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CURATIVE MEDICINE.

PART II.

THE CONSTITUTIONAL DISEASES.

Meaning of Constitutional Diseases.—By constitutional or organic disease is generally meant a visible disorder of structure; that disease and disorder are, however, essentially the same thing, is clear from the circumstance that function and organism are united. The state of the organ will always influence the function, just as a power applied to any machinery will produce effects according to the nature of the machine and the materials acted upon. The power and function of the machine are dependent on its intrinsic mechanism, though set to work by an extrinsic influence. The mode of working is not visible in the vital organs, nor are the functions of life mechanical, except so far as they act in time and space.

ACUTE RHEUMATISM OR RHEUMATIC FEVER.

Symptoms.—Acute rheumatism is an inflammation of the joints, characterized by general fever, by pain, heat, redness and swelling of the points affected, and by a tendency to leave one joint suddenly and fasten upon another. The affection sometimes commences by chills and fever, and general uneasiness; and these symptoms (rheumatic fever) may last for twenty-four hours or more before the local manifestations show themselves. More frequently the local symptoms make their appearance at the same time with the fever, and occasionally they are present some little time before it supervenes.

The Pain.—The pain in the joint or joints affected, commonly but little felt while the patient is perfectly quiet, becomes intense on the slightest motion, so that he is rendered completely helpless. The superficial joints become swollen and tense, they are hotter than natural, and the skin covering them is generally more or less reddened.

The Swelling.—The swelling is sometimes mainly caused by effusion within the capsular ligament of the joint itself, at others by the inflammation and thickening of the fibrous tissues external to the joint. The pulse is generally full, strong and moderately frequent, rarely rising over 100 beats in a minute; the skin is warm and copious sour perspirations are commonly present; the tongue is thickly coated, the bowels somewhat constipated and the appetite completely lost.

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Freaks of Inflammation.—The inflammation at first affects one or two joints, rarely three; after a variable time it commonly leaves the joints first affected as suddenly as it attacked them; and fastens on some other articulation; often, however, new joints are attacked without the disease leaving its original seat. As a rule the larger joints are the ones most liable to be attacked, the knees, elbows, ankles, wrists and hips; more rarely the smaller joints of the toes and fingers become affected.

Heart Attack.—Besides the articulations, acute rheumatism frequently attacks the heart, not by metastasis or transference of the inflammation from one part to another, but by seizing on the fibrous textures of the heart as in one of the series of textures liable to the disease. Sometimes the pericardium is attacked (pericarditis), sometimes the lining membrane of the heart's cavities (endocarditis). The younger the patient the more liable is the heart to be affected; so that when rheumatism occurs previous to the adult age the heart is attacked in a large majority of cases.

Rheumatism Hereditary.—The rheumatic constitution is frequently hereditary, and rheumatism is peculiarly a complaint of cold, damp seasons and climates.

Causes.—The cause of rheumatism has provoked more thought and research than any of the commoner diseases; at least one type of the disease is due to excess of fibrin in the blood. There is an exudation of this fibrinous material into the sheaths of nerves about tendons, especially where inserted into the bone, the fasciae of muscles, the serous capsules of organs, their ligamentous attachments, in joints, heart valves, and so forth, wherever fibrous tissue is found normally. This fibrinous exudate organizes into bands, fungus, nodules, and so forth, of cicatricial tissue, obstructing circulation and movement of parts and modifying cell nutrition. The presence of this fibrinous exudate makes the muscles hard and stiff, so that they contract with difficulty and pain, yet appear large and strong. Impinging upon nerves it causes pain and perverted nerve action. Especially is this the case where the deposit occurs near the bony opening whence the nerves emerge.

The Fibrous Exudation.—This fibrinous exudate is precisely like the membrane of diphtheria, of membranous dysmenorrhea, colitis and croup, the exudate in lobar pneumonia, and so forth. Its appearance in the muscles and other structures is also preceded by a similar weakening of the vaso-motor nerves. When the blood gets into this hyperplastic state it must get rid of the excess of fibrin-forming materials in some way, or it would finally solidify, organize like a clot, and the individual turn to stone. So nature sounds the alarm, and sacrifices a part to save the organism. But sometimes her warnings are not heeded.

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A Chief Cause.—The chief exciting cause, we know, is the application of cold to the body when unusually heated. Cold is more liable to produce this effect when combined with moisture, whence a cold and humid atmosphere and wet or damp clothes are the most frequent sources to which rheumatism can be traced. Partial cold, as when parts of the body are subjected to currents of cold air is very apt to give rise to rheumatism; when the body is predisposed a very transitory exposure of this kind will suffice to bring on an attack; if the current be sustained for any time, few will wholly escape some contingent suffering. Of the fact that rheumatism is so excited there can be no doubt. When it is reflected, however, that for every instance of rheumatism so induced, numbers continually endure as much or greater exposure to the alleged cause without any disease ensuing, too much importance should not be attached to it.

Diagnosis.—The only disease with which it is liable to be confounded is gout. Formerly discrimination in this respect was deemed of high importance, the prevailing theories of gout demanding a course of treatment very different from that to which rheumatism was subjected. In the present day a juster pathology of gout assimilates the treatment of both diseases sufficiently to render extreme accuracy of discrimination of very slight moment.

Prognosis.—The prognosis is dependent on the promptitude with which suitable treatment is resorted to. Generally speaking there is little immediate danger to life, there being no inflammatory disease of equal intensity which so little deranges the vital functions. This, most probably, is owing to the disease expending its violence in the joints and other external parts, and being little prone to attack the viscera. The peculiar character of the inflammatory action, too, and the little liability which it has to pass into suppuration, or undergo the other changes consequent to phlegmonous inflammation, may account for the safety with which even the metastasis of rheumatism to internal parts is borne. It is certain that such metastasis is not attended with so much danger as the severity of the symptoms would seem to denote.

