expected from their use. Hitherto the best remedies have been those which time has proved to be beneficial, and which came into use regardless of any à priori consideration as to their modus operandi. Amongst the medicines which have a marked and decided control over nervous action, the most striking are opium, quinine, aconite, digitalis, &c. All these have, under peculiar circumstances, a marked effect in controlling inflammatory processes, and the accompanying febrile action.

In a part of the body which is inflamed the blood-vessels are dilated, but whether this condition is to be regarded as the first stage, or simply as a necessary accompaniment to increased cell growth, according to Virchow, does not much concern the argument therapeutically, since, as a matter of fact, a remedy which acts on the vessels to their contraction, tends to arrest the inflammatory process. Thus the application of nitrate of silver to the eye in conjunctivitis, or to the skin in erysipelas, will contract the vessels and allay the inflammation; also the strapping of a joint or testis will effect the same in a mechanical manner. I suppose it must be admitted that, if an internal remedy could act on the vessels of the conjunctiva in the same way as a local one, to arrest the inflammation, it would be deserving of the name antiphlogistic; and if so, the administration of iron, now a very favourite remedy for erysipelas, if it act by constringing the vessels must be entitled to the same name. At present, I believe, the usual explanation of its beneficial action is, that it improves the condition of the morbid blood.

There would then appear nothing remarkable in the idea of an antiphlogistic remedy, or one that should so act on the nerves, and through them on the blood-vessels, as to actually arrest an inflammatory process. If we remember the remarkable effects which result from the administration of quinine in some febrile disorders, we are led to the conviction that its mode of action must have been in the manner indicated; thus I have as much reason to believe that I have cut short a case of acute rheumatism by this drug, as I have by the use of any of the ordinary remedies. In the same sense, I should say that opium is the most important anti-inflammatory remedy at present known. It never could have maintained its position as a medicine in all forms of inflammation unless this had been its true nature. In various forms of inflam mation of the abdomen and chest, it is a remedy almost universally given; and if administered less in affections of the pulmonary mucous membrane, it is only because there is a fear that by lowering the respiratory process it may tend to prevent expectoration; but it is in these very maladies that its effects are most striking. I have seen the case of a child suffering from bronchitis, and supposed to be dying from an over-dose of laudanum, who, from time to time, fetched what appeared to be its last breath, during a most anxious period of two or three hours, and then recovered from the effects of the medicine, and, what was most extraordinary, from the disease at the same time. I have seen a somewhat similar case of croup, where there was a narrow escape of poisoning by opium, and a sudden arrest of the symptoms. How a sore throat or bad cold can be at once checked by a Dover's powder, or dose of laudanum, is in every one's experience; as also, how an ulcer on the surface of the body will sometimes rapidly heal under the influence of opium. This well-known fact would, it might be thought, have given us a hint as to the controlling power of the drug in nutritive processes. I cannot refrain from mentioning a case which came under my own notice, where the remedy saved the patient's life almost as directly as if he had been snatched out of the river when on the verge of drowning. A friend, seventy-five years of age, was knocked down in the street and struck upon the leg; the skin gave way, ulceration ensued, and in a few days nearly the whole of the limb, from the knee to the ankle, was denuded. He took to his bed, and I visited him to take a final farewell. I found the ulcer still rapidly spreading in all directions, and I was asked to prescribe. I therefore wrote to his medical attendant, stating that, following the footsteps of my old master Mr. Aston Key, I should have ordered in such a case a grain of opium every four hours. This was done, and I heard in a day or two that the old gentleman was better, and when I visited him at the end of another week, I found a most re

markable change had taken place; not only had the ulcerative process stopped, but healing had already commenced. After this, repair went on rapidly, and he was soon able to leave his bed, and continue his out-of-door

exercise.

Since, therefore, we see this very evident action of opium on nutritive processes, and as we already know that this drug is of service in various inflammatory processes, we might advance a step further, and infer the possibility of opium being able, in a very large dose, to arrest such a disease as pneumonia at its onset. In speaking of this disease, and some of the usual remedies for it, I am reminded of antimony, which has long had the reputation of being an antiphlogistic. It is one which I still prescribe, and believe that its action is beneficial. It may be supposed, like many other of the metals, to exert a contractile influence over the small arteries, and thus, in the same way as lead or iron, tend to arrest hemorrhage.

