metal.

The inquiry before us, therefore, is not an idle question. Its solution concerns many thousands of our suffering fellowcreatures, who are shut out of society all their lives, and are often willing to confess that they have thought seriously of suicide, and have long prayed for death.

To return to the question, then :-How is arsenic to be used? In order to simplify the inquiry, we will suppose the preparation to be Fowler's solution, this being the most commonly in use with the profession. There is an objection to this preparation which will be considered presently. But it is an objection of little weight; and we proceed to inquire how it is to be used. First, it should be given in divided doses-three doses in twenty-four hours, simply to avoid an unnecessarily large dose. Second, it should be diluted with pure water, or if the case require the influence of antimony, the vinum antimonii, say thirty-five minims, may be combined with five minims of the liquor arsenicalis, and this may be taken diluted three times a day. Third, this dose should be taken with, or immediately after, a meal, in order, that being mixed with the patient's food, it may find a ready entrance into the blood, and that the bare possibility of its irritating the mucous membrane of the stomach or bowels may be avoided. Not that there is any danger of mischief, but the patient, aware that he is taking arsenic, may thus be disabused of all fanciful or imaginary suffering of this kind. Fourth, it should be clearly understood that arsenic acts very slowly, and therefore it is best to begin with an average dose, say five minims of Fowler's solution, and this should be increased, not day by day, as was the practice thirty years ago, but two, three, or four weeks should be allowed to elapse before any necessity can exist for augmenting the dose. If, during this time, there should be set up an active or severe inflammation of the tunica conjunctiva in both eyes, the lower eyelid being swollen and showing on its lining membrane a horizontal streak of inflammation, then the medicine is not to be abandoned in a panic, but the dose may be reduced to four minims, and in a week or ten days the conjunctiva will be less inflamed; or, if not, a lotion of the liquor plumbi acetatis dilutus, or of cold black tea, will generally suffice to relieve the investments of the globe of the eye, and even to remove the slight degree of ecchymosis which is sometimes seen in the sklerotic tunic. during this week, if the patient has been properly prepared for the course. the disease of the skin will show some amendment; it will be shorn of its strength, and from this time the cure will be easy enough, although it may take many weeks, or even months, to effect it entirely. If it should be requisite that the course be continued for several months, the soles of the feet, and less frequently the palins of the hands, become more or less

But

inflamed or rough, and very rarely slight vesications occur on the feet. These inconveniences must be borne patiently: they will only exist during the course. Sometimes, also, after a protracted course, the skin of those parts of the body which are covered by the dress assume a dirt-brown, unwashed appearance, and under a lens present fine scales. This also is an ephemeral appearance, somewhat annoying to females of delicate complexion, but not for a moment to be compared with the afflictive form of disease which requires arsenical treatment. Other symptoms are sometimes complained of; such as restless nights, hiccough, pains in the stomach and bowels, depression of spirits, and general nervousness. But all these, except the first, are mere mental impressions. They seldom or never occur in dispensary practice, when the patient knows nothing of the medicine he is taking. And, on the other hand, it is far more common for the patient to feel better and stronger under the course. The feet and legs become warmer in those cases in which the extremities are habitually cold; and nothing is more common than for patients to say, after a long course of this medicine, that they have never felt so well in their lives.

Hitherto we have supposed that the dose has been rather in excess. But it often happens that the reverse is the case, and that after a month's treatment the medicine shows no sign, and the disease remains in statu quo. It will now be necessary to increase the dose slightly, and perhaps repeatedly, not every day or every week, but about once in a month, nothing doubting that the effects will sooner or later appear.

Meanwhile it must not be forgotten that we are not dealing with a mere machine. The health of the patient must be closely watched, and the secretions carefully sustained. Above all, the bowels must not be allowed to act sluggishly. In many cases a full dose of calomel and compound colocynth pill will be required two or three times a week; and these doses are sometimes essential to the cure. If the legs, or feet, or abdomen become puffy or cedematous, the urine being scant and turbid, the case will not go on well until we have roused the kidneys to vigorous action by full doses of spiritus ætheris nitrici and acetate of potash, largely diluted with water, and accompanied with draughts of sonie aqueous fluid several times a day. This treatment is seldom required, but when it is necessary it must be adopted, or the case will become unmanageable.

In other cases there will be present an atonic diathesis, with pale upper lip or amenorrhoea. Here we must combine iron with the arsenic, taking care that our chemistry is not at fault. We may mix the vinum ferri with Fowler's solution, or the tinct. ferri sesquichloridi may be combined with the liquor

arsenici chloridi, taking care that the National Pharmacopoeia does not lead us into error, of which there is no small danger. It is never necessary, and rarely expedient, to exhibit triple compounds of arsenic, such as Donovan's solution, a very active but most unmanageable preparation. Neither mercury_nor iodine should ever be given in combination with arsenic. Each of these three energetic and useful medicines bas its value. Each acts in a different way, a way of its own, and each has its own peculiar power over disease. But mix them, and this distinctive power is buried, not blended. According to the constitution of the patient, one or another of these remedies has the upper hand, and you have no means of ascertaining if each or either is defective or excessive in the dose, nor could you alter it if you had.―Journal of Cutaneous Medicine, Jan. 1869, p. 350.

117.-AN ADAPTATION OF THE REFLECTING MIRROR TO THE UTERINE SPECULUM.

By Dr. LEONARD W. SEDGWICK, London.

To see better is so frequently to know more that I do not besitate to submit to the consideration of the profession an adaptation of the reflecting mirror to the uterine speculum, which for some time back I have found most useful.

