"THE ACTION OF THE WATER OF LLANGAMMARCH WELLS ON URIC ACID."
1883 from hospital until March 29tb. In other words, he was two months in hospital under constant observation and with ' every comfort after convalescence was established. A similar case with equally happy results had been under my care in the hospital a year previously, and although this patient returned to the ward for a short time while the patient whose case I now describe was under treatment there has been no recurrence of his extensive dropsy since his convalescence. He also was kept for
... long time in hospital. This patient was as old as the one whose case I now record, and had even harder arteries and a dilated and arrhythmical heart, and the full consolidation of his convalescence appeared to have established a compensation even under these circumstances which had successfully coped with the wear and tear of another year. As regards the efficacy of mercury administered in the combination indicated and under the circumstances under consideration Sir Thomas Watson,2 discussing the treatment of "anasarca," remarks: "Sometimes a combination or farrago of diuretic substances proves more efficacious than larger doses of any of the ingredients administered singly and the operation of some of these combinations is undoubtedly quickened or exalted in many instances by the addition of mercury. A fluid drachm of the officinal solution of the bichloride in each dose in a mixture or small quantities of calomel or of blue pill when the medicines are given in a solid form. A very useful pill of this kind, much recommended by the late Dr. Baillie, consists of three or four grains of the pilula hydrargyri, mixed up with one grain of the dried powder of squills, to be given twice or thrice a day. Dr. Baillie states that squills and digitalis are much less effectual by themselves than when combined with mercury." The .formula of this pill, which is given in the second and third editions of Dr. George Gregory's " llements of the Theory and Practice of Physic," is three grains of pilula hydrargyri and one each of powder of squills and of digitalis, to be taken at midday and in the evening. As the formula is not given in the first edition which was published in 1823-the year in which Matthew Baillie clied-it is probable that the usual posthumous extension of Gregory's armamentarium took place after the death of his great and good contemporary. But Baillie would have been the first to acknowledge that the principle of the combination of cooperative elements was as old as the world itself, and exemplified by all the healing waters known to bathers and physicians from and prior to the days of the name-father of our society down to those of the last bath-doctor who has lost his mental equilibrium in enthusiastic praises of a new spring. Withering, indeed, writes of the therapeutic relation of squills to digitalis thus : "Next to the lancet, I think nothing lowers the tone of the system more effectually than the squill, and consequently it will always be proper in such cases to use the squill, for if that fail in its desired effect it is one of the best preparations to the adoption of the digitalis." 3 We now know that the active principle of squills acts much in the same manner as that of digitalis and that neither "lowers the tone of the system" except when administered in excessive doses or after too protracted use, but the above quotation shows that Withering's practical sagacity had detected the aid which one at times could lend the other. At page 170 of the same essay a prescription of Withering is given in which two grains of 11 gray mercury " were combined with 20 of powdered digitalis leaves and divided into 14 pills of which one was to be taken twice a day-evincing, surely, quite a modern timidity of mercury. I have not, however, met with any actual combination of all these ingredients in one pill in Withering's work and we may therefore assume that the attribution of that combination to the clinical acumen of Baillie is correct, but I have not so far met with a note of it in his works, which are well worthy of perusal even to-day. The addition of a grain of hyoscyamus -the "Guy's pill" used at the Great Northern Hospital-I was probably not intended by its originator or originators to be other than a corrective to the intestinal effects of the other drugs, but it is just possible that as a drug of the belladonna group it may not be without influence upon the circulation when administered for a length of time. I have, indeed, occasionally used extract of belladonna in the pill instead of hyoscyamus on this principle and especially when there is a bradycardial rather than tacbycardial tendency in the 2 Lectures on the Principles and Practice of Physics, vol. ii., p. 597. 3 An Account of the Foxglove and some of its Medical Uses, 1775, p. 190. arrhythmia so frequently associated with arterio-sclerosis-The beneficial influence of mercury in the combination is, I think, clinically indisputable, but the discussion of the precise manner of its operation might lead to much, and perhaps not very useful, speculation. A fact, however, among the effects of mercurials to which Sir William Broadbent (to whom I attribute a considerable share in the revival of the medical use of mercury) attaches much importance is its lowering the tension of the pulse. How this is brought about-whether by the elimination from the blood of waste material which has a spastic effect upon the arterioles or by direct dilatation of the peripheral vessels in the process of its own elimination-it is not necessary at present to inquire and is very difficult to determine. That the permeability of peripheral vessels by a lessening of their resistance is secured appears to be clinically demonstrable. This being so it is not difficult to imagine, and is indeed permissible to suppose, that the combination of mercury (a peripheral dilatant) with digitalis and squills (which are in part central stimulants as well as peripheral contractors) constitutes it a rationally indicated adjuvant to the action of the latter in cardiac failure due to arteriosclerosis. Like many other happy therapeutic combinations, however, it was probably at first employed in this connexion empirically, even by men of the calibre of Withering and of