the change of one form of cardiac tonic for another is often very beneficial; I have seen great improvement when convallaria has followed digitalis.

I turn now to the evidence concerning agents of an opposite character-cardiac depressants. For the treatment of pain having the characters of angina, nitrite of amyl, by inhalation, and nitro-glycerine, in solution or in tablets, are agents of the highest value; there is nothing to add to the valuable evidence of Drs. Brunton and Murrell on this point. It may, however, be an important matter for consideration whether these agents may be administered continuously for long periods. In some cases manifesting high arterial tension without evidence of valvular disease, I have seen great advantage from long-continued courses of nitro-glycerine. Often very small doses-1-200th gr. thrice daily--suffice to keep all adverse symptoms in abeyance. In the case of a female patient of mine, aged fiftysix, manifesting aortic obstruction and regurgitation but very high arterial tension, I allowed the administration of nitro-glycerine tablets for five months. For seven weeks the administration of 1-100th grain twice a day was attended with the complete removal of all symptoms of distress; then, pain occurring, three instead of two doses were administered daily. Great improvement followed for nearly two months, when rapidly fatal edema of the lungs occurred. In this case there were chronic renal disease and marked albuminuric retinitis. The necropsy showed acute nephritis engrafted upon the chronic. There was an atheromatous lesion of only one aortic cusp, and the left ventricle was hypertrophied. It can hardly be doubted that the immediate cause of death was renal rather than cardiac, and it is probable that the influence of the drug was wholly beneficial. I can conceive that it could be baneful, however, if regurgitation had been more free, or if there had been great and increasing obstruction of the coronary circulation; at any rate, I am sure that a caution is necessary to patients who are intrusted with a prescription for nitro-glycerine, for I have had evidence that as there is a morphinomania, so also there may be a nitro-glycerinomania. In cases manifesting high arterial tension without implication of the aortic valves, such doses and it has been a matter of surprise that a dose of 1-200th of a grain three times a day suffices--may be continued for an indefinite time with nothing save advantage. It seems quite probable that the general arte

rial tension being thus relieved, atheromatous changes may be kept in abeyance. It is different, however, if disease exist about the aortic orifice; then the relaxation of tension may lead to an insufficient supply of blood through the coronary arteries to to the heart. This is no valid objection to the occasional use of these medicaments in such a case, for heretofore I have found no treatment of greater value when the pain is paroxysmal and severe.

Concurrently with these agents which immediately affect the heart and circulation, and occasionally for periods to supplant them, in cases in which the aortic valves are involved in atheromatous change, I consider that alkalies are of signal advantage. A very convenient form for protracted administration is this: Of bicarbonaté of potash and soda, of each ten grains; of powdered ginger, five grains; of powdered leaves of digitalis, one grain: the powder to be taken in water thrice daily one or two hours after meals. The iodides, especially the sodium iodide, have been strongly recommended in these cases, and, indeed, my friend and colleague, M. Huchard, considers that iodide of sodium is almost a specific for angina. In those in whom there is a distinct history of syphilis, the administration of the sodium iodide in gradually increasing doses, five, ten, fifteen, and twenty grains, three times a day, concurrently with cardiac tonics, is indicated, and I consider that M. Huchard's estimate of the value of the drug may be justified; but in others in whom the on-come of the disease has been gradual, and in association with lithemia or with chronic renal disease, there is no advantage over the treatment by the alkaline bicarbonates, and in some the iodide is distinctly hurtful. Certainly I have not found it so uniformly beneficial as in cases of aneurism of the thoracic aorta.

Concurrently with these means of internal medication and friction, massage, and in some cases systematic bathing, can, I consider, be proved to be of signal advantage. Liniment of aconite and belladonna may be employed, and often distinctly relieves the pain referred to the sternum, but for protracted daily use no liniment has any advantage over massage practiced with the soft portions of the thumb and palm, dusted occasionally with a little lycopodium or powdered fuller's earth. In a case of advanced atheromatous disease at the aortic orifice, I should hesitate before advising thermal treatment at any of the well-known watering places; but in a lady manifesting

aortic obstruction, with albuminuria, which happily passed away, together with arthritis, I found great improvement follow a course of treatment at Aix-les-Bains.

