With all this in mind I have never made use, either in the treatment of heart disease or of obesity, of extreme limitation of the daily quantity of water taken; I generally consider 15 c.c. of urine in the twenty-four hours per kilo of body weight as the daily secretion of urine to be desired. Neither have I prescribed abstinence from water at mealtimes, except in cases of cardiac incompetence, which may be known in their early stages by extreme variations in the quantity of urine passed, and in urgent cases give preferably small doses of digitalis corresponding to three to four teaspoonfuls per diem of our infusion, and for the rest tell patients never to drink much at once. Most of my cases of heart weakness, however, are mild ones.

Oertel adopted the limitation of fluid, as well as other points, from Stokes' treatment, and he cannot be exonerated from having carried this part of the treatment too far. It is worth while, however, to make oneself acquainted with Oertel's procedure, since, owing to the searching criticism he incurred, his views were fully developed.

At a certain stage of the disturbance of hydrostatic equilibrium in cases of fatty heart and other cases of cardiac weakness we find more or less definite (Edematous swellings in those patients generally fat and pale, who eat, and more especially drink, too much. We have reason to believe that the blood in certain regions is very watery and that the whole of the lymphatic system is over-full. We have, in other words, hydremia and serous plethora. The flow in the lymphatics is rendered more difficult by the diminished elasticity of the tissues (= verminderte Gerwebespanming), and a diminished supply of fluid results in an increase in the quantity of urine. It is in these cases that diminution of the supply of fluid gives the best result, the excess of fluid in the tissues is diminished, and palpitation and dyspnoea lessen or disappear.

In some other cases, which generally include early stages of heart failure with valvular disease, in patients who do not eat, and more especially do not drink, too much, and whose kidney functions are still healthy or fairly so, one can observe no local oedema. But a marked stasis takes place in the pulmonary circulation and in the systemic veins. It was in such cases as these that Bamberger and Lichtheim constantly found the blood in the outlying veins very concentrated, of high specific gravity, with increase of blood corpuscles and other solid constituents, a concentration which in hemiplegic patients is greater on the paralysed side (Penzoldt), the flow of venous blood towards the heart being unaided by muscular movements, and which diminishes and disappears under digitalis (Toenissen). Oertel points out that in these cases the lymph (infolge der gut erhaltenen Gewebespannung) flows easily towards the large veins, and that the quantity of fluid in these, in the pulmonary circulation, and in the arteries of the systemic circulation is not diminished, but increased. If the intake of fluid is diminished in these cases the quantity of urine is not increased, but, if altered at all, is diminished. Oertel considers that the total quantity of blood in these cases is not increased. It was cases of this kind, according to Oertel, that Lichtheim meant when in a fortunate hour at a congress in Wiesbaden he opposed the reckless limitation of the intake of fluid then in vogue. Oertel recognises that the effect on these patients of marked restriction of fluid is often bad, and contents himself with regulating it, and lets it be taken in smaller quantities. The quantity of urine varies markedly with the variations in the strength of the heart.

Oertel's third category consists of those cases in which the cardiac incompetence is advanced, in which the kidneys act badly, serous accumulations and extensive oedema are present, and the physical changes in the tissues (verminderte Gewebespannung) are extreme and hinder the lymphatic circulation. Marked stasis is present in the lymphatics, the venous blood in the systemic circulation is very concentrated, but the arterial blood in the systemic and all the blood in the pulmonary circulation is markedly thinned, so that the protein sinks from normal (at least about 72 : 1,000) down to 60 : 1,000. In these cases Oertel does not use Stokes' terrain-cure, but makes use of passive movements and massage to ease the circulation. He limits the intake of fluid in these cases, while giving digitalis and other diuretics, if the quantity of urine is thereby increased, but the water given is always divided into small quantities.

The most important conclusion one can draw from this is, to my mind, that the supply of water should be limited in those cases in which it has been too large and in those cases in which its diminution produces an increased flow of urine.

