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idly developing acute rheumatic fever, till he ends the week with the development of a mitral lesion. A year afterward we find him dyspneeic, with congested lungs, sallow skin, enlarged liver, and with much oedema of the lower extremities. Another man, fifty years of age, who always had considered himself healthy, has noticed a gradually increasing shortness of breath on going upstairs. We find him with a pulse of high tension, a hard radial artery, and with a ringing second sound at the semilunar valves. A year afterward he also is very dyspneeic, with viagra online pharmacy con- gested lungs, enlarged liver, and with ttdema of the legs. But, however numerous the symptoms which these two patients have in common, they certainly are very different from each other when we can properly say to the first that viagra online pharmacy he should stay in bed, and to the other that he should stay out-doors as much as pos- sible. The valvular lesions, and the results of those valvular cialis viagra paypal lesions, may be the same in both cases, but for all that they are not cases of the same heart dis- ease, for in the first the trouble began with the heart, while in the second it ended with the heart. In how- many respects, therefore, the treatment of the cardiac affection mav be accordingly contrasted on account of these elements in the history of these patients, is a subject which affords a convenient text for our remarks on some points in the therapeutics of heart disease. Primary heart affections are so commonly of rheu- matic origin that this fact alone furnishes us with cer- tain indications which should not be lost sight of. The first of these is the progressive nature of rheu- matic heart disease, simply because it is rheumatic. Thus, I have been struck by the number of cases in my experience in which a primary condition, not of rheumatic origin, occurring in young subjects, though it caused permanent valvular change at the time, yet remained thereafter stationary. In the beginningof my practice I was called to a girl, aged twelve, with endocarditis developing in an attack of measles. She 1 Read before New York County Medical Society, viagra online pharmacy May 25, 1896. has had a loud mitral murmur for twenty-five years since, but without any seeming injury whatever to her health. On the other hand, nothing is so deceptive as the favorable prognosis, as regards life, of the first attack of a rheumatic carditis. The patient may leave his bed with apparently nothing but viagra online pharmacy a slight cardiac murmur, cialis viagra paypal and soon he feels quite well. He returns, however, twelve months afterward, complaining of attacks of palpitation and of cardiac cialis viagra paypal pains, and aus- cultation reveals a much increased and permanent condition of cardiac mischief. This has been shown to be particularly the case in children after recover- ing from chorea, and the rule is, the younger the pa- tient with, therefore, the most tendency to active mus- cular exercise and rapid heart action the more surely inclined is a slight initial cardiac lesion to develop into a serious structural alteration. What is true, therefore, in general of rheumatism, that any one once cialis viagra paypal attacked by it is more liable than others to repeated returns of the affection in his joints, is still more the case with his heart. Inflammation is more likely to recur there with him than anywhere else because of special reasons. The first of these reasons arises from the continued mechanical operation of the initial valve lesions. These begin with the deposit of beaded rows of fibrin just within the border lines of the valves. Soon these become organized upon the smooth lining membrane like so many trachomatous masses in granular con- junctivitis, with the same grating and viagra online pharmacy viagra online pharmacy irritating effects upon the incessantly moving valves, thus leading in time to deeper cialis viagra paypal inflammatory thickening, with tendency to deforming contraction of the subjacent textures. The heart, therefore, becomes more irritable and liable to inflame with much less provocation than at the first attack. Meantime, its own functional activ- ities explain how, from the first, the rheumatic inflam- mation caused more structural change there than rheu- matic inflammations ordinarily do viagra online pharmacy elsewhere, for here we have the seat of cialis viagra paypal the most unceasing and rapid movements in the whole body. It viagra online pharmacy is therefore the last place in the body where the great indication in inflammation, of rest to the inflamed part, can be se- cured. The only other texture which is apt, though far less often than the heart, to have permanent struc- tural changes set up in it by acute rheumatism is the pleura, and that also is an unresting tissue. From these considerations, one of our first indica- tions in the treatment of primary heart affections is the prophylaxis of rheumatism. For this purpose I would recommend particular attention to the state of the tonsils in those who give, along with a tendency to rheumatism, a history of frequent attacks cialis viagra paypal of sore viagra online pharmacy throat. The prompt use of salicylates internally, with the first signs of tonsillitis, and the local application of tincture of iodine are, in my opinion, good pre- ventives in these patients of subsequent rheumatic infection. The habitual employment of hot water douches night and morning to the throat, with the ad- dition of oil of peppermint to the water, is also an ex- cellent measure in the hygiene of the mouth, for the relation of oral infection to chronic pharyngitis, otitis, rhinitis, and tonsillitis is, I believe, a fact of much practical importance for physicians to recognize. 794 MEDICAL RECORD. [June 6, 1896 Of equal, if not of greater, importance is the pro- tection of the skin, owing to the easy sweating of rheumatically inclined persons. Whatever be the re- lation of acute articular rheumatism to microbic in- fection, the clinical fact is undoubted that rheuma- tism prevails most in the localities where persons are