Management of Acute Rheumatism.—One of the most important points in the management of acute rheumatism is to watch the supervention of the morbid action in the fibro-serous tissues of the heart. If is not necessary to repeat here the symptoms of pericarditis and endocarditis, but the occurrence of dyspnoea, with more or less anxiety, jerking or feeble and rapid pulse and tumultuous action of the heart ought to direct the attention of the practitioner to that viscus, and if he discovers by the physical signs and functional phenomena the existence of inflammatory action there, it must be treated as if the disease were unconnected with rheumatism, for no truth is better established than that, although acute rheumatism, seated in the fibrous and muscular tissues around the joints, is remarkable for its great and rapid change of location; chronic rheumatism loses this mobility when it fixes upon a serous membrane.

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Treatment 1.—Acute rheumatism produces, we have seen, diseases of the heart; it is, therefore, incumbent on the practitioner to prevent the continuance of the rheumatic inflammation of the serous membrane of the heart. The indications are to subdue fever and remove inflammation. The promptitude with which the local inflammation in its earliest stage yields to the treatment by which a plethoric state of constitution is corrected, and febrile action allayed, and the obstinacy of the local ailments, whenever the constitutional state is overlooked or inadequately treated, furnish the best proofs of the correctness of this pathology.

2. The treatment has been pursued in various ways—bleeding, mercurials, mercurials with purgatives, opium, sulphate of quinine and nitrate of potassa in large doses have been at various times resorted to. Of these methods, those by large doses of sulphate of quinine and by nitrate of potassa have seemed to have an influence in controlling and cutting short the disease, and the treatment by quinine appears to be successful in the acutest and most violent attacks; but they are both subject to inconvenience and dangers which counterbalance their advantages.

3. The treatment which is most generally relied on is the alkaline. Our aim being to liquefy and eliminate the fibrinous deposit. The iodides, ammonia preparations, jaborandi, hot vapor baths, massage, and counter-irritation have all been employed; overfeeding, especially with meats and highly concentrated foods, should be rigorously avoided. Persons having this fibrous diathesis should employ a resolvent treatment at intervals, for weeks at a time. Exercise must be systematic, and too much cannot be said of the value of hot vapor baths, massage and joint movements.

4. If the heart shows signs of being affected, and embolism or phlebitis occur, use ammonia, carbonate and acetate with nitro-glycerine, warmth to and rubbing of extremities with mercury to move the bowels. The old custom of venesection and cups, in vigorous subjects, was very fair practice. It made the patient thirsty and so called for diluents to thin the viscid blood. The cups relieved engorged parts, and paved the way for a better circulation through them.

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5. The fibrous diathesis varies from that of the uric acid, and the same treatment will not always relieve the rheumatic pains of both. In the former, there is a tendency to congestion of the brain, the liver and kidneys are apt to be sluggish. In the uric acid type of rheumatism irritability is contrasted with the torpor which characterizes the fibrous. Enlarged joints are common, and storms of disease sweep over the system. Muscular development is slight, and the powers of endurance small. In the fibrous diathesis the patient is well developed, tough and resisting.

As rheumatism is invariably accompanied by loss of appetite and embarrassed metabolism, it is naturally the result of accumulated secretions and imperfect excretion, hence it is best treated by freeing the bodily outlets and carefully measuring the supplies. While recognizing the necessity of salicylate treatment, we would advise that such be combined with mild cholagogues, diaphoretics and diuretics. The salicylate appears to exert a general action on all the excretions in the exact proportion in which such is needed.

6. If any organ requires but little correction, it receives no more, and on that account sufficient force is retained to exercise itself where it is more in demand. As a result, the beneficial effects of the salicylic acid treatment are utilized to its fullest extent without being followed by bad reactionary conditions.

MUSCULAR RHEUMATISM.

Symptoms.—Of the minor painful maladies it is probable that this disease is the most common in many parts of the country. Among the varieties frequently met may be enumerated lumbago, which affects the sheaths of the large muscles of the back and loins, sometimes extending to the ligaments of the sacrum. The pain is severe and generally of very sudden occurrence, so that the patient often imagines that he has strained his back without being able to specify when the accident took place.

Causes.—Stiff neck or cervical rheumatism generally follows exposure to a current of cold air striking the shoulder and neck and affects the large muscle attached to the side of the head behind the ear, and, at its other extremity, to the breast bone and the collar bone. The business of this muscle is, by contracting, to turn the face to the opposite side, and when affected with rheumatism, in order to put it on the stretch as little as possible, the patient rotates his head toward the affected side instinctively, and retains it in that ridiculous position because it causes so much suffering to hold it in the usual way.

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Pain in the Side.—Pleurodynia or pain in the side usually arises from a similar rheumatic affection of the muscles concerned in breathing, especially the short, flat muscles between the ribs, named the intercostal muscles. It is also called intercostal rheumatism, and as the pain thus produced very closely resembles that of pleurisy, it often gives rise to much needless alarm or fear that the more serious disease is present. In many instances the only way to be sure in regard to this matter is to make a thorough examination of the lungs with a stethoscope and determine their healthful condition; but as a general rule the absence of pleurisy may be at least strongly suspected if there is no cough, no fever in testing with the thermometer, and if the muscle on the affected side is very sore to the touch or on pressure.

Treatment 1.—The treatment of pleurodynia consists in putting the rheumatic muscles at rest as far as possible, which, however, can only partially be accomplished, because, being concerned in the vital process of respiration, they must continue to do some share of the duty. The best way to accomplish this object is to apply strips of adhesive plaster, overlapping each other, around the affected side so as to compress that half of the chest as tightly as possible.

2. The same thing may be secured, though less perfectly, by careful application of one of the ordinary porous plasters so much in vogue, and these are also useful in lumbago and stiff neck. Fifteen drops of wine of colchicum, with a quarter grain of opium, using these in small but frequently repeated doses, is often beneficial in these forms of rheumatism, and if the suffering is intense, a hypodermic injection of a quarter of a grain of morphia will afford very prompt relief.

CHRONIC RHEUMATISM.

Character.—The distinctive characters of this malady are a febrile state of the general system, with more or less pain and swelling in certain tissues and joints. And in this, precisely as in acute rheumatism, the continuance of febrile action undermines the general health, while the local inflammation, however indolent, disorganizes the joints, occasioning eventual decrepitude. The pain and swelling of joints with progressive thickening of the ligaments and effusion in the several bursae sufficiently evince the morbid actions from which such effects result. But coincident with these will generally be found a quickened pulse, some increased heat of skin and a furred tongue.