Lastly, many believe that in certain kinds of baths, especially in baths with free carbonic acid after the Nauheim type, we possess important resources in heart affections. We have these baths, too, in Carlsbad, in which we use carbonic acid gas under different atmospheric pressures for different lengths of time and at different temperatures for the bath, beginning with slight atmospheric pressure, ten to twelve minutes' bath at a temperature of 33° to 34° C. every other day, and when it seems suitable we increase the atmospheric pressure to two, two and a half, or three atmospheres for twenty minutes every day and lower the temperature by degrees to 30°, 29°, 28°, or 27° C. An irregular, quick, feeble pulse becomes more regular, slower, and stronger during the bath and for the hours immediately following. For my part I consider these baths useful in neuroses of the heart, and will certainly not deny that they may have some value also in other cases. The intra-arterial pressure sinks during the bath cure, probably on account of the consequent widening of the peripheral blood stream. But the statements concerning baths which are made by doctors who presumably have often handled pathologically altered hearts are most astounding. For my part I should as readily believe in "spiritualism" as that the Nauheim bath could have a perceptible effect on the reabsorption of inflammatory products in the endocardium.

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There is no other heart massage worthy of mention than that consisting chiefly of different forms of tapotement, as chest-hacking, chest-clapping, heart-clapping with the hand cupped "a l'air comprime," heart-shaking, etc., which is commonly used, and which aims at and produces a slowing of the pulse when it is too frequent. In Sweden the procedure in this treatment often begins and ends with stroking over the heart region, including stroking from the axillary line to the front of the sternum without any very clear aim, and for the rest consists of the above-mentioned forms of tapotement, which alone are really effective.

In most cases chest-shaking produces a slowing of the pulse, due to vagus reflex. It would seem to be uncertain whether the effect is more than temporary; on the other hand, one may safely say that this "heart massage" is one of the least valuable forms of massage.

Professor Oertcl, of Munich, has also in massage put forward impractical and ill-grounded propositions in reference to mechanical treatment in diseases of the heart. In combination with the equally absurd respiration saccadee used in his terrain treatment he allows massage to be performed by strokings which begin with expiration, go from each side of the chest in the axillary line at the level of the fifth and sixth ribs forwards to the seventh and eighth costal cartilages and xyphoid process of the sternum, and end, as soon as the hands of the masseur have reached the sternum, by his pressing it inwards with both thumbs, while with his other fingers he exerts pressure on the sides of the chest. By varying pressure such as is given in all massage he believes he can affect the heart in weak conditions of the heart muscle, overfulness of the veins, and corresponding deficit of blood in the arteries, and where the work of the heart is increased (by valvular disease, tumours, struma, emphysema, kyphoscoliosis, etc.); also as an accessory to the terrain-cure.

With all respect to Professor Oertel, I must deny the value of this massage, and can only believe that incorrect opinions as to physical and physiological laws allow him to lay so much stress on this form of massage. One incorrect statement certainly is contained in the following quotation from his work: " Der Druck unter welchem die Expirationsluft wahrend der Zusammenwirkung einer erhoheten Leistung der Expirationsmuskeln and der ausseren Pressung steht, und der sowohl auf der Innenflache der Lungen und der Bronchialschleimhaut als auch auf der Herzoberflache und der Oberflache der grossen Gefass-Stamme lastet . . ." That pressure which is present in the lungs and respiratory tract during expiration is a pressure entirely different from that which takes place in the thoracic space outside the lungs and the pressure which affects the heart. When the glottis is open there is a negative pressure in the thorax outside the lungs with ordinary expiration. During expiration this pressure becomes less negative, but in deep inspiration it can sink to as much as 30 mm. mercury below the atmospheric pressure. But the pressure never becomes positive, however deep the expiration. It is only in forced expiration that the pressure may become positive, apart from straining or closing the glottis. But if one agrees with Oertel in the possibility of influencing the heart by varying pressure with the hands outside the fixed ribs and through the soft, elastic, and yielding lung tissue which surrounds the greater part of the heart, as one influences skeletal muscle by massage, one should never allow such manipulation when pathological changes are present. The most experienced physician can never quite ascertain the condition of the heart in all its details, and it is quite impossible to exclude with certainty pathological changes in which such massage would be dangerous. Oertel's massage is of a certain theoretical interest, but is of no practical value.