As regards the therapeutics of traumatic lesions at the aortic orifice, I shall only consider the evidence which cases afford in reference to the questions of (a) muscular exercise and effort, and (b) emotion. It has seemed to me probable that in times past the policy of rest may have been too rigorously enforced. A lesion of the aortic valves of whatever kind, if only regurgitation were in evidence, being diagnosed, the danger, of movement was inculcated, and probably the fears of the patient unnecessarily invoked. A great protraction of rest in the recumbent or partially recumbent position may give too much repose to the heart, and, its physiological activity being suppressed, it is ready to follow the universal law of degeneration from disuse. On the other hand, the teaching of Oertel in favor of exercise pushed to the point of distress, and especially mountain climbing, in some forms of cardiac disease, may possibly induce evil in the opposite direction. It can, I think, be taken as proved that even a healthy aortic cusp can be lacerated by physical effort, and that such may not be realized as a violent effort at the time of its production. That the damage of an already diseased orifice can be increased by an undue effort is a proposition established a fortiori. Yet when an aortic lesion is quiescent and compensated, we have abundant experience to show that considerable exertion can be undertaken with the maintenance of seemingly perfect health. One of my patients was an energetic cricketer. To greatly reduce the amount of physical exertion in some cases would be to impart the danger of a lessened cardiac nutrition. The middle course is the best. First let us be assured that actual disease at the aortic orifice is quiescent, not progressive. Then commence with gentle exercise, always deprecating sudden effort. Every day the dose of exercise may be a little increased until our patient may be enabled to undertake such an amount as can ordinarily be sustained by an individual of his age, only under no circumstances should he be subject to sudden strain.

Now as to the effect of emotion in disease of the aortic valves, an effect that I think we are in danger of underrating. It may be a novel proposition that valvular disease may be produced by emotion, but I believe it to be true. I have been led to this view

by the observation of a large number of cases of chorea. The most notable antecedents in cases of chorea in children are (a) rheumatism and (b) fright. In Dr. Stephen Mackenzie's most valuable Report on Chorea it is stated that in 439 cases of the affection fright or shock was the immediate antecedent in 115, and rheumatism, acute or subacute, 116 cases. It has been my experience, as probably it has been the experience of many other observers, to meet with cases in which a child, to all evidence perfectly healthy, has been the subject of a sudden terror, and soon after has manifested the ordinary symptoms of chorea, and in such a valvular murmur has become audible. In some cases this murmur has been discovered with difficulty; a case has been examined again and again, and afterward, on a given occasion, an apical or basic bruit has been noticed, which has in some cases become permanent, and in others has passed away. I have found a diastolic aortic murmur to have been thus manifested. As to the disappearance of such a murmur in course of time I am quite certain, for I have known one of the most musical character to become quite inaudible and that without any sign whatever of infarction. When one considers the phenomena attendant upon sudden terror and the delicate structure of the cardiac valvular apparatus in childhood, I think we can arrive at a reasonable explanation. At the moment of fright the heart is inhibited, the arterioles contract, the surface is blanched, and the lips perhaps become livid from injection of the venous radicles. Then follows reaction, the heart palpitates violently, and the mitral curtains and aortic cusps may reasonably be expected to suffer from the violence. Pathological anatomy demonstrates to us that it is precisely at the margin of the valves where impact and attrition can occur that vegetations form. this ocasion I do not intend to develop this hypothesis further, nor do I wish it to be implied that I accept the embolic theory as explaining the universal causation of chorea, but I put it forward as a prima facie case that in the delicate endocardium of a child it is highly probable that the vegetations of a simply papular endocarditis may be initiated by the palpitation due to sudden emotion. These considerations point to the importance of keeping a patient who is suffering from aortic disease, at any rate at periods when endocardium may be considered unusually vulnerable, from mental as well as from physical shock. I may briefly here call attention to the question of the admin