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Symptoms.—Chronic rheumatism presents itself under two forms. In one the Joints are swollen and painful, the pain being aggravated by motion; there is no general fever and the appetite may be good and the digestion sound. The affection is exceedingly obstinate, attacking new joints without leaving those first affected; it frequently attacks the smaller joints, rendering them permanently swollen and deformed, while the immobility to which the joints are sometimes reduced may cause atrophy of the muscles connected with them.

Gout.—When the type is precise and definite it presents sharply-drawn distinctive characters which distinguish it from gout; but it must be admitted that there are many cases in which it exhibits so great a resemblance to chronic gout that it is almost impossible to establish an absolute distinction between the two diseases. Mobility is the primordial character of rheumatism; this character at once presents itself. In gout—on the other hand— mobility does not show itself until the malady has become inveterate, until the attacks, which at first were strictly local, have frequently recurred, or the progress of the regular manifestations has been interfered with.

Treatment 1.—In the treatment alkalies and diuretics are of service, also the iodide of potassa, while the different mineral waters are frequently of great service. Warm salt water baths, the use of flannel and stimulating liniments afford relief.

2. It would be vain to enumerate the various stimulants which have obtained character for the cure or relief of this disease. The principal are the different essential oils; various balsams and gum resins; sudorific decoctions; electricity. Any of these may benefit according as the general constitution is prepared for their operation, or as the special ailment may require. If there be no plethoric or febrile state present, their use will at least be harmless, if not beneficial; but should the case be such as to need depletory treatment and the operation of mercury, then must the use of such stimulants as are now named be watched with great caution. Warm bathing and active exercise are among the unexceptionable and most powerful means of relieving chronic rheumatism.

Local Treatment 1.—The local treatment as directed for the regular or acute rheumatism also requires to be assiduously employed. For this various liniments are useful; none are better than those containing oil of turpentine, oil of sassafras, ammonia and laudanum, diluted with soap liniment, or where pain is considerable, chloroform or aconite liniment. Blisters may be applied in obstinate cases. Dry cupping to the back, leaving a number of cups on for twenty or thirty minutes at a time makes a more pervading favorable impression sometimes than might have been expected.

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2. For rigidity of the joints and even for pain in them or in the muscles, pouring hot water continuously over the parts does great service. The hot bath or vapor bath, or, as some prefer, the hot dry-air bath (130 degrees to 200 degrees) will be powerful for relief in many cases.

Electric Treatment.—Electricity also will aid in hastening the restoration of use to the stiffened parts.

SYPHILITIC RHEUMATISM.

This affects the long and flat bones chiefly, and mostly between the joints, not at them. Generally there is nodosity upon the bones affected, or some degree of periosteal inflammation at least. Our main reliance in this affection is the iodide of potassium.

ARTHRITIC RHEUMATISM.

This designation is applied to a form of subacute or chronic inflammation of one or more large joints of greater severity than ordinary chronic rheumatism. Effusion into the joints, with deformity and permanent lameness may occur. The treatment pursued in chronic rheumatism has proved beneficial.

GONORRHEAL RHEUMATISM.

A peculiar inflammation of one or more joints occasionally commencing in the course of gonorrhea or even of urethral inflammation from forced catheterism. The local affection may be severe, with suppuration in a few cases and anchylosis of the joint in many. It appears to be an ichoraemic affection; the result of absorption into the blood of morbid matter effused into the membrane of the urethra.

CANCER, OR MALIGNANT DISEASE.

Common Form of Cancer.—The most familiar and characteristic form of cancer is that which attacks the female breast, usually past the middle period of life. It first appears as a local induration situated beneath the skin, in the glandular tissue of the organ, for the most part in the neighborhood of the nipple. It increases slowly in size, becomes adherent to the skin and involves more and more of the substance of the breast.

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Cancer Pains.—In most cases sharp lancinating pains are experienced at this time, sometimes causing much distress. When the glandular substance of the breast has become fully affected, it is also found to be adherent to the walls of the chest, so that it can no longer be moved from side to side, and the skin over its whole surface is discolored. Smooth in texture, raised in irregular knobs or eminences and in spots red and tender.

The Ulceration.—The early hardness now yields to local softening, the skin gives way at some prominent point, and the ulcer thus formed shows no tendency to heal, but constantly enlarges and discharges a dark-colored and fetid exudation. Subsequently the morbid growth involves the subjacent muscles, the ribs and even the substance of the lungs. Internal cancer, however, is often developed as a secondary affection without being directly continuous with the external growth. The patient may be gradually exhausted by the pain, discharge and constitutional irritation dependent upon external cancer alone, or the fatal termination may be principally due to the secondary affection of the internal organs.

Course of Cancer.—The course of cancer is for the most part slow, requiring several years to pass through its successive stages. This is generally the case in cancer of the breast. In other forms, particularly where the morbid growth is softer and more vascular at the outset it often terminates fatally in a few months or even weeks.

Train of Cancerous Symptoms.—The cancerous humor possesses these characteristics:

1. The peculiar power of infiltrating every tissue as it encroaches upon it.

2. It spreads to the lymphatic glands of the neighborhood through the absorbents.

3. It affects the body generally through the vascular system, thus giving rise to secondary deposits, that is to say, to the development of similar growths in the viscera or remote parts, the lungs and liver being particularly prone to its attack.

4. It is liable to recur after removal.

The stroma is abundant, tough and resisting, giving a tuberoid circumscribed appearance to the mass when superficial. It is of great hardness, and when fully developed is firmly adherent to the adjacent parts. Upon section it presents a bluish-white, glistening appearance and yields a creamy, oily fluid known as cancer juice. When situated subcutaneously, as in the mamma, the tumor commonly assumes a dark purple or livid color, and is subject to darting, stinging or neuralgic pains. It is apt to ulcerate, when the sore will present hard and everted edges and the neighboring lymphatics will become indurated and enlarged. It is found most frequently in the mamma, liver, stomach and rectum. It is more frequent in women than in men. It is of slow growth, and rarely occurs before forty or forty-five years of age.

