John Macpherson
1873 The Lancet  
294 injunctions to remain in the hospital for protracted rest, and leave us under the impression that they are well and able to resume their work. Sooner or later in the course of this disease, unless the patient is cut off by sudden death, or some complication, the urine becomes albuminous. This condition is often delayed to a late period. It probably never occurs until the mitral valve gives way, and it is often coincident with the setting in of dropsy. Now let me call your attention to the
more » ... attention to the circumstances under which, as far as the history will guide us, the disease in our patient Bprobably arose. This will lead to the consideration of some of the causes by which valvular affections of the heart are produced. The man was a fireman at some glass-works and exposed to great heat, and doubtless his occupation was a laborious one and attended with great muscular exertion. There is no history of rheumatism, nor of any sudden injury to the valvular apparatus of the heart; nor did we find after death any deposits, either inflammatory or atheromatous, in the valves. They were somewhat thickened, it is true, but they were smooth, and apparently not diseased. I think we are perhaps too apt to overlook the effects of strain on the heart-the influence which long-continued powerful action of the heart may have on its orifices, especially the aortic, and on its valves. We know well, from numerous instances which have been recorded, that sudden violent muscular efforts may rupture or injure the valves, and the prevalence of valvular disease amongst men who lead laborious lives-lives of long-sustained powerful muscular efforts-must strike all who have had experience in cardiac diseases. My belief is, that many cases of valvular disease are produced by the powerful action of the heart necessarily resulting from following certain occupations, and also from violent gymnastic exercises. In the case of B-, it appears to be highly probable that the aortic incompetency was the result of the dilatation of the aortic orifice and of the base of the aorta, from the distension to which they were subjected by the oft-recurring powerful action of the left ventricle. The symptoms in such a case would be slow in developing themselves. Dilatation must proceed to some extent before valvular insufficiency would result: this, at first, would be slight, but, once commenced, it would daily increase, and all the secondary consequences of the affection would ensue. I know how difficult it is to speak positively in reference to this question, but I have now seen several cases in which I could trace no other probable cause of valvular disease than that of strain from strong muscular exertion ; and I have under my care at the present time a gentleman who is suffering from aortic regurgitation with symptoms of dilated aorta, which, I think, I can distinctly trace to the practice, some years ago, of gymnastic exercises. I must defer what I have to say further on aortic insufficiency and its treatment to another lecture. THERE is an inexpressible feeling of quiet and repose and friendliness about the little cluster of baths known as the Kniebis group. They are easily reached by carriage from the railway station of Appenweier. In natural scenery and in mineral constituents they are all essentially the same. They are all in wooded valleys, and more than 1000 feet above the sea. Their waters are pretty strong chalybeates, containing small quantities of Glauber salts. The only exception to this is the quiet little Sulzbach in a side valley off the Rench Thal, at a height of 1068 feet-not to be confounded with the place of the same name on the other side of the Rhine already mentioned. It is a little off the road to Petersthal, three-quarters of an hour from Oppenau. It supplies lukewarm waters of the temperature of 725°, containing about 6 grains of sulphate of soda and 4 of its bicarbonate, with little more than a trace of iron. They thus closely resemble the waters of Bertrich, but are 20° cooler. The place is little visited; it offers a mild climate, quiet and simple amusement, and cheap living. Without turning aside to this spot, I went on along the valley, and reached Freiersbach, 1281 feet, which is, indeed, practically a portion of Petersthal, being scarcely twenty minutes distant. Of the four springs I shall only say that the Gas one contains 10 grains of carbonate of lime, 4'5 of carbonate of magnesia, 6 grains of sulphate of soda, and nearly '4 of carbonate of iron, and is extremely pleasant to drink; while the Sulphur well, so called owing to the presence of a little sulphuretted hydrogen, is a very pure and strong chalybeate, containing '77 per cent. of iron. There are prettily wooded banks and old-fashioned hotels, like barracks, containing the baths ; also vapour and pineextract baths. A new building has recently been erected over the Sulphur spring. But Freiersbach is quite eclipsed by Petersthal, 1333 feet above the sea level, with its showier and more modern arrangements, its pretty and at the same time comfortable hotel, and all the ordinary appliances of a bath, which now numbers some 8000 annual visitors, among whom are many Russians. The three springs here are all essentially the same, and characterised by the presence of an immense supply of carbonic acid. The Peters, the Salt, and the Sophia wells all contain about 11 gr. of carbonate of lime, 35 gr. of carbonate of magnesia, and about 6 gr. of sulphate of soda, with '34 gr. of carbonate of iron. The different action of the springs is thus characterised : the Petersquelle is supposed to suit weak digestion best; the Saltzquelle, having a grain and a half more of magnesia, acts most on the intestines; and the Sophiaquelle, containing '111 gr. of carbonate of lithia, is declared to be especially useful in affections of the bladder and kidneys. Though the waters are used mostly for drinking, they are also employed for baths; and you may have sitz baths and douches, and the wellen or wave baths of which the Germans are so fond, in the stream of the Renche. Seeing Petersthal as I did in beautiful weather, it appeared to me a very attractive spot. Its waters and, indeed, those of Freiersbach are largely exported. The Peterswell is the pleasantest to drink, and is most bottled. Going up the valley to Griesbach, which is only four miles distant, one passes on the left the road leading to Antogast, the oldest of all these baths; it was described in 1538. Indeed, all the Kniebis baths were quite as well known in the end of the sixteenth and the beginning of the seventeenth centuries as they are now. Antogast lies at a height of 1610 feet above the sea level. Its waters differ from the neighbouring ones in containing a few grains of carbonate of soda, and less carbonate of lime, also less iron. It is said to be a quiet, picturesque place, but is little frequented, and the arrangements are not of the first class. We soon reach Griesbach (1614 feet), which has of late become extremely popular. As there are only the public establishments,itis often difficult to get accommodation here. A new bath-house has lately been erected. Everything looked fresh and new and comfortable, and the neighbourhood is very pretty ; gardens and walks have been laid out. The waters of Griesbach contain less carbonic acid than those of Petersthal, which is a disadvantage as regards bathing. But the drinking-well, with '6 of carbonate of iron, is quite strong enough, and contains more carbonic acid, but its proportion of carbonate of lime (12'2) is rather high. There are arrangements here for pine extract baths and inhalations. Griesbach is a very favourite bath'for ladies. It is quieter than Petersthal. I have known an English family go there for several successive seasons. Immediately beyond Griesbach, the road over the Kniebis commences to ascend in a series of zig-zags, from which there are beautiful views over the Black Forest. The top of the Kniebis is flat and uninteresting. The road soon takes us down into the Kinzig valley on Rippoldsau-on the whole, the most important, as it is the most picturesque and the highest of the group, situated in pine forests at an elevation of 1886 feet.
doi:10.1016/s0140-6736(02)65605-3 fatcat:oxsg3zbpynfpjakhhezpcw55lu