Amongst other remedies which have had a long-timed reputation, as capable of depressing the heart's action and lowering the circulation, is aconite, but one which has never come into general use on account of its highly poisonous nature, and from want of precise rules as to the class of cases demanding its administration. There have, however, always been some in the profession who have attributed the very highest value to its use; there is nothing remarkable in this, when I know, with such a time-honoured remedy as digitalis, there are many medical men to be found who are ignorant of the indications for its employment; and yet it is a drug which may be put before any others in the Pharmacopoeia, as showing the most striking effects from its administration. As regards aconite, I am acquainted with two medical men who in the course of a long practice have been in the habit of daily using it, but have not cared to speak of it too openly for fear of having their names associated with members of an eminently quack system; and it may be remembered that the late Mr. Liston brought no little odium upon himself on account of his advocacy of the use of this drug in erysipelas.

I myself have been in the habit for some years past of occasionally ordering this remedy, when favourable cases occurred, but unfortunately have preserved no notes of them. As a rule, hospital practice does not afford a good opportunity for the trial of the drug, as it is only at the onset of an inflammatory process that it is lik ly to be beneficial; it must, therefore, be left to gentlemen in general practice to efficiently put its properties to the test. I will give a few cases where I have a firm conviction that the medicine acted beneficially, and I may add I am still engaged in the trial. Aconite, it may be remembered, has a most powerful depressant influence on the system; in those persons who have accidentally taken a poisonous dose, the heart action has become enfeebled and the pulse very slow; it is supposed, therefore, to have a very direct effect on the circulating system, through nervous agency: but whether the febrile condition, which is diminished under its use be due to the simple lowering of the heart's action, or to a more immediate contraction of the blood-vessels, may be a question, but I believe that the latter opinion is the one most usually held.

Pneumonia.-John D., aged 17, admitted into the hospital Dec. 31, 1867. He was a healthy lad, and by employment a groom. Three days before admission he was exposed to wet and cold, when he was seized with a shivering fit and catching pain in the side, followed by great headache and loss of appetite. On admission his appearance at once denoted the malady from which he was suffering; his face was flushed, his breath quick and catching; and in a high state of fever; pulse 88. At the lower part of the left side the chest was dull on percussion, and there was ægophonic bronchophony. He was ordered to take three drops of tr. aconite every four hours, and to be put on low diet. On the following day, Jan. 1, he was not seen, but on Jan. 2 the change in his appearance was most marked, and it was at once evident that the inflammatory process had ceased; he had regained his natural look; the skin was cool, tongue cleaning, and the pulse at 60. An examination of the chest showed that there had been no advance of the pneumonia, but that

the affected part was recovering itself.

The medicine was omitted; he

made a rapid convalescence, and left the hospital well on Jan. 13.

Acute Rheumatism.-Frances C., aged 15, admitted to the hospital July 17. All the joints swollen, red, and so acutely painful that an accidental jarring of the bed forced her to cry out; and with this all the other usual symptoms of rheumatic fever; pulse 104. She was ordered two drops of the pharmacopoeial tincture, every three hours, and to be continued regularly through day and night. This was done and administered without intermission during the day and night of the 18th, and during the day of the 19th. In the evening she became delirious and so strange in her manner that the house surgeon was sent for, and ordered a placebo. He informed me on the following morning that he believed she was bysterical, and was quite unaware that she was the subject of acute rheumatism, as he found her lying on her side with her arms over her head, screaming out and moving about in a manner which is seldom seen when the joints are inflamed or painful. When I saw her on the following day, I observed a strangeness and restlessness in her manner, and she complained of a burning in her throat and pain in her back, but all trace of the rheumatism was gone. I had no hesitation in attributing the new symptoms to the effects of the remedy. She subsequently had a slight pain in the ankle and wrist, and then rapidly convalesced. She was walking about the ward on August 1.