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Causes.—The observations which we have made on the relative frequency of cancer as to age, sex-temperament and condition of life contain the greatest part of what we have to say on the predisposing causes of the disease. Among these have long been enumerated the frequent and direct operation of irritating substances; external injuries, especially blows; the abuse of stimulating potions; immoderate indulgence in venery; the depressing influence of moral afflictions; bad food, conjoined with the debilitating effects of cold and otherwise unhealthy habitations; the injurious influence of one or more of these predisposing causes on particular organs being determined or modified by the individual or accidental circumstances of the case.

Cancer may be Hereditary.—The frequent occurrence, however, of cancer in individuals in whom none of these predisposing causes seem to have cooperated in the production of the disease has led many pathologists to consider it as having an hereditary origin.

Transmission of Cancer Germ.—The germ of the disease, or cancerous virus, is transmitted from the parent to his offspring. The evidence on which this opinion rests is shown in the fact that the material element of the disease is contained in the blood, and is separated from this fluid after the manner of nutrition and secretion, either in the molecular structure or on the free surface of organs; and that, while the formation of the disease is thus going on, there may be no appreciable physical or physiological modification of the part in which it is observed. It is thus that we meet with carcinomatous tumors in the brain, which, from their bulk and other characters, must have existed long before the functional disturbance of the organ gave signs of their presence; and we have an equally striking example of the silent development of these tumors in the eye, until acting simply as a foreign body, they obstruct the rays of light and render vision more or less imperfect.

Cancer Pimple.—In persons, too, apparently in the enjoyment of the most perfect health, we often see the disease making its appearance in the form of a small pimple, proceeding more or less rapidly in its course, extending in breadth and depth and terminating ultimately in death, in spite of all the means which art has devised. In others, a similar pimple arises under similar or even unfavorable circumstances, proceeds like the former to ulceration, and although it may have been neglected, irritated and excited from time to time, disappears and leaves the patient in perfect health.

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Diagnosis.—It is not until carcinoma has made some progress that we are sometimes able to recognize its presence in internal organs by means of a careful consideration of the local and general symptoms which we have enumerated. Little importance in general is to be attached to any one of them taken individually. But when the local signs, viz., the changes in the bulk, form and situation of organs, occasioned by the disease, its relative frequency in different organs and in particular portions of the same organ are taken in connection with the special and general modification of function which may be present in individual cases, the greatest possible assistance is afforded us in establishing the diagnosis. Thus it is more easy to detect cancer of the stomach than of the lungs, of the latter than of the brain; because of our being able to ascertain the presence of the greater number of the local signs of the disease in the first case, only a few of them in the second and none at all in the third.

Further Diagnosis.—And when the sense of sight can be applied with that of touch and hearing the diagnosis seldom presents much difficulty, as in the case of carcinoma of the os uteri and rectum. It is necessary to observe that too much reliance is not to be placed on the presence of these general symptoms which constitute the cancerous cachexia, for there are morbid conditions of the stomach and duodenum associated with the derangements of the biliary secretion which give rise to a state of debility and emaciation, accompanied with discoloration of the skin, which so closely resembles this cachexia that the one is not to be distinguished from the other.

Difficulty of Diagnosis.—The difficulty of establishing the diagnosis in such cases is likewise increased by the circumstance that the same chronic character prevails in both. It is hardly necessary to remark that the presence of carcinoma in an external part of the body is to be regarded as a diagnostic sign of great importance in all cases of a doubtful character in which functional derangement of an internal organ has existed for some time. In such a case we should regard the frequent occurrence of vomiting after meals as indicating the existence of carcinoma of the pylorus, even should no tumor be felt in this situation or dilatation of the stomach.

Abdominal Tumor.—If the presence of a tumor were detected in any part of the abdominal cavity we should not hesitate to say that it was of the same nature as the external affection, and the occurrence of paralysis, under the same circumstances, would justify us in attributing it to carcinoma of the brain or spinal cord.

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Possibility of Cure.—In no disease is a fatal determination so universally admitted as in carcinoma. The possibility of the cure of cancer of the internal organs has never been supported by substantial evidence, and the examples are few indeed in which we are disposed to believe that the disease has been removed from an external part by surgical or other means, without its recurrence in the same or some other part of the body at some other future period.

Symptoms.—Changes in the color, temperature, circulation and nutrition of the affected organ cannot be detected by direct observation, and those of bulk consistence and form can be determined only in certain organs, and at a more or less advanced period of the disease, such as the stomach and intestines, liver, spleen, kidneys, ovaries and uterus, lungs and mesenteric glands, in all of which organs these changes may be recognized either by the touch, percussion or auscultation. But it is more particularly the change of bulk which is detected by these means, and which, as a local symptom of the presence of cancer, is that to which the greatest importance is to be attached. The increase of bulk which accompanies the presence of cancer is not perceptible until the disease has made some progress. It is most considerable in solid organs, such as the liver, kidney, ovaries and so forth, and is seldom very marked in hollow organs, such as the stomach or intestines.

Further Symptoms.—Considerable increase of bulk may, however, have taken place in the walls of the stomach and intestines without our being able to detect its presence, which happens when cancerous matter accumulates in the direction of the internal surface of these organs. In such cases an increase of bulk of a different kind is produced, viz., dilatation, in consequence of the obstacle presented by the carcinomatous matter to the passage of the food or feces. When dilatation of the stomach is thus produced, the obstacle is situated at the pylorus; when of the small intestines, it is, in the great majority of cases, situated at the termination of the duodenum or commencement of the jejunum and caput cecum coli; and at the sigmoid flexure of the colon and rectum when the dilatation occupies the larger intestines.