On

istration of hypnotics in aortic disease. When the heart is very irritable and palpitation is frequent, a wakeful night may mean much mischief. As a hypnotic, the action of which is attended with no ill consequence whatever, I have employed urethane in a single dose of twenty grains at bedtime; but this loses its good effect by frequent repetition. Paraldehyde, in thirtyminim doses in almond mixture, may be given as an alternative, the dose being repeated in half an hour if sleep fails to come. These failing, as they do when pain and distress are severe, then the hypodermic injection of morphia and atropine is the best curse, and a few nights of such treatment may suffice to tide over the peril of insomnia. That insomnia is a peril in an aortic case I am well assured, though I am equally assured that the physician must take pains that the morphia habit be not inculcated.

I must now briefly consider the treatment in Class 4-septic or ulcerative endocarditis attacking the aortic cusps. In most cases--for in the majority the attention of the physician is not called till the destructive agencies have been too long in operation- it may be that all treatment is futile, but recent experience has convinced me that in all it is not so. I have recorded a case in which I administered sulpho-carbolate of sodium in thirty-grain doses three times a day for thirty days with inunction of carbolized oil, and, apparently in causal relation with this treatment, there was an extraordinary recovery, so that the patient left the hospital in perfect health, with the exception that a slight diastolic murmur was manifest at the base. Since my paper was written I have had an opportunity of following the case to its end. The patient was readmitted nine months after her discharge with a renewed attack of the disease, which proved rapidly fatal. At the necropsy we found, besides innumerable recent vegetations, a small portion of one of the aortic cusps eroded as from an old disease. Micrococci were abundant, penetrating among all the recent exudation, but not into the deeper layer of old inflammatory tissue. The appearances gave one the notion that the old attack had been cut short, and so the evidence of morbid anatomy seemed to confirm that of clinical observation. It is evident that for the antiseptic agent to do its work efficiently there must be a certain time given, but that the blood can be charged with an efficient amount of substance capable of acting as a poison to micro-organisms seems in

the highest degree probable. In any case manifesting the signs of endocarditis accompanied by very low arterial tension and not in definite association with rheumatism, I should advise the protracted administration of the alkaline sulpho-carbolate in large. doses. Dr. Arthur E. Lansom, in London Lancet.

TREATMENT OF DIPHTHERIA. The Boston Medical and Surgical Journal gives a summary of a paper read before the New York County Medical Association (19th inst.) by Dr. J. Lewis Smith, on present opinion regarding the pathology and treatment of diphtheria. The part relating to treatment follows:

In speaking of the preventive treatment of diphtheria, Dr. Smith said that Dumas had recommended iodine as a prophylactic, giving to exposed children, in course of twentyfour hours, a four-ounce mixture containing eight drops of tincture of iodide, and ten centigrams (1.34 grains) of iodide of potassium. The most effective method of preventing diphtheria, however, was the isolation and disinfection of the apartments, in addition to preventing the inhalation of n xious gases wherever an outbreak of the disease bad occurred.

Dr. H. B. Baker, of Lansing, Mich., had published statistics showing that in one hundred and two outbreaks of diphtheria the average number of cases where disinfection and isolation (either one or both), were neglected was sixteen, and the average number of deaths 3.23; while in one hundred and sixteen outbreaks in which isolation and disinfection were enforced the average number of cases per outbreak were 2.86, and of deaths .66. These precautionary measures, therefore, prevented thirteen cases and 2.57 deaths for each outbreak, or, in the total 1,545 cases and 298 deaths in the year.

