and gentle diffusible stimulants, with warm applications applied to the surface, would soon restore him to comparative comfort.

Climate affects this patient very little, although a high altitude is not to be advised on account of its temporary adverse effect on the patient, and contributes nothing except indirectly by building up the general system.

In the management of compensated valvular disease, the physician conducts a defensive campaign, so to speak, whereas when compensation has failed, he is called in to wage an active offensive warfare against all those forces that are striving to destroy the patient.

The attention to the details of daily life and complications, however trivial, are just as necessary in this class as the former. The proper management of these cases consists in much more than the administration of heart tonics or other medical remedies. An even life, with special care as to the digestion, so that toxines are not generated to disturb blood pressure should be strongly urged. The exercise as advised in the first class should be interdicted except in homeopathic doses.

Here the same restrictions are not placed in medicines. In this case, digitalis, or one of its congeners, unless contraindicated, by certain conditions as will hereinafter be mentioned, is generally of great service and indispensable.

Strychnine sulphate, one of the best of heart tonics, should not be given with over confidence. In other words, on account of its mode of action-stimulating the organ through the cardiac motor ganglia,-it should not be given continuously in heroic doses, for it is likely to produce short and irritable systoles instead of long and strong contractions of the ventricles which are required to drive the blood along energetically. In fact, this matter of small dosage applies alike to both strychnine and digitalis.

The nitrates, Hoffman's anodyn and glonoin, act well in these cases, even if we give digitalis. They act especially well in aortic regurgitation; these agents remove vascular tension by flooding the capillaries, and leaving the venous system engorged; which, in turn, should be relieved by depletants and cathartics.

The same principles apply to the third class where compensation is entirely lost.

If all that was needed in these cases was to increase the driving power of the ventricles, digitalis would be the remedy par excellence.

In these valvular diseases, however, we can not be unmindful of the fact that there is an impediment to the flow of veneres, that is, of the return blood through the lungs and heart. Behind this impediment the circulation becomes dammed up; then the surest and only way of preventing inundation is to unload by blood letting, or remove some of the water of the blood through the intestines. When this has been accomplished, then and not till then, do we find the rationale of the heart tonics. Even with the field clear, unless there is rapid failure, stimulants should be given with hesitancy, for pounding of the already wounded valves will extend the mischief not to say anything of whipping up tired muscles, which have their limit of endurance. This argues for absolute and continued rest. When at rest active muscular movements are abolished and respiration is less rapid and more shallow. Venous blood is delivered to the right auricle less rapidly and the right ventricle is given less work to do. Cardiac contractions become less frequent but more efficient and the chambers are better able to empty themselves.

Medicines that are of positive value are all those that facilitate the better digestion of food and lessen the likelihood of gastro-intestinal fermentation. These are pepsin, pancreatin, taka-diastaste, hydrochloric acid, and the various antiseptic remedies such as salol, salophen, etc. Most heart diseases are best treated when the diseases to which they are secondary are treated, as for instance acute endocarditis, superinduced by articular rheumatism.

Cases of large weak heart that seek treatment on account of dyspnoea, precordial distress, cardiac asthma, or subjective disturbance of rythm; need treatment usually back of the immediate cause of the hypo-or hyper-distension, which may be obtained only by the sphygmomanometer.

On account of the lamentable tendency of the profession to use digitalis in every case of heart trouble there is small wonder that it played a conspicuous part in the discussions of the last American Medical Association.

Its efficacy has probably not been overrated, but its application has been too common in valvular lesions or, more properly speaking, its misapplication has been too common. I am quite sure that the indefinite and promiscuous administration of the drug is responsible for the complaint on the part of some doctors as to its inefficiency, notwithstanding the disagreement extant as to the physiological action of the drug; the most

thorough investigators agree that (1) digitalis has influence. on the cardio-inhibitory system. (2) It has power to raise blood pressure and increase the energy of the heart's contractions.

There is no doubt that digitalis employed in mitral regurgitation with symptoms of loss of compensation is often an extremely helpful and satisfactory drug. On the other hand, any one who has seen the uncomfortable effects of digitalis in cases of aortic regurgitation, with left ventricle hypertrophy, especially where people are allowed to be up and on their feet, will realize how much harm can be done by its use in heart disease without proper selection of the cases.

The typical cases in which digitalis does good, according to the consensus of opinion of those who took part in the discussion at Atlantic City, are those suffering from chronic mitral endocorditis due to rheumatism. In these cases, if both the aortic and mitral valves have become affected, as sometimes happens, then digitalis does good, notwithstanding the fact that in simple aortic regurgitation, it is usually contraindicted. Whenever there are sclerotic changes present in the arteries which is most always the case in aortic disease, then digitalis is contraindicated.