Bulk of Stomach.—The increase of bulk which the stomach and intestines acquire in consequence of an obstacle of this kind is sometimes very great. In some cases of scirrhus pylorus the stomach has been found to occupy the greater part of the abdominal cavity, stretching down to the symphysis of the pubis and from one lumbar region to another; and the large intestines sometimes measure from four to six inches in diameter when similarly affected. We have seen the small intestines equal in size to the ordinary dimensions of the stomach. It is important to know that the extent of the dilatation is not to be taken as the measure of the extent of the disease. The greater the dilatation the greater we may infer is the obstacle by which it is occasioned, but this obstacle may consist in a slight scirrhus enlargement, which prevents the passage of the food or feces as effectually as when it is occasioned by one or more tumors of considerable size or great thickening occupying several inches in length of the whole circumference of the walls of the stomach and intestines.

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Pain of Cancer.—The only modification of the sensibility which as a local symptom accompanies cancer is that of pain. There is, however, no symptom of carcinoma more deceptive than pain. Of all varieties of carcinoma it is that of scirrhus which is most frequently accompanied with pain, and it is also in this variety that the pain is most severe, acute and lancinating. Vomiting is an invariable consequence of carcinoma of the pylorus, accompanied with a diminution of bulk of the orifice of this part sufficient to interrupt or impede the exit of the chyme or indigested food.

Vomiting in Cancer.—Perhaps the most frequent cause of vomiting is the mechanical obstacle occasioned by the carcinomatous substance in the pyloric portion of the stomach. The quantity and quality of the matters vomited are variable. Both will be modified by the quantity and quality of the food and drink; the former by the capacity, of the stomach and the absence or presence of irritation; the latter by the nature of the ingesta, the state of digestion and the stage and variety of the disease. It is only at the early stage of carcinoma, or at least before softening and ulceration have taken place, that the vomiting consists of a watery or mucous secretion. In the great majority of cases, and always toward the termination of the disease, the contents of the stomach rejected by vomiting contain a substance resembling the lees of wine, a mixture of chocolate or soot and water. The substance may appear in the form of little particles, patches or streaks, and indicates the effusion of the blood into the cavity of the stomach from hemorrhage, either in consequence of the softening of the carcinomatous matter or the sloughing of this substance and of the contiguous parts.

Cancer of Liver.—Carcinoma of the liver may occur without any appreciable derangement of the special function of the organ being observed. There is often no apparent alteration in the quantity or quality of the bile, even in the most extensive forms of cancer of the liver.

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Cancer of Kidney.—There is no apparent modification of the secretion of urine in cancer of one of the kidneys, although the disease may be so extensive as to leave no trace of the natural structure of the organ.

Cancer of Uterus.—The much more frequent occurrence of cancer after than before the cessation of the menstrual discharge, prevents us from estimating accurately the influence which this disease exercises on the special function of the uterus and ovaries. Impregnation, however, has been known to have taken place in carcinoma of the os uteri, and of one of the ovaries.

Cancer of Spleen.—As regards the spleen its cellular organization may be completely effaced by the presence of the carcinomatous matter, and consequently it is rendered incapable of receiving more blood than is necessary for the nutrition of its solid parts and the growth of the disease.

Cancer of Duodenum.—Cancer of the duodenal extremity of the pancreas, in consequence of the compression of the duct which passes in this direction, gives rise to an accumulation of the secretion of this organ, and great dilatation of the duct throughout its whole extent. Diminished or suspended absorption are the occasional consequences of cancer of the mesenterie and lymphatic glands.

Cancer of Brain.—The functional lesions which accompany cancer of the brain, cerebellum and spinal cord vary considerably with the seat of the disease relative to these organs individually, as well as to particular portions of them. But in neither of these respects does it give rise to any symptoms which can be regarded as pathognomonic of its presence. As a foreign body it gives rise sometimes to a degree of compression sufficient to produce partial or complete paralysis, loss of memory or difficulty of speech and derangement of the intellectual faculties.

Symptoms.—But these latter changes depend principally on the irritation and softening of the substance of the brain in contact with the carcinomatous mass. Even paralysis is more frequently produced by these subsequent changes than by compression.

The Spinal Cord.—Paralysis of the superior and inferior extremities of the muscles of respiration, and of the bladder and rectum take place in carcinoma of the spinal cord, the seat and extent of the paralysis depending on the portion of the spinal cord occupied by the disease.

General Symptoms.—The general symptoms of carcinoma do not make their appearance before the last stage of the disease. Their severity depends much on the nature of the organ and the extent to which it is affected, but it is principally the irritation produced by the presence of the cancerous substance during the period of softening, sloughing and ulceration that determines the gravity of these symptoms. It is in this, the last stage of the disease, that the circulation and innervation become deranged, and that fever and a diminution of the nutritive function are first observed. It is likewise at this period, but more frequently a few days or weeks before death, that the skin assumes a pale earthy or dull ochery tint the debility and emaciation make rapid progress, and all the functions of the economy become implicated in the deteriorating influence of the disease. It is this group of the general symptoms which constitute what is called the cancerous cachexia.

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Fever Symptoms.—The febrile symptoms, as well as the diminution of nutrition in general, are greatest when the seat of cancer is the uterus or stomach, and least in those organs as the brain and lungs, in the former of which softening and in the latter compression may terminate in death before either of these symptoms has become conspicuous. General dropsy does not often occur and is never great. Ascites frequently accompanies carcinoma of the liver.

Cancerous Dropsy.—Dropsy of the inferior extremities occurs more frequently in cancer of the ovaries and uterus than of any other organ. It is the consequence of compression of the iliac veins, but it may also be occasioned by the extension of the inflammation which accompanies the ulcerative stage of the disease to these vessels. Compression of the vena cava by tumors in the liver, or by the enlarged mesenteric glands, may also give rise to the same state of the inferior extremities.

Colloid Cancer.—Colloid or alveolar carcinoma is characterized by the stroma being tolerably thick and so arranged as to divide the mass into a number of cystiform chambers, or alveoli, which are occupied by a jelly-like substance. Generally pale and transparent this may be firm as the white of a hard-boiled egg in the older cells, or of the consistency of half dissolved glue or currant jelly. In any form it is non-adherent to the walls of the cells, and may be readily removed. The disease assumes two forms, the circumscribed and infiltrated. The former is met with in subcutaneous tissue and in the bones of the extremities, constituting the osteo-sarcoma and spina ventosa. The latter is seen in the walls of the alimentary canal. It is of much slower growth than either of the above varieties, and rarely or never ulcerates or softens.