Acute Rheumatism.-John M., aged 16, admitted Sept. 23. He had been ill three days with febrile disturbance and pains in the limb. I was unable to say whether it was the onset of rheumatism, or merely a " bad cold," which is technically called "febris catarrhalis rheumatica." He had had rheumatism before, and there was present a slight systolic murmur; saline only was ordered. On the 24th he was much worse; he had a sweating skin, with the characteristic rheumatic odour, with pains in all his joints, and pulse 104, temperature 102°, and the case was now clear. He was ordered five drops of tr. aconite every four hours, night and day. I did not see him on the 25th, but on the 26th I was much struck with his altered condition: instead of finding the disease more developed, the pains in the limbs had diminished, and the fever was disappearing; the most striking fact being that the pulse was 64, having been reduced by 40 beats, the temperature 99°. He had taken ten doses of the medicine. I now ordered it to be taken only three times daily. He continued to improve, and on the 28th appeared tolerably well; pulse 60. He then omitted the aconite and continued to convalesce; when, on Oct. 8th, being dissatisfied at taking no medicine, I ordered him some quinine. On Oct. 12th he said he was very unwell, and I then ordered him an aperient. On Oct. 15th I found him in bed with a relapse of the rheumatism, complaining of all the symptoms as on admission; pains in the joints, hot and sweaty skin; pulse 124. I again ordered the tr. aconite to be taken every four hours. I did not see him on the 16th, but on the 17th all the febrile symptoms were subsiding, and the pulse was down to 80. On the 18th it was 72, when I omitted the medicine. After this he convalesced and left his bed, though he still complained of occasional pain in the knee or wrist. His pulse was now always between 80 and 90.

Whooping Cough (?) and Bronchitis.-Caroline C., aged 20, admitted May 31; had been ailing with a severe cough for two months, and what her medical attendant believed to be pertussis. She had got very thin; had considerable dyspnoea, face dusky, and eyes swollen; had severe paroxysms of coughing, which lasted some minutes, in which she whooped, and followed by the expectoration of a large quantity of purulent phlegm. She occasionally vomited and spat up some blood. I ordered her tr. belladonnæ x every four hours. She gradually became worse, and on June 4 I found her sitting up in bed with much dyspnoea, cheeks and lips livid, mucous râles throughout the chest, tongue furred, pulse 144. I now ordered her tr. aconite miv every four hours. June 5, seemed little better; pulse 140, respiration 37. June. 6, decidedly better; pulse 100. On June 8, still improving, although expectorating very much. In a few days the cough less, the patient altogether bet

ter: some cascarilla mixture was ordered, and she gradually gained strength and flesh, and left tolerably well at the end of the month.

Chronic Catarrh.-A gentleman came to my house complaining of a bad cold which he had had for two or three weeks, and could not get rid of; he had running from the nose and eyes, with pain over the forehead, as is seen from the effects of the iodide of potassium. He had taken all the ordinary medicines without effect, and therefore I thought it a good case to make trial of the aconite, which I ordered him in 5 doses every four hours. He called on me three days afterwards, when all the symptoms were subsiding. It is probable that opium might have had the same result.

In giving the above cases I should mention that I have given aconite to other cases without success, but they were scarcely comparable with the foregoing. Those of late were the cases of two women of middle age with subacute rheumatic gout of three weeks' duration, and in which, there being no marked effect, in a few days I omitted it. In a case of pneumonia of one lung the stages were passed through in the usual manner whilst the remedy was being taken, no obvious effect being produced. Also, in a girl who came in desperately ill with acute rheumatism and pericarditis, I gave a few doses, and then thought it right to omit it for more approved remedies. I now regret this, as the case would have afforded a good example for the trial of the remedy.

In the successful cases I have given above, I should direct attention more especially to the first three, where I cannot but doubt of the efficacy of the remedy, seeing that, besides the subsidence of the disease which was being treated, there was such a marked influence on the pulse. This cannot be accounted for except by the action of the remedy. Their publication cannot at present prove much, but they tend to corroborate the opinion of those who have used aconite beneficially, and may tend to further its employment in the hands of others.-Practitioner, Dec. 1868, p. 330.

10.-ON THE EFFECTS OF REMEDIES UPON UNCOMPLICATED ACUTE RHEUMATISM.

By Dr. W. H. DICKINSON, Senior Assistant Physician to St. George's Hospital.

[The following paper is the sequel to some tables which very fully record the result of treatment upon a considerable number of cases of acute rheumatism.]

