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most apt to be chilled while the surface of the body is wet. It is, therefore, endemic not viagra high price only in damp and wet climates, but also among the inhabitants of hot and dry desert regions where the rapid radiation of heat in the night causes the early morning tempera- ture to be often quite cold, and thus act upon the skin generic viagra directions of those who were freely perspiring from the heat of the previous evening. Rheumatic patients, therefore, should always protect the skin with flannel, and this is quite as needful by night as by day. Coining to the affections of the heart itself, the pulse of rheumatic patients should be frequently tested, as it often furnishes valuable advance infor- mation of the imminence of increased cardiac mis- chief. I have repeatedly advised such patients to go to bed on account of habitual generic viagra directions rapid action of the heart when they did not otherwise complain of rheu- matic symptoms, and with the best results. Indeed, to rest in bed we would assign the very first generic viagra directions place in the therapeutics of primary heart affections. We have here virtually a case of isolated disease. Practically it is the heart alone which is to be considered, and the first indication is to quiet it. This cannot be done unless the patient lies down. I need not say how often we find hospital patients admitted with every symptom of cardiac distress, and then note a marked improvement in them in a few days, solely due to their being kept in bed, without generic viagra directions any medica- tion meantime having been administered. It is easy to see that an embarrassed valve may work fairly well if only seventy-five movements a minute are de- manded, but quite otherwise if there be one hundred and twenty instead, and that the most urgent symp- toms may subside spontaneously after any measure which eliminates the element of overaction. In many acute conditions of the kind, however, rest in bed does not suffice to bring down the pulse, and for such we have a medicine whose service in primary heart disease I regard as invaluable, and that is aco- nite. Many times I have found the patient's symp- toms not only not relieved, but rather aggravated by digitalis, strychnine, and other supposed heart tonics, the pulse growing feebler and more irregular, until by a change to aconite the dyspncea has viagra high price been lessened, the anginose attacks have been relieved, and the pulse h is become both fuller and steadier under the influence of this drug. Aconite is not only a heart sedative in inflammatory cardiac states, but it has a decided effect upon inflammatory pains. In a great many cases also the cardiac rest which it induces will tend to increase the strength of the heart more than will follow upon the administration of heart stimulants. It should also be noted that in viagra high price common with other vegetable nervines, it produces no permanent effects upon heart muscle, any more than viagra high price tobacco does upon tiie habitual smoker. I have never seen .1 c tse of heart disease in which aconite has si emed to weaken the heart in inflamma- tory states, though it be taken three times a day for months continuously. I. of course, in the limits of this paper, cannot more than touch upon certain aspects of the subject of the treatment of heart affections, and I will therefore only allude to the relief of some special conditions. ( inc of these presents us at times with the 'most dis- tressing example of how heart disease can produce dyspncea, and that is when a pericarditis has resulted in the formation of adhesions to the pleura, sternum, and ribs. Every movement of inspiration may then tend to draw upon the walls of the heart and thus in- terfere with the cardiac systole. To give such a pa- tient digitalis may simply increase his sufferings, but I have found firm strapping of the left side of the viagra high price chest sometimes of the most undoubted service. In mitral stenosis, as Foxwell has shown, the resul- tant hypertrophy of the right side of the heart causes- the area of cardiac dulness in adolescents to increase- in a different direction from generic viagra directions what it does in right di- latation in older patients, as after emphysema, the dulness extending upward and to the left, in many instances quite up to the second left generic viagra directions rib articulation instead of transversely to the right. viagra high price For the dyspncea of mitral stenosis, especially when viagra high price it occurs in severe paroxysms, I have found belladonna, often combined with compound spirits of sulphuric ether, much the best remedy. In no other valvular lesion do we find such a tendency to irregular rhythm as in mitral ste- nosis, and that may be one reason for the superiority of belladonna here, as also for its incontestable superi- ority in the relief of cardiac pains when they occur in the hypertrophied hearts of rheumatic patients. I would ascribe these pains to the disturbance of the rhythm of the cardiac contractions when the balance between the two sides of the heart is disturbed by the greater hypertrophy of one side, and belladonna, with its allies among the solanacea-, is characterized above all other agents with the property of restoring the de- ranged action of rhythmical muscular fibre, and thus relieves spasm whether in the bronchial tubes, generic viagra directions in the alimentary canal, or in the generic viagra directions urinary bladder. In mitral generic viagra directions stenotic cases I have often found digitalis inferior to strophantus, sparteine, and caffeine. In all primary heart diseases we should always re- member the evil effects of anaemia. Anaemia of itself may cause structural heart disease, as in chlorosis. The most extreme fatty degeneration which we may ever find in a heart is often met with in patients who have died from pernicious anaemia. Now, considering the special tendency of acute articular rheumatism to produce anaemia, it would seem as if we should generic viagra directions early administer iron to combat this sequel. But, however invaluable iron is generic viagra directions in other forms of heart disease, I regard it as almost certainly mischievous in rheuma- tism. Repeatedly have I found its administration in these patients to prolong the convalescence, keep up a subfebrile temperature, increase the pain, and appar- ently increase, instead viagra high price of diminish, the anaemia. In fact, there are a gpod many loose ideas about iron as a specific for all forms of anaemia, but which we have no time to discuss now other than to say that in all febrile anaemias, as in phthisis, rheumatism, and per- nicious anaemia, iron is as likely to do harm as it is to do good. The best remedy for rheumatic anaemia, in my opin- ion, is cod-liver oil along with small doses of arsenic.