half a drachm of citric acid dissolved in four ounces of water. At the same time, if the bowels are torpid, ten grains of colocynth and calomel pill are prescribed at bed-time. As soon as the urine, when freshly voided, ceases to show an acid reaction -which is usually the case after twenty-four hours the quantity of the alkali is diminished by one-half, six drachms only being administered during the succeeding twenty-four hours. At the expiration of that time, if the urine remains alkaline, three drachms only are given in the next twenty-four hours; and on the fourth day, if the urine still shows an alkaline reaction, the form of the medicine is altogether changed. The treatment ceases to be essentially alkaline: either a cinchona draught is ordered to be taken three times a day, containing a scruple or half a drachm of bicarbonate of potash-a little more or a little less, according to the condition of the urine, which should be kept nearly neutral-or three grains of quinine dissolved in lemon-juice is given three times a day in effervescence, with half a drachm of bicarbonate of potash or soda. Throughout the attack an aperient pill is given whenever it is needed, and opium is rarely, very rarely administered-never except under conditions of extreme nervous irritation. The diet is restricted to beef-tea or broth, with soda-water and milk and barley-water as a drink, as the smallest quantity of solid food, given a day before the tongue has thoroughly cleaned, is apt to induce a recrudescence of the disease. Wine and spirits are strictly forbidden, though experience has convinced me that wine and spirits prove less hurtful than the smallest quantity of solid food. If the patient is chilly, he is ordered to lie between the blankets; but, otherwise, he is allowed to lie between the sheets, and is kept tolerably cool. The heaping of extra blankets on the bed is strictly prohibited, as they tend to keep up excessive perspiration, and thus, by producing exhaustion, retard the patient's recovery. The merits which I claim for this plan of treatment, which I have carried out both in hospital and private practice for twenty years, are: 1st. That it affords very speedy relief to the patient's sufferings-relief far exceeding that produced by any opiate. 2nd. That it checks the rheumatic action, mitigates the severity of the disease, and promotes the speedy recovery of the patient. 3rd. That it protects the heart from mischief, and thus obviates one of the most distressing maladies to which flesh is heir. In proof of these stateinents, I would adduce the following facts-1st. The patients very commonly doze, without the aid of opiates, within twenty-four hours after the first administration of the remedies and almost invariably sleep tolerably soundly for an hour at a time within forty-eight hours after the commencement of treatment, showing how great is the relief afforded. Coincidently with the repose thus obtained, the temperature of the body falls-usually to the extent of two or three degrees within forty-eight hours, and not unfrequently to its natural standard within three or four days-the frequency of the pulse decreases by ten or fifteen beats, the quantity of the urine is largely augmented, and the pain in the joint is greatly lessened. 2nd. In many instances, within a week, and almost invariably within ten days from the commencement of treatment, the patient-who on admission was in agony of pain with swollen joints, incapable of moving, and bathed in the profuse acid perspiration of rheumatic fever-becomes cool and free from pain, and anxious to leave his bed. In ninety-four consecutive cases, which were tabulated with a view to this inquiry, the average duration of the disorder after the commencement of treatment was only eleven days-in other words, the patient not only reported himself free from pain, but was up and dressed at the expiration of eleven days. The hospital register of my cases tells a very similar tale, though the figures are necessarily somewhat different. Taking 116 consecutive cases of rheumatic fever which were admitted under my care into St. George's Hospital, between January 1, 1860, and December 30, 1865, and excluding twenty-eight in which pericarditis existed at the time of the patient's admission, the average term during which the patients remained in hospital was only 20·1 days; and as the patients are always kept in hospital for a week or ten days after the pains have ceased in order to guard against a relapse, the average duration of the disease under treatment was only eleven or twelve days. These figures include all cases attended with endocardial murmur. Even including the twenty-eight cases of pericarditis, the average stay in hospital was only 22.2 days; a result, I believe, which has never been attained under any other plan of treatment. 3rd. I have submitted 439 cases of rheumatic fever to the alkaline treatment in hospital and private practice: the disease has not proved fatal in a single instance; in nine cases only, or in little more than 2 per cent., has any cardiac complication occurred while the patient was under my care, and in six of these the murmur was discovered within twenty-four hours after the commencement of treatment, and, therefore, before the remedies can have taken effect; nay, it may even have existed in an incipient state, though it escaped detection when the patient was first seen. Dr. Dickinson's statistics are almost more striking, because they exhibit the contrast between the effects of the alkaline treatment when properly carried out, and all other varieties of treatment, including alkalies in inadequate doses. While he was Medical Registrar at St. George's Hospital, he carefully noted all the cases of rheumatic fever admitted under the physicians, and during the space of five years there were admitted 161 patients whose hearts were sound at the date of admission. One hundred and thirteen of these cases were submitted to treatment other than alkaline, and in thirty-five of these, or in 30.8 per cent., the heart became involved; whereas the heart remained free from mischief in forty-seven out of the forty-eight cases which were submitted to the alkaline treatment -in other words, the heart was affected in little more than 2 per cent. Thus, then, it is obvious from statistics on a large scale, carefully collected by independent observers in the wards of St. George's Hospital, that "the alkaline treatment," when properly carried out not only affords speedy relief to the patient's suffering, but almost ensures immunity from disease of the heart. It only remains for me to point out the causes which have led to the failure of this treatment in the hands of certain practitioners. In so doing, I give the result of clinical experience, both in hospital and private practice. The first, and most common cause of failure, is the administration of insufficient doses of the alkalies in the early period of