The tables supply the following facts:-161 cases of acute rheumatism, as yet without evidence of cardiac affection, were admitted. In 36 of these, heart complications arose while the patients were under treatment. These complications, though more frequent early than late in the disease, were found to have come on at all times during the first four weeks of the rheumatism. The cardiac disturbance was found in the first week of the disease in 12 cases; in the second in 9; in the third in 5; in the fourth in 3. In 7 cases the date of the murmur was uncertain.

These statements cannot in strictness be looked upon as contributing to the "natural history" of rheumatism, for all the patients were subjected to therapeutical measures, and some to measures which, there is reason to believe, conferred such protection upon the heart as to reduce the proportion of cardiac affection.

A nearer approach to the natural proportion of cardiac disturbance would probably be obtained by excluding all the cases subjected to alkaline treatment. This would give 35 cases of heart affection coming on in hospital among 110 of rheumatism.

The chief object, however, of this communication is to examine into the frequency of cardiac mischief in relation to different methods of treatment. Of the 161 cases of rheumatism, 48 were subjected to the alkaline treatment—that is, to the daily administration of between half an ounce and an

ounce and a half of the carbonates and vegetable salt of potash and soda. Three cases were treated with salt of ammonia. 110 cases were treated by various means, other than the full alkaline system, including blood-letting, mercury, nitre, guaiacum, opium, iodide of potassium, quinine, and such small doses of the alkaline salts as are described as "partial" or come under the designation of salines.

Among the 48 patients under alkalies one case of heart affection was recorded; among the 3 under ammonia, none; among the 110 under treatment other than alkaline were recorded 35.

Thus the alkaline treatment gave a proportion of heart disease of 1 in 48; non-alkaline treatment a proportion of heart disease of more than 1 in 4. The number of cases is large enough to afford a weighty deduction.

It is, of course, not unlikely, as the notes which the tables represent were taken for the most part in the ordinary course of hospital work, that a slight or transient murmur may now and then have been overlooked; but this source of error must have affected alike all modes of treatment. With the evidence before us it is not possible to question that, as compared with the other methods in use at the same time, the alkaline system gave a much smaller proportion of cardiac disease.

It will be observed that under alkalies the duration of the disease was shorter than under most other plans, a point, however, of little importance as compared with the safety of the heart."

It is not necessary to consider other remedies; venesection and mercury are practically abandoned in acute rheumatism. Next to the alkalies, nitre appears to give the best results. With regard to the other drugs which are represented in the table, we can trace no advantage from their administration, and need not too precisely inquire whether they are mischievous or merely useless.

With regard to Dr. Davies's blistering system—a method of treatment of which the tables give no example,-from clinical evidence as well as the theoretical probability of the withdrawal, by this means, of a rheumatic poison, we may believe it to be attended with advantage. On the other hand it is inconvenient to the patient, and probably does not protect the heart to the same extent as can be claimed for alkaline medicines.

It does not seem that any method of treatment which has yet been invented is able entirely to do away with the tendency which acute rheumatism has to affect the lining and covering membranes of the heart. Of late years, alkalies in some form have boen almost invariably used at St. George's in cases of this disease; thus a much larger number of cases have every year been subjected to this treatment than was formerly the case. Dr. Reginald Thompson, the present medical registrar, has collected a considerable number of cases both of endocarditis and pericarditis, under alkalies; but it is not necessary to dwell upon this fact, since, as no other method of treatment has been employed to any extent during the same period, we have no means of comparing these cases with others under different circumstances. Though it must be allowed that heart complications occur occasionally under alkalies, the conclusion may fairly be drawn that, as compared with other modes of treatment, alkalies give the best results.

It may not be out of place to refer to the experience of Dr. Fuller, who was the early, and has been the persistent, advocate of the alkaline treatment. He states that among 168 cases of acute rheumatism, the heart became involved, subsequent to the commencement of the treatment, in only five.

Whether alkalies give better results than mint water, or what is called expectancy, is a question to which the details I have given supply no answer. If the proportion of cardiac disturbance which occurred (as shown in the tables) under treatment other than alkaline be allowed to approximate to that which would have taken place had nothing been done, we may see something of the results of expectancy in the non-alkaline cases. Some of the methods of treatment were apparently harmless; we may perhaps believe that under their influence the disease was not materially aggravated, and did