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read to, chatted to, or otherwise amused. Great patience must be exercised: it is only by very slow and small degrees that the heart can regain its strength: remember how little it had to spare before, how tiny its length of "rope"! Remembering this, and perceiving clearly how difficult, how disheartening it is to fight against the grim duress, the lack of courteous give and take, which thickened arteries show, the length of time required is easily understood by us and must, with many repetitions and never-failing gentleness, be constantly impressed upon the patient. From this it follows. that the most important indication is to keep the arteries constantly dilated: first, by scrupulous attention to metabolism, correcting any evil tendency by diet, rhubarb and mercury; next, by temporary vaso-motor dilators, and it must not be forgotten that the dose of these required to dilate thickened vessels is far greater than that needed in the case of healthy ones. But, usually, the heart muscle also requires a tonic. Strychnine is the best; if the pulse be quick and irregular, strophanthus or digitalis may be added, but it must always be guarded by a vaso-motor dilator; nearly always a sedative such as a bromide is desirable.

the following prescription:

Liq. Strychninæ

Tinct. Strophanthi.

Liq. Trinitrini

Sodii Bromidi

Tinct Card. Co.

Aq. ad

Hence we arrive at

m v.

m x.

m ij.

gr. x.

m xxx.

31.

t. d. s. p. c.

With this should be given the calomel and rhubarb pill and, in between each dose, a chocolate tabella containing Liq. Trinitini mj.

The longer I live the more important seems to me to be the rôle played by the cirrhotic kidney in inducing dyspnoea. If there be no albumen in the urine it is often overlooked, especially in women; yet albumen is rarely present continuously in pure renal cirrhosis, and is not seldom absent for a week together; nothing less than estimating the quantity, weight, urea excretion and microscopic findings of 24 hour samples for several consecutive days can give us any certainty

of diagnosis. Here again we have to bear in mind that it is not the morbid anatomy of the organ we desire to know, but the state of its functioning: does the kidney function well? If it do, then it is not the cause of the dyspnoea, though perhaps it may have some fibrosis or other change. But if the renal excretion be deficient, and the deficiency be due to organic degeneration, then we must insist upon our patient now and always living down to the level of his damaged kidneys, so that the waste products of his metabolism never exceed the excretory power of these; this is the fundamental law in renal dyspnoea; if it be not fulfilled other treatment is mere transitory alleviation; your patient will ever be ailing, and lives in danger of serious illness. Should the reduced diet be insufficient to enable him to carry on his life work, this work must be lessened correspondingly; yet it is wonderful how small a quantity of sustenance is requisite for the steady performance of most human occupations.

When once this balance of metabolism and excretion has been adjusted, things will slowly right themselves. So long as it is maintained, the patient is doing more than relieving his dyspnea; he is lessening, if not entirely preventing, the increase of his renal fibrosis- -a far more important matter.

Whatever the organic condition of the arteries, renal cirrhosis is accompanied by more frequent and longer periods of unduly contracted vessels than is the case in healthy individuals; the treatment before mentioned must therefore be put in force-with one note of warning: renal cirrhotics stand courses of mercury badly; the continuous exhibition of the drug for seven days should be your limit, with a corresponding interval of rest.

Strengthening the heart and the induction of diuresis may also be necessary.

I have no space now to discuss cardiac and pulmonary dyspnoeas; nor does it matter, for they are quite another story; their signs and symptoms are more obvious, and their treatment more apparent and less complex. Let my obiter dictum be this―The chief causes of chronic dyspnoea lie below and not above the diaphragm.

ABSTRACTS.

ACUTE RHEUMATIC FEVER AND ITS

ETIOLOGY.

By W. V. SHAW, M.A., M.D. (Oxon.) (Journal of Pathology and Bacteriology, December, 1903).