The mirror is three inches and a half in diameter, and is of five inches' focal length. Like the laryngoscope mirror, it is mounted in a light metallic back, and to its circumference a brass arm is attached by a ball-and-socket joint, which is easily tightened or slackened by a screw movement. The arm can be lengthened or shortened by a simple telescopic slide; it is bent at a somewhat obtuse angle close to the joint, and is, when closed, four inches long. At its other extremity the arm is also bent at an angle, and is square; it fits into either side of a short socket attached to the upper surface of the outer end of the speculum, and is speedily secured there by a turn or two of a screw-cap.

By this means the mirror has a firm, easily fixed attachment to the speculum; and by the aid of the ball-and-socket joint and the telescopic movement it can be placed at any angle in relation to the axis of the speculum, and at such a distance from it as may be most convenient, or may afford the best illumination.

The mirror may, of course, be adapted to any speculum. It has been made for me, with their usual success, by Messrs. Weiss and Son; and I have latterly used it attached to a speculum of their construction, which, I venture to think, is the most satisfactory instrument yet made.

The form of the speculum originated, I believe, in a sugges tion of Sir James Simpson. The lower blade is of the duckbill shape; the upper is flat, and fits on to the lower in such a manner that a small interval is left between the two, so that in closing the instrument for withdrawal no pinching of the vaginal mucous membrane can occur. The upper blade is shorter than the lower one, so that when the speculum is opened the cervix is easily received into it. The duck-bill shape of the speculum secures the very easy introduction of the instrument, and also so distends the vaginal walls as to prevent their falling in and obscuring the view of the os uteri. By this configuration the wooden plug is rendered unnecessary, and lateral blades are made useless: both very desirable arrangements; for, by the consequent simplicity of construction, thorough cleansing of the instrument is facilitated, and no absorbing surfaces or tortuous chinks are left where infecting particles may lurk or be overlooked. The dilating mechanism is Messrs. Weiss's improvement of that of Custo.

By the use of the mirror thus affixed, it becomes unnecessary to alter the position of the couch or bed on which the patient is lying; for, wherever the source of light may be, the mirror can be so adjusted as to reflect it upon the cervix uteri.

There are no formidable preparations to be made; for the patient may lie in the usual obstetric position on the bed wherever it may be placed.

A

A better illumination is obtained by daylight, inasmuch as a larger amount of light-rays are concentrated on the spot to be examined than can be obtained by direct transmission. better illumination is also obtained when artificial light is used; for not only does the same reflection of light occur as in daylight, but the part is relatively as well as positively brighter; for, as the lamp or candle may be placed on a table at some distance away, the great disadvantage of looking over through a bright light at a place not so bright is avoided. The impossibility of the occurrence of such unpleasantnesses as the dropping of grease or the singeing of bed-clothes is an additional recommendation.

ог

In all cases one hand of the medical man is entirely set at liberty, and in many instances both are free. Where the speculum does not of itself retain its position, and both hands are needed, the finger of an assistant or of the patient herself serves to secure its steadiness.

If the mirror be on a lower level than the source of lightand this may always be managed-it does not interfere with the use of both eyes; and as it is always set at an angle, it is never in the way of any instrument which may be in use. One can thus accomplish with greater certainty many necessary

mechanical interferences with the os uteri, because both hands are at liberty, and one has a clear and continuous view of all that is going on, especially if the instruments used are, as they may often be, trowel-handled.

I may add that this mirror may be used attached to the rectum speculum with advantage.-Lancet, April 24, 1869, p. 561.

118.-REMARKS ON RHEUMATIC FEVER.

By ALFRED FLEISCHMANN, Esq., late Physician-AccoucheurAssistant to King's College Hospital.

Since I entered the profession I have had thirty-four cases of acute rheumatic fever under my care. In each case I have depended upon (1) alkalies, (2) opiates, (3) blisters, (4) flannel envelopes; and with those four remedies, the rest of the drug-list may be burnt. Had I to treat as many thousands as I have had units, I should seek no further for means of cure. After careful comparative watching, I find the acetate and nitrate of potash is the best conjunction of alkalies. I give a maximum dose of half an ounce of the former and half a drachm of the latter in a claret-glass of dill water every two hours, until vomiting or nausea is produced, or, failing that, until the sweat ceases to redden litmus. In some cases it is astonishing the weight of alkaline antidote that is required to neutralise the acid poison. In one case my patient took two pounds of the acetate and a corresponding amount of the nitrate before he had had enough. If these doses are exhibited and borne, the pain is, as a rule, mitigated in twelve hours. I do not feel sure whether it is better in all cases to give or withhold opium; I think it should depend upon the amount of pain, rather than the amount of disease. The complete envelopment in flannel and wadding is a valuable aid, for which we should never forget to thank that admirable physician, Dr. Chambers, of St. Mary's Hospital. Blisters should be a later resort, with the exception of one, half the size of a playing card, an inch and a half below the left clavicle-an application I look upon as an almost certain preventive of cardiac mischief. In all my cases I have had only one instance of original heart complication, and that was a case rather of carditis than of rheumatic fever (the patient was well and dead in thirty-six hours.)

Of course all this has been written a hundred times: I rewrite it, not as a novelty, but simply recording its adoption and success in my hands. I would make, however, one or two remarks which I do not remember to have seen in print. When a patient has once had an attack, he should, if an intelligent person, be prepared for his own subsequent behaviour in any