Black Pigment.—Melanosis is a form either of scirrhus or encephaloid, in which a deposit of black pigment has taken place.

Soft Cancer.—Encephaloid or soft carcinoma possesses a matrix less abundant and firm than in the preceding variety. So deficient is this that the mass is of jelly or brain-like consistency. Its cells are for the most part large, with a tendency to assume the caudate form. The growth may be circumscribed (forming tumors often of immense size), or it may occur in the tissues as an infiltration. It is elastic, occasionally fluctuating under pressure, as though pus was present. When opened it shows a whitish-yellow surface, dotted with pinkish spots during life. It is very vascular, giving a purplish-red tinge to the contiguous skin and possessing oftentimes a distinct fruit. Hemorrhage resulting from the spontaneous rupture of some of these vessels is not infrequent, forming apoplectic clots in the interior if confined, but constituting frightful loss of blood if rupturing the matrix. When ulcerated the surface of the tumor assumes a dark, sanguineous appearance, in which condition it is often described as fungus hematodes. From the first the peculiar cancerous cachexia is better marked in this than in any other kind of malignant growth. Its most frequent sites are the eye, cavities of face, articular ends of bones, the testicles, uterus and breast. The disease runs its course rapidly.

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Skin Cancer.—Epithelioma or epithelial cancer differs from the above in having an imperfectly defined matrix which possesses a tendency to form concentric laminae around the cellular elements. These are generally mixed up with altered epithelial cells of the part, and are more constant in their outline than other cancerous growths. Epithelioma is found chiefly at the margin of the mouth and at the anus, though it is occasionally seen on the hands and feet.

Cancer of Bones.—Osteoid cancer is defined as a malignant tumor, usually commencing in the bones, consisting almost entirely of bone and followed by similar growths in the glands and viscera.

Membranous Cancer.—Villous cancer is the name given to cancer in a mucous membrane when covered with a villous or velvet-like growth.

A host of remedies have been proposed for the cure of cancer; the greater number of them have been tried in almost every form of the disease, but they have nearly all failed to justify the high praises bestowed on their curative virtues.

Remedies.—1. The remedies which retard or arrest the progress of cancer consist of those which exercise a direct or indirect influence on the nutritive function of the affected organ. Among the former are those which operate directly—the local abstraction of blood by means of leeches and compression hold the first rank. The first of these means should be employed for a considerable length of time, at intervals of one, two or three days, and the quantity of blood taken should be regulated chiefly by the strength of the patient. The diminution of bulk of the original tumor which follows this mode of treatment is sometimes very considerable.

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2. In the great majority of cases the tumor is not entirely removed. It may be reduced from the size of a hen's egg to that of a nut, and in this state remain stationary for years without giving rise to pain or any inconvenience whatever. The alternate use of local bleeding and compression effect more rapidly the reduction of bulk just noticed than when either is employed separately.

3. Although compression and local bleeding are employed beneficially they are by no means to be altogether relied upon. In consequence of a modification of nutrition in general, and consequently of that of the affected organ, the beneficial effects of some general remedies in carcinoma of external organs are chiefly to be attributed. Some of these remedies appear to modify nutrition by effecting some unknown change in the composition of the blood, as aconitum, conium and arsenic; others, by acting on the capillary circulation and absorption, as mercury, in alterative doses, and various preparations of iodine.

4. The beneficial effects of tonics, as preparations of iron, the fixed and volatile alkalies, mineral waters and all other remedies which increase the vital energies, invigorate digestion and promote absorption and secretion, may also be referred to a favorable change induced in the nutritive function of the affected organ by the introduction of these remedies into the circulating system.

5. The salutary operation of these local and general remedies is much increased by a judicious combination of both, regulated according to the circumstances of individual cases.

Diet.—But while employing any of these remedies it is of the utmost importance to regulate the diet and regimen of the patient in such a manner that neither of them may interfere with the operation of the remedy employed.

Virtues of Conium.—For example, the curative virtues of conium depend greatly on the quantity of food consumed by the patient, that is to say, the operation of this remedy is more or less powerful when only a small quantity of food was allowed and hardly perceptible when the quantity was considerable.

The following has been our experience with the use of conium in this disease:

1. The patient takes a dose of the extract of conium, morning and evening, two hours before each meal. The amount of the first dose is half a grain, which is gradually increased to six grams each time. This dose is continued for about three weeks in order that the organs may become habituated to its operation, and is afterward increased to twelve grains each time, beyond which it is not necessary to carry the remedy because of its influence being sufficient. The twelve-grain dose is continued from two to four weeks.

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2. After each dose of conium, as well as at meals, the patient uses a glass of the decoction of sarsaparilla.

3. Only the third of the ordinary quantity of food is allowed, which ought to be very simple and divided into three small meals.

4. If the conium disagrees in one form it should be given in another or the aconitum may be used instead, but in lesser quantity than the conium. Toward the end of the treatment the dose of the conium is gradually diminished and the diet gradually increased.

Further Remedies.—The only class of remedies which can be expected to afford any essential benefit are those that are capable of inducing a new condition in the system by modifying the function of nutrition, such as the various preparations of iodine, combined with a thorough change of everything surrounding the individual. The cachexia is the real morbid condition and the cancerous affections in particular organs are but so many evidences of it, as tubercles in the lungs are mere expressions or indications of another form of cachexia, equally possessing the whole system. Hence it is that cancerous tumors on the external parts of the body are so apt to recur after they have been removed by the surgeon.

Removal of Tumors.—Still it must be admitted that in cases of scirrhus tumors, when they have been removed early, there has very frequently been no return of the disease. In such cases the cachexia has been less strongly marked and time, apparently, has not been permitted for the local mischief to increase the morbid disposition. It would seem, too, that the particular species of cancer influences the probability of recovery. There are a few examples of permanent recovery after the removal of encephaloid tumors.