MANY bacteriologists claim to have found the specific infective agent of acute rheumatic fever, and have held different micro-organisms, and even more than one kind, responsible for the morbid changes. Klebs, Popow, and Netter all associated the disease with an infection by a streptococcus, and Dana isolated a streptococcus from the meninges in a fatal case of rheumatic chorea. In 1891 Achalme found an anaerobic bacillus which he considered the causal agent, and he has been supported in his view by Thiroloix, Bettencourt, and Hewlett. On the other hand, Hiva claims to have demonstrated that a micrococcus is the specific organism, and his opinion has been confirmed by Triboulet and Apert, who found a diplococcus in a series of eleven cases of rheumatic fever. Wassermann, Westphal, and Malkoff have isolated a diplococcus, which grows in chains in a fluid medium, and from a series of animal experiments they consider this to be the specific organism of acute rheumatism. Poynton and Faine investigated eighteen cases of rheumatic fever, and isolated a micrococcus from each, which was very similar to the organism found by Wassermann, and proved its causal connection by a series of animal experiments. Beaton and Ainley Walker have lately investigated fifteen cases of acute rheumatism and have also obtained a similar micrococcus in every case and often in a pure culture. It is with cultures obtained from Wassermann, Poynton, and Walker that the experiments recorded in this paper have been carried out.

After the infective nature of acute rheumatism has been accepted, there are still various views on the actual process of the disease. The bacteriological view is that the disease is a specific one produced by a specific organism. On the other hand, Chvostek, Singer, and others consider that rheumatism is not caused by a specific organism, but is merely an attenuated pyæmia, the exciting cause of which may be any one of the pyogenic cocci. Another view is that an unknown virus is the cause of simple uncomplicated rheumatism, and that a secondary infection with pyogenic cocci produces the cardiovascular lesions.

The author, accepting the view that the organism described by Netter, Triboulet, Wassermann, Poynton and Paine, and Ainley Walker is the specific agent of acute rheumatic fever, shows that by the experimental infection of animals with this organism lesions are produced which closely agree with those of the disease as they appear in the human subject.

Wassermann's "Streptococcus aus Chorea."

This micrococcus was isolated originally from a child suffering from chorea. The organism grows as a streptococcus and is usually smaller than the streptococcus pyogenes. It will grow well on the ordinary nutrient media, but the author found that it grew best on alkaline beef broth and glycerin blood agar. After incubation on blood agar for twenty-four hours at 37 degrees C., small, discrete, colourless, and transparent colonies make their appearance, which in another twenty-four hours become somewhat flattened out, and after still further incubation grow down into the medium. About the second day the blood agar changes from a bright red colour to a dull brown or even greenish tint. This alteration in colour is due to the action of the micrococcus, as was proved by a control experiment; the change in colour only takes place where the organism is actually growing. It does not occur in cultures of the streptococcus pyogenes or of the streptococcus septicemia, and is probably due to acid formation and the reduction of the oxyhemoglobin by the micrococci of rheumatic fever. The micrococcus grows

on peptone agar 1 per cent. alkaline to phenolphthalein, on glycerin agar, and on peptone gelatin; the last medium is not liquefied. It will also grow in milk and broth, neutral to litmus, and in peptone broth 1 per cent. alkaline to phenolphthalein. Of the fluid media a growth is best obtained in glycerin veal broth, and is visible as a flocculent mass after twenty-four hours' incubation, which tends to settle at the bottom of the tube. When grown on solid media the micrococci are about 0.5 to 1 μ in diameter, and form chains with eight to ten cocci in each chain. The individual cocci in these chains are usually arranged in pairs. After incubation for 48 hours at 37 degrees C., the organisms appear as diplobacilli, each bacillus apparently representing an individual pair of cocci. After longer incubation further involution forms are seen, small bacilli of irregular shape, about 2.5 to 3 μ in length, and 0.5 to 1 μ in thickness, arranged in short chains. In the fluid media the chains do not consist of more than six cocci, sometimes grouped as diplococci.

These characteristics also apply to the micrococcus sent to the author by Dr. Ainley Walker and by Dr. F. J. Poynton. The organism isolated by Dr. Walker was obtained from the blood and urine of patients suffering from chorea, endocarditis, subcutaneous nodules, and arthritis, i.e., from patients suffering from acute rheumatism. Dr. Poynton's culture was obtained by incubating the valve from the mitral orifice of the heart in a fatal case of acute rheumatism.

In this paper the author describes in detail his own inoculation experiments on twenty-eight rabbits and two monkeys. For these experiments, cultures forty-eight hours old were used, and the life history of the particular cultures is given in each case. The rabbits were inoculated in various ways, for the injections were made into the veins, joints, and pericardium in different cases; the monkeys were inoculated intravenously.

The result of the innoculations was the production in these animals of all the changes which are found to occur in acute rheumatism. A microscopical examination of the diseased tissue of the infected animals was made in all cases, as well as of the exudations into the joints and pericardium, and in by

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