The proper treatment of diphtheria was far from being determined; and a chief reason why there was such a difference of opinion in regard to the value of remedies was because the disease varied greatly in severity in different localities and at different times. In some epidemics a large majority recovered, whatever the treatment (and even with injurious treatment), while in others a large proportion perished under the best possible remedial measures; so that statistics were misleading as to the value of therapeutic agents. In the year 1882 Dr. Lunin met with the following results from different remedies employed at the hospital of Oldenberg. In the fibrinous form of the disease

By tinc.of chloride of iron,32.60

According to Lunin's observations, therefore, in the fibrinous form temperature was the most useful therapeutic agent; but in the phlegmonous and septic form the chloride of iron was the most efficient. The cases of fibrinous diphtheria numbered 142, with 43 deaths; of the phlegmonous and septic form 122 cases, with 103 deaths. In all the cases treated in the Oldenberg hospital, aggregating 296, 164 were fatal. After having spoken of the value of tincture of chloride of iron, as observed by various writers, Dr. Smith took up the consideration of bichloride of mercury, which he said was at the present time regarded by many physicians as the most efficient agent at our command in the treatment of diphtheria. It was the most active and certain of the germicides employed in medicine, whether used locally or internally, and its use in diphtheria rested upon the fact that it quickly destroyed all micro-organisms. It was evident, however, that when this agent was employed as a spray in as strong a solution as was recommended by some, that it should be used with very great caution; and this was all the more necessary, of course, when the remedy was given internally at the same time.

Dr. E. N. Oatman, of Nyack, New York, had reported that he lost but one patient out of twenty-three, when employing the follow ing local treatment: Cotton is firmly wound around the end of a stick about the size of an ordinary lead-pencil, being drawn out as it is wound, and made to project beyond the end. This is dipped into a solution of bichloride of mercury, two grains to the pint (1 to 3,840), and passed into the throat until it touches the posterior wall of the pharynx. It is then instantly withdrawn and burnt. This treatment is repeated hourly, with a new swab usually in forty-eight hours. Dr. Smith thought that the quantity of bichlo

Turpentine had been highly recommended recently by physicians of experience for its prompt action, when used locally as well as internally, in arresting the formation and extension of the pseudo-membrane, and as an antidote to the diphtheritic virus. Dr. Rewentauer had reported that an infant of two years, treated by other remedies, began on the fourth day to have symptoms indicating invasion of the larynx. Tracheotomy was resolved upon; but previous trial was made of pure turpentine in a teaspoonful dose. The result was that the croupiness ceased, the other symptoms improved, and the child recovered without tracheotomy. Delthil, by the alleged success of his fumigation treatment, appeared to have been the first to draw attention to the use of turpentine in this disease. His treatment was as follows: A mixture of 1 kilogram (2 pounds) of coal tar, 8 tablespoonfuls of turpentine, 8 grams (2 drams) of resin of benzoin, and 100 grams (3 ounces) of cajaput oil; or a mixture of 200 grams (7 ounces) of coal tar, 80 grams (2 ounces, 6 drams,) of turpentine; or turpentine alone. was constantly burnt in the sick-room. The vapors arising from the burning mixture were tolerated by the patient and did not give rise to vomiting; while they appeared to aid in arresting the diphtheritic process. Schenker modified Delthil's treatment as follows: A mixture was prepared of 200 grams (6 ounces) of coal tar, and 80 grams (2 ounces, 6 drams,) of turpentine; and of this, 50 grams (1 ounces) was vaporized at the bedside four times a day, each use of the vapor occupying half an hour. His observations had led him to believe that the benefit from this treatment accrued chiefly from the turpentine, and largly from its general effect upon the system. He therefore employed turpentine internally, in doses of 10 minims to one teaspoonful, given from one to three times a day, in milk, sugar-water or gruel. At the same time he employed it as a spray.

He also used alcoholic stimulation; and, of 36 cases treated by the turpentine. 31 recovered. Rose, of Hamburg, treated 58 cases of diphtheria with turpentine, with the result of 95 per cent recoveries. He gave it three times a day in teaspoonful