Remedies for Cancerous Fevers.—The remedies best calculated to prevent, remove or mitigate the local and general effects of carcinoma of internal organs vary with the nature of these effects and the seat of the disease. The state of irritation and fever and pain, at whatever period of the disease they may occur, may be greatly moderated by the use of conium, aconitum, opium, hyosciamus, the acetate or muriate of morphia, while at the same time the use of all kinds of stimuli is to be avoided, particularly if the digestive organs be the seat of the disease, and the patient himself kept as much as possible in a state of quiet of body and mind.

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Treatment.—When cessation of pain and a return of strength and appetite take place, treatment is suspended for a month. It is then resumed for two consecutive months, then suspended for two months, and recommenced, continuing during a month. This plan is pursued for at least two years, which by pursuing the patient is not only greatly benefited, but frequently cured.

Ferruginous preparations must not be omitted when there is great anemia caused by profuse hemorrhage or imperfect nutrition.

Hemorrhages.—Hemorrhages are treated by rhatamy, sulphuric acid and ice. When they have been arrested, and when the pain is subdued, bitters, such as the decoction of cinchona, infusion of quassia, or of Columbo root, are given; sometimes also certain remedies which combine bitter with slightly purgative properties, such as rhubarb, are used; and finally the preparations of iron.

Classes of Remedies.—The only class of remedies that can be expected to afford any essential benefit are those that are capable of inducing a new condition in the system, by modifying the function of nutrition, such as the various preparations of iodine, combined with a thorough change of everything surrounding the individual. The cachexia is the real morbid condition, and the cancerous affections in particular organs are but so many evidences of it, as tubercles in the lungs are mere expressions or indications of another form of cachexia, equally possessing the whole system. Hence it is that cancerous tumors on the external parts of the body are so apt to recur after they have been removed by the surgeon. Still it must be admitted that in cases of cancerous tumors, when they have been removed early, there has been frequently no return of the disease. In such cases the cachexia has been less strongly marked, and time, apparently, has not been permitted for the local mischief to increase the morbid disposition.

Mitigation of Pain.—When the carcinoma or cancerous disease has arrived at that period when the cancerous cachexia announces the extensive and fatal termination of the disease, the efforts of the physician must be directed solely to the mitigation of the sufferings of the patient. If this symptom were removed, there are many cases in which carcinoma would run a much longer course, and give rise to comparatively little functional derangement.

Termination of Cancer.—With regard to the termination of cancerous affections of the hollow organs, it takes place frequently in the uterus and stomach, the rectum and urinary bladder, the transverse arch of the colon and jejunum, and the peritoneum. The perforation of the rectum, bladder and peritoneum is the consequence of the extension of the disease from the uterus; that of the transverse arch of the colon, the consequence of its extension from the stomach. If the os uteri be the seat of the disease additional benefit may be derived from the use of leeches applied to this part, and also sedative injections. It is only in this latter situation that sloughing and ulceration can be detected, and local remedies applied to remove some of the disagreeable effects of the one, or retard the progress of the other. Antiseptic disinfectants are perhaps the best remedies we can employ in this case, as they not only destroy the disgusting odor which accompanies this stage of the disease but remove the putrid and irritating fluids which are then discharged. The retention of the contents of hollow organs from compression or obstruction is an occurrence to be guarded against by regulating the quantity and quality of food, for negligence in this respect may be followed by fatal consequences if the obstacle be situated in the intestines.

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Further General Treatment.—The same general treatment is applicable to all forms of cancer. If the growth be well defined, as in carcinoma of the breast, of not very long standing and not involving neighboring lymphatic glands, it may be removed, but severe hemorrhage from a large encephaloid cancer or the complication of important structures in any variety having deep attachments will preclude any operative procedure. Even when extirpated under favorable conditions it is very apt to return, eventually to destroy the patient. The removal of epithelial growths by the knife, or their destruction by caustic applications before glandular evolvement has supervened, in many instances may effect a permanent cure.

Care in Removing Cancerous Growths.—When a cancerous tumor has been removed all surrounding parts should be carefully examined, because it is not uncommon to find small cancerous tubercles in the connective tissue, fascia or muscular sheaths, which, if passed by unheeded, would soon increase and give rise to a recurrent growth.

COLLOID.

Characteristics.—This new growth, formerly called colloid cancer-gelatinous or gum cancer, is no longer considered to be malignant, in the sense of its having the power to infect other and distant portions of the system. Its great characteristic is the formation of a new growth in the large open meshes of which it exists a glue-like, gelatinous, transparent substance like half dissolved gum arabic. This matter is strikingly transparent. Greenish-yellow is its predominant hue. This jelly-like matter is exceedingly soft; a colloid mass is, however, firm and resisting, although not apt to be produced elsewhere, these growths may obtain an immense size and even prove fatal by the disturbances which they cause in the system. Fortunately they are quite rare in this country.

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NOLI ME TANGERE OR LUPUS.

Character.—This is a spreading, tuberculosis inflammation of the skin, usually of the face, tending to destructive ulceration. Its name is supposed to be derived from a fancied resemblance which the sores left in the progress of the disease have to the bite of a wolf.

Symptoms.—1. The "lupus erythematosus" occurs chiefly upon the face, and is symmetrical; each patch has well-defined edges and a red, scaly surface with small horny points upon it, due to accumulation in the dilated mouths of sebaceous ducts.

2. The "lupus vulgaris" has its origin in a skin tubercle, or tubercles, of a flat form, fleshy consistence and pink shining appearance, and these at times ulcerate. This lupus ulceration, when once originated, progresses steadily, destroying every tissue it attacks and when it reaches the nose, its favorite seat, it simulates cancer.

Treatment.—In the treatment of lupus, although the disease has probably a constitutional origin and requires tonic treatment, both by medicine and regimen, there is no disease that derives more benefit from local treatment. Quinine, with vegetable tonics; cod-liver oil, and iodide of potassium are all useful in this respect. When the ulceration is superficial and the skin is not deeply infiltrated, the local application of codliver oil on lint and the covering up of the part with cotton to keep it warm has in some cases worked wonders.

GOUT OR PODAGRA.