In stenotic conditions at the various valves and where there is immovable obstruction in the pulmonic circulation, it is pernicious. This is especially the case with aortic stenosis, as the increased action of the left ventricle produced by digitalis when exercised in the direction of the already blocked path through which all the blood in the body passes about twice a minute, is sure to produce over distension of the cavity with rapid degenerative changes rather than hypertrophy. The same reasoning applies to mitral stenosis where the dilatation. would be more rapid on account of the auricular fibres being less capable of hypertrophy. While stress has been laid upon the fact that high blood pressure or hypertension contra indicates the use of digitalis, it is just as important to invite its use in hypotension. The latter condition is serious to the heart because loss of vaso-motor tone soon leads to death, for the ventricles discharge their contents into the flaccid arteries and receive less and less blood from the relaxed veins.

In general it may be said, however, that the most important factor in the therapeutics of heart disease, whether we use. digitalis or not, is rest.

It would be unfair practice to administer digitalis freely to patients going about and using practically all the strength they have when they should be resting quietly in bed and giving their heart the indispensable opportunity to recuperate after the strain and overwork which caused the break in compensation. For the sake of comfort and long life, I say give the heart

rest.

HIP-JOINT COMPLICATIONS IN TYPHOID FEVER.

BY MCLEAN PITTS, M. D.,OF SELMA.

Member of The Medical Association of the State of Alabama.

In bringing this subject for your consideration, I desire to report a case which recently came under my observation and to bring out a few points of special interest. Then I wish to call your attention to a few cases reported from different sections of the country and what some of our leading authorities have to say on this subject.

Lillian, white, age nine years. Was placed under my care on the 30th day of June, 1904, in the 29th day of her sickness with typhoid fever. Her temperature was running a regular course, ranging from 101 2-5 F. to 103 2-5 F. After a thorough examination, I confirmed the diagnosis of typhoid fever. She was also suffering with a neuritis involving the nerves of both limbs which proved very painful.

I had her sent to the Selma Infirmary, where she received every care and attention. After about four weeks the temperature was normal, and there was every indication of a complete and rapid recovery. In due time she was up and going around the hospital, showing no symptoms of future trouble. Two weeks after the temperature became normal, she had a rise of temperature and a return of the neuritis. The pain was not as severe, nor was the temperature as high as in the first attack. She ran this temperature about two weeks, and then seemed to make a nice recovery. She was up in a chair and commenced going around the hospital. She was weak, but

could walk with assistance and showed no symptoms of the trouble that was so soon to make its appearance.

She lived about fifty miles from Selma. Her people were anxious to take her home, and I consented. I examined her thoroughly two or three days before she left hospital, and to all appearances, she needed only time to gain her strength. I saw her the day before she left hospital and she was bright and cheerful. About two weeks after she went home, her brother told me that the local physician had examined her, and was of the opinion that her right hip was displaced. I told him to bring her back to me at once so that I could examine her. The next day her father brought her to Selma, and at a glance I could see that there was some hip joint complication. 1 requested Drs. Furniss and Gay to examine her with me. We found a backward and upward displacement of the head of the femur, and advised her to return to the hospital. Her father consented. She was carried to the hospital and placed under an anaesthetic. Great difficulty was found in reduction, and we had to resort to the Lorenz method. After reduction, we found that the least movement would cause the head of femur to leave the acetabulum. It was then decided to flex and rotate outward the limb, and to hold it in this position by plaster. This we intended to remain about three months, but on second day we had to cut the plaster on account of swelling, due to manipulation of the Lorenz method. On sixth day, . another plaster, more heavily padded, was applied.

The patient remained in the hospital for five weeks, and with the use of an extension shoe and crutch, she could get around very well. This plaster remained, (I am informed), one week after the patient's return home. I have seen her once since the removal of the last plaster. She had fleshened very much, was enjoying good health and could walk well without the assistance of stick or crutch. When she walked any distance, she used the crutch, as the use of this prevented her becoming tired. The only difference that I could notice was that the involved limb was about a half inch longer than the other, and the foot of the affected side was rotated outward.

I have seen her father several times since, and he tells me she is going about all the time without assistance, and is apparently perfectly well. He says that the involved limb is a little longer than the other. This I attribute to one of two things. Either the child is in the habit of bending a little to the other side; or, the acetabulum is partly filled and the head