptated; then, instead of caused by such murmurs, and during which the introducing sutures, a wide elastic rubber band stethoscope need not be employed at all. "If we shaped like the cervix, and large enough to cover trust," he urges, "to ascultation alone, as it is the whole os and neck with the exception of a hole generally understood and applied to the heart-in the end for the secretions to pass through, is that is, if we attempt to diagnosticate the exact slipped over the os while the lacerated edges are nature of any given cardiac lesion by the discovery held together by a pair of tenaculum forceps, over and discrimination of murmurs, assigning to each its appropriate physical cause in accordance with its position on the cardiac area at which it is best heard, as well as with its rhythm or relation in time to the several acts which constitute a cardiac pulsation, without being actually misled we shall yet often fail in attaining an accuracy of diagnosis which is perfectly possible and frequently important." The value of strychnia as a stimulant of the intrinsic ganglia is pointed out, and a strong defence of arsenic as a neurotic is presented. Dr. Balfour, moreover, insists that no drug can replace digitalis in the treatment of cardiac disease, and places little trust in ergot and belladonna in this connection, The iodide-of-potassium treatment of aneurism Dr. Balfour considers perfectly safe and free from risk, while being equally certain as any more dangerous plan to afford relief. He has "not yet seen any case where relief was not attained, though naturally enough that relief is not always to be got instantaneously, but requires the treatment to be continued some time." He, however, warns against expecting absolute cure, or indeed anything more substantial than relief, except in favorable cases which come early under treatment, and in which adjuvant treatment, such as rest, etc., can be carried out. Dr. Balfour says:

which the band is first passed. The band being wide and covering the whole neck, it keeps up equal pressure on the blood vessels, thus preventing blood enough getting into the parts at any one time to produce inflammation or swelling, and, as a natural sequence, union takes place much sooner than it otherwise would. The introduction of sutures is quite often followed by inflammation, and when suppuration follows there is non-union, which is prevented by the use of the elastic band. The advantages of this method are: 1st. As about all the pain experienced during the operation is from the introduction of sutures, if they are not introduced there is little pain, and hence an anesthetic may be dispensed with. 2nd. If the patient is not etherized it is not necessary to have professional assistance, and one can operate upon patients that would not listen to such a proposition if strange physicians were to be present. 3rd. The parts are kept in just as close contact, and union takes place just as soon. 4th. There is less danger of inflammation. 5th. There are no stitches to remove. 6th. In light cases, patients can be operated on without their being obliged to keep their beds for a single day, or their knowing that they are undergoing any important operation. Since the publication of this method of operating