cardiac diseases in general is this, that the more nearly normal the muscular tissue of the heart is, the more we may expect from their use, while the greater the degree of degeneration the less we may expect from their use and the less are they indicated.

Our case of valvular disease once fully compensated may remain so for life or, as so frequently happens, may again present with broken compensation due to various causes. But when this occurs we are introduced to a pathology that is essentially myocardial, for we have here a hypertrophied heart muscle unequal to its task, brought to this condition either by overloading or by interference with the nutrition. The case, therefore, approaches the degenerative type. But the foregoing remarks as to medication, in aid of again securing compensation, will apply to the degree that we have a heart muscle capable of improvement. We shall give no special consideration therefore to cases of this kind, but turn our attention to the degenerative type of disease.

We'recognise well enough the important relation of general nutrition to heart nutrition, to know that the two are dependent upon each other and to appreciate the great importance of an efficient capillary circulation in every organ of the body, including the heart. When cardiac degeneration actually occurs, whether fibrous or fatty, we usually have some constitutional condition present, of which the cardiac change is only one evidence or result, for the statement will apply here that degenerative disease of the heart is usually secondary, the most common antecedents being a specific endarteritis, senile degeneration and faulty metabolism. We may add that it may likewise be secondary to the endocardial or valvular disease when compensation has been lost; so that the treatment of broken compensation may need to follow not only lines heretofore considered but those that will follow.

Let us now picture our typical case of myocardial disease. We have a heart hypertrophied to some degree, but now dilated, giving, it may be, a fairly strong impulse, but the circulation is not correspondingly efficient. The heart muscle has suffered some degeneration, in consequence of which we have irregularity. The rate of pulse is variable, rapid if the heart retains its normal irritability, slow if it does not. The peripheral circulation throughout is poor, primarily because of changes in the small arteries, to which the contribution of lessened cardiac forces is soon added. The hardening of the peripheral vessels occasions a certain resistance against which the heart is working. It is this added work that has doubtless led to the earlier hypertrophy of the heart and now, with the nutrition of that organ failing, the resistance still calls for extra work. Frequently no murmur is to be heard unless

endocardial disease previously existed. In some cases, however, murmurs produced by either atheroma or dilatation of the aorta, or else caused by a relative insufficiency, may be heard.

The most essential points in this picture, in my view, are insufficient capillary circulation and degeneration of the heart structure. It would be interesting to study the relation of cause and effect in these two conditions did time permit, but it must suffice to say that, when the case is progressed to the point of showing serious cardiac symptoms, we have reached the result of years of disease in the circulation and that the time for most efficient treatment is forever past. The fate of the possessor of such a heart is well known to us and our efforts can only postpone the end. Present methods of treatment, however, do frequently prolong life for years, but it must be admitted that comparatively little of credit for this can be given to the administration of medicines. The importance of peripheral conditions, both circulatory and cellular, finds emphasis in the truly remarkable improvement that often follows the employment of the Schott bath and properly graduated exercise.

But we are chiefly concerned at this time with the influence of medication. In taking up the drugs which we are most likely to employ, we will consider, first, digitalis. Calling attention again to the two essential points, that of reduced peripheral circulation and that of heart degeneration, we find two serious objections to the use of digitalis. First, its vasoconstrictor action will tend to still further reduce the capillary circulation and increase the peripheral resistance, which will add to the work of the heart. Second, the muscular tissue of the heart has been reduced in quantity, thus presenting less tissue for the characteristic and best action of the drug. It is commonly held that this drug is contraindicated in fatty degeneration, but it is probably better to state that the less of good muscular tissue remaining in the heart, the less can we expect any good result from a drug of this class.

The two objections given might be sufficient to forbid its use. were it not for two very decided indications; one is to reduce dilatation and the other to secure a better nutrition of the heart by raising arterial pressure. Much as we say about the influence of trophic nerves of the heart, the trophic influence that appeals most to our knowledge and responds most to our efforts comprises the coronary arteries well filled with blood of good quality, and this is an essential condition of improvement. Active elimination in order to improvement of the blood, is here again. called for as in the acute cases. The reduction of dilatation, it seems to me, is so important a matter as to call for special effort,

provided there is still enough muscle tissue left to respond to digitalis. The heart is thus given the best possible advantage in its action and a great contribution will be made toward securing its better nutrition. The first objection, that of its peripheral influence, must be overcome, in case the drug is administered, by the combined use of vasodilators and by the employment of baths, massage, and exercise. These are the cases in which we must carefully weigh our indications and contraindications in arriving at a course of treatment.