Character.—A painful disease affecting principally the fibrous tissues about the smaller joints and intimately connected with an excess of uric acid and its compounds in the blood. Various names have been given according to the part affected, as podagra when in the feet, chiragra when in the hands, and so forth, but all such and probably many cases of neuralgia, accompanied by oxalic deposits in the urine, are mere forms of one disease.

Symptoms.—A common attack of acute gout is generally preceded by uneasiness, indigestion, loss of appetite, nausea and vomiting, biliary derangement, dull pains or numbness in the parts affected, often with feverish symptoms; but in some cases, on the contrary, the disease comes on in the midst of apparent health and well-being, and ocassionally at night during refreshing sleep. In most cases it makes itself known by an acute pain in the joint of the great toe.

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Further Symptoms.—This is accompanied by feverish symptoms, urinary sediment, extreme tenderness, restlessness, involuntary muscular contractions, sleeplessness and perspiration; the affected joint is swollen, red and hot. This series of symptoms may last four or five days, to be followed after a day or two by three or four others, continuing in all from two to three weeks; the severity of the attack, its persistence, its seat and its metastases vary according to circumstances.

Chronic Gout.—When gout becomes chronic the attacks are more irregular, less severe, more frequent and sudden, leaving one joint for another after slight exposure to cold and moisture, excess at table or vivid emotions; in this form the continuance of the pain and the fear of injuring the gouty joints render its subjects cross, fretful and disagreeable.

Chalky Deposits.—Toward the end of the spell chalk-like deposits are thrown out about the joint in some, but not in all cases. The suffering with the gouty inflammation is often very intense.

Hereditary Gout.—Hereditary gout is sometimes podagra or foot-gout, but more often is of the hardening kind. Neuralgia, indigestion, palpitation and urticaria or eczema upon the skin are its most common manifestations. In such a system rheumatism and other affections are to a considerable degree modified by the "gouty tendency."

Causes.—High living with indolent habits generates gout. Even excess of animal food, with scanty exercise, has been known to produce it. But strong wines and malt liquors much increase the tendency. Weak wines do not seem to have the same effect.

Diagnosis.—Between gout and rheumatism there is great resemblance. In gout the small joints are chiefly affected; in rheumatism the larger joints. Repetition of attacks is much more frequent in gout; their duration is greater in rheumatism. In gout the heart is seldom attacked and spasmodically; in rheumatism the heart is often subject to inflammation. In gout the stomach is sometimes spasmodically affected with violent symptoms; in rheumatism, almost never. In gout, and not in rheumatism, uric acid is in excess in the blood. In pure gout, colchium does good; in rheumatism, hardly ever.

Treatment 1.—There are few diseases which have more empirical remedies extolled for their cure than gout; almost every drastic purgative, diuretic, tonic and narcotic has been pressed into the service either for external or internal use. To say nothing here of soothing topical applications, colchicum has enjoyed, and deservedly, a great reputation in the treatment of gout and neuralgia between the attacks and in their chronic forms; it is most efficacious when it acts upon the skin and bowels. The acetate of potash and other alkalies are in favor both for their diuretic property and as alkalizing the acid in the blood and urine.

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2. During the attack colchicum and the alkalies are the remedies. Wine of the root of colchicum may be given in ten- or twenty-drop doses several times daily. The stomach and bowels are sometimes irritated by large doses; but for a few days most patients will bear fifteen drops thrice daily. It should be stopped when relief has been obtained. Carbonate of potassium—ten to thirty grains at once with half drachm doses of rochelle salts will be important in addition. Opiates or other anodynes may be craved by the patient during the extremity of his pain.

3. Gouty attacks affecting the stomach or heart spasmodically are usually sudden, violent and prostrating, requiring prompt stimulation, as brandy, laudanum, Hoffman's anodyne, chloroform or Warner's cordial (tinct. rhei et senna). Small or moderate doses of one or another of these should be given at short intervals. Mustard plasters to the epigastrium or chest and back will be important, and the feet may be placed in hot mustard water for revulsion.

Diet.—Regulation of the diet is of primary importance. But it should not be too low, especially when the patient's habits have been those of free living. Nourishment must be full, while the digestive power is economized and positive stimulation avoided. Attention to hygienic rules and avoiding exposure to dampness, cold and fatigue of body or mind are absolutely necessary as aids in the treatment of this disease. To promote all this adequate exercise is the natural agent, the use of which cannot be superseded by any medicines however valuable or however lauded.

Change of air, traveling and mineral waters are generally useful during the intervals between the paroxysms. Alkaline springs and baths have an especial reputation as prophylactics against gout.

ELEPHANTIASIS OR TRUE LEPROSY.

Symptoms.—This is a constitutional, hereditary affection, essentially chronic in its nature, showing itself mainly as shining tubercles of different sizes, of a dusky red or livid color, on the face, the ears and often on the legs, the skin being thickened, wrinkled, rough, unctuous, devoid of hair, and the perspiration from it highly offensive. After a time there is a circular margin enclosing the central red part free from scales and quite resembling the irregular scaliness of psoriasis.

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When the local disease has reached its highest degree a remarkable constitutional affection appears. The patient then becomes very languid, asthmatic, particularly at night-time; smothering fits seize him, he coughs violently and spasmodically, and spends the night in perfect sleeplessness, falling into excessive, colliquative, clammy sweats, which give an intolerably fetid odor. His voice becomes weaker and hoarser, the appetite for food and drink is preternaturally increased, and the temper becomes gloomy. Finally, various nervous symptoms arise—faintings, convulsions, paralysis of some parts—and death arrives, preceded by the highest degree of exhaustion.

Causes.—Its origin has been ascribed to want of cleanliness and to unwholesome diet, especially the constant use of bad fish, to long-continued exposure to the heat of a tropical sun, to dampness of situation or occupations requiring the frequent immersion of the limbs in cold water.

Where Occurs.—The disease occurs chiefly in warm climates—Arabia, China, India and some of the West India Islands.

Dry Leprosy.—In this the wasting of the disease is circumscribed, and limited to all the muscles of the hand. The skin is thick, reddened, and completely anesthetic; the fleshy masses have entirely disappeared, and the fingers assume the shape of claws. This disease rarely attacks women. It is accompanied with great torpor of