the attack-of doses which, though they would be regarded as large under ordinary circumstances, are practically useless for the arrest of rheumatic fever. An ounce and a half is the minimum dose of an alkaline carbonate, which will suffice to overcome the acid condition of the system during the first twenty-four or forty-eight hours of treatment, and in sthenic cases two ounces are often needed. Four or five drachms, which form the maximum dose, administered daily by many persons who imagine that they are using alkalies efficiently, are simply useless. They neither mitigate the pain nor shorten its duration, nor do they protect the heart from mischief. The second cause of failure is mistaken diagnosis, and the consequent administration of alkalies in cases in which they do not exercise a curative influence. It constantly occurs to me to see persons, who have been drenched for a week or ten days with alkalies, under the impression that they were afflicted with acute rheumatism, who, on investigation, prove to be suffering from acute osteo-arthritis, or so-called rheumatic_gout from gonorrhoeal rheumatism, or from atonic gout-disorders which, though resembling rheumatic fever in many of their features, are yet totally distinct from it in their essential characters, and require an entirely different plan of treatment. Indeed, in most of these cases, full doses of the alkalies prove absolutely noxious; they depress the patient, and fail together to relieve his symptoms. The third cause of failure is an improper alimentation. The diet should be restricted to broth, beef-tea, or other liquids; all solid food being strictly prohibited; but, in many instances, I find that little heed is paid to this matter, and that throughout the attack the patient is permitted to take whatever nourishment his appetite will enable him to swallow. Yet there is nothing of which experience has more fully convinced me than that the strictest dietary is of the utmost importance-of infinitely greater importance than in gout--and that the taking of solid food, such as fish or meat, however small the quantity, will serve to keep up imperfect assimilation, and not only counteract the effect of remedies, but almost indefinitely protract the disease. The desire for solid food returns long before the power to digest it, and so it happens that a piece of meat taken a day before the tongue has cleaned, and the stomach is in a condition to digest it, proves not unfrequently the cause of a relapse. [Dr. Fuller illustrates the treatment he ordinarily pursues by the following case.] G. S., a groom, aged 22, was admitted into the Hope ward on the 18th of May. He had suffered from rheumatic fever a twelvemonth previously, and was under treatment for a period of six weeks. The present attack commenced, a week before his admission, with shivering, followed by wandering pains in the limbs, and inflammation and swelling of several of the larger joints, which at the date of his admission were red, swollen, and exquisitely painful. The heart's sounds were clear and its rhythm was normal; the skin was hot and perspiring profusely, the perspiration being intensely acid; the pulse 118, regular, and of good strength; tongue thickly furred and red at the tip and edges; bowels costive; urine scanty and turbid, with a copious deposit of lithates. He was ordered ten grains of colocynth and calomel pill immediately, and the following draught every four hours, viz. soda bicarb. 3jss., potasse acetatis ss., haustûs acetatis ammonia 3ij., to be taken in a state of effervescence, with half a drachm of citric acid dissolved in an ounce and a half of water. His food was restricted to beeftea. On the following day the urine had become clear and alkaline, and the pains were somewhat easier; the draught therefore was repeated only three times in the twenty-four hours. On the 20th the urine was still alkaline, the pulse had fallen to 80, the pains had greatly subsided, and he had slept at intervals throughout the night. On the 24th very little pain remained, and as the urine was decidedly alkaline the following draught was substituted for that already given, viz. potassæ bicarbonatis 3ss. haustus cinchona 3jss. ter die. On the 26th he was quite free from pain, and was up and about the the ward; and as he complained of being hungry, an egg was given in addition to the beef-tea. On the 30th he remained free from pain, and the urine was still alkaline; fifteen grains of the potash were therefore omitted, and he was allowed the "ordinary diet" of the hospital. On the 1st of June he had been a week free from pain, and he was therefore permitted to leave the hospital. During the time I held the office of Medical Registrar, namely from January 1st, 1845, to May 1st, 1848, 246 cases of acute rheumatism were admitted into St. George's Hospital, and they remained in the hospital on the average thirty-five days; of these 246 patients, 119, or 1 in every 2-06, had some form of recent affection of the heart; and 1 in every 6-3 had pericarditis. During the six years ending December 31st, 1850, 17 cases, or about 1 out of every 27 cases of rheumatic fever admitted into the hospital, terminated fatally. [The results of the plan of combating the disease by full and repeated doses of alkalies present a remarkable contrast to those first referred to.] I have submitted 417 cases of rheumatic fever to the alkaline treatment in hospital and private practice; the disease has not proved fatal in a single instance; in nine cases only, or in little more than 2 per cent, has any cardiac complication occurred while the patient was under my care, and even these, for the reason below assigned, can bardly be regarded as consequent on failure of the remedies; the disease has been arrested, and the patient has been out of bed in many instances within a week from the commencement of treatment, and in ninety-four eonsecutive cases which were tabulated with a view to this inquiry, the average duration of the disorder, after the commencement of treatment, was only eleven days-in other words, the patient reported himself free from pain and was up and dressed at the expiration of eleven days. The Hospital Register of my cases tells a very similar tale, though the figures are necessarily somewhat different, because, with a view to guard against relapse, the patients are kept in hospital for a week or ten days after cessation of their pains. I have gone over my case-books and the Hospital Register for five years, beginning with the 1st of January 1860, and terminating on December 31st, 1865, during which period I find that 116 cases of rheumatic fever were admitted under my care. Excluding eighteen cases in which pericarditis existed at the time of the patient's admission, the average term during which the patients remained in hospital was only 20.1 days, which gives about 11 or 12 days as the average duration of the disease; and even including the cases |