Before passing to the consideration of other drugs, permit me to call attention to another factor which is not always of minor importance, the pulse rate. It cannot be stated that we have a characteristic pulse rate of the degenerated heart; neither can we say that the slow pulse which is frequently seen is due to excessive inhibition. It may be due to a diminished power of reaction in the heart structure. It would seem reasonable to regard rapidity of the pulse as an index of the reactive power of the heart and to be encouraged within normal limits. A very slow pulse would present another objection to digitalis; however, I recall a case where a slow, irregular pulse became more rapid and regular under digitalis, doubtless through improvement of heart nutrition and its power of reaction. On the other hand, atropine would be well suited to a case presenting this feature By stimulating directly the heart muscle and lessening the opposing inhibitory influence, it might give us a very decided advantage. The group of nitrites, well represented by glonoin and sodium nitrite, have a similar action in that they paralyse INHIBITION, but they are superior in their peripheral effect in that they allow a free capillary circulation by dilating the arterioles. These drugs have not been proven to be direct heart stimulants. The acceleration of pulse is due to depression of the vagus and the vasodilator effect to paralysis of the muscular coat of the arterioles. Inasmuch as their action is essentially a depressant one. the propriety of their continuous use may be questioned, but as an aid to an overburdened and poorly nourished heart, they will serve us by removing peripheral resistance and permitting a freer capillary circulation. With or without digitalis, their temporary use is often of decided advantage; but, as in the case of digitalis, they would better be regarded as emergency drugs and permanency of their effects maintained by nonmedical measures. The main object to be sought always is not stimulation of the heart, but an improvement in its nutrition.

1335 MAIN STREET.

Consideration of the Advisability of Athletics in Professional Colleges, with Special Reference

to the University of Buffalo.'

BY BURTON T. SIMPSON, M. D., Buffalo, N. Y.

N DISCUSSING this subject, my object is to state plain facts as they stand in the hope of bringing out a fair discussion of the subject, and a satisfactory solution of the problem.

I favor athletics here, but in view of the fact that our college closes so early in the spring, track athletics and baseball are out of the question; therefore I will only consider foot-ball, a game which is played in the fall, and the only form of athletics in which the University of Buffalo can participate.

Why should we have athletics in this university? This question naturally divides itself under two heads, first, the value to the university as an institution, and, second, the value to the students. It is upon these two propositions that I base my arguments.

In considering the value of athletics to the university, it will be well, first, to get some definite idea of what other colleges are doing in this direction.

There are 146 institutions of higher education represented by foot-ball teams. Of these 53 are purely technical colleges and it will interest us to know that 12 of these technical schools are medical colleges, among them some of the best in the country.

The past season Harvard University spent $80,000 to maintain athletics, and this is a fair figure for the other large institutions of her size. The University of Pennsylvania spent $25,000 for a gymnasium, and has invested $600,000 for an athletic field. I think you will agree with me that unless athletics were of decided benefit such sums would not be paid to foster sports. Not being satisfied that my conclusions upon the attitude of college officials would be convincing, I wrote to the presidents of some of the larger universities in the United States, asking for their individual opinions. Thirteen consider athletics beneficial to their institutions, while three only are negative. These figures give a higher percentage of negative replies than would be the case if I had a greater number of answers, for I find Prof. Dextar, of the University of Illinois, who has studied the question from the same. standpoint, gives the percentage as 1 in 17, basing his figures upon 100 replies.

No one can deny public interest in foot-ball. One has only to look at local papers on the Sunday after a game to be convinced. The entire front page is usually given up to a description of the

1. Read before the faculties of Medicine, Law, Pharmacy and Dentistry of the University of Buffalo, December 17, 1904.

game, and usually there are photographs of the men who makeup the teams.

Let me give an illustration having local interest: a young man, who had quite a reputation in his own town as a high school foot-ball player, came to the University of Buffalo (and I might add he chose to come here because we had a foot-ball team) and entered the school of pharmacy. He played on our team, and succeeded in making the only score which won the Columbia game by a drop kick from the field. The papers of his native city, which are read by the people in the surrounding country for a radius of 25 miles, came out with a two-column article on its front page, with double head lines, to this effect: "University of Buffalo defeats Columbia University, 5-0. Carl Rice, who is studying pharmacy at the university makes the only score by a drop kick from the field."

Let us analyse the above statement: first, there is a University of Buffalo; second, it has a college of pharmacy; third, it has a foot-ball team; fourth, it is of such standing as to compete favorably with Columbia University.

What value does this have in attracting students to the university? Do they come to college to study foot-ball? Most certainly not; but whom do we get as students? I think you will agree with me that they are mostly high school graduates, at least that is what the records of the last four years show in this medical college. What is the average high school student's conception of a college? Usually, that it consists of a number of buildings, a body of students and an athletic field, where, even if he is not an athlete, he can go and cheer for the team which represents his college. This conception is formed, I think, from information derived from college men at home on their vacation. talking of the prowess of their college's athletes and athletic teams, and from newspapers.

Foot-ball is the most popular athletic sport we have. All small towns have teams, and nearly every high school in the country is represented by an eleven. I think it will surprise you somewhat, as it did me, to learn there are 57 organised teams in the City of Buffalo, which means at the lowest estimate 700 players.

That men have come to our college because we had a football team, I have letters to show, and I know of two men who went to other colleges this fall because we did not have athletics. I do not think, on the other hand, you can show me a man who went away because we did play foot-ball.

The esprit de corps among students and alumni is encouraged by athletics. It is a noticeable fact that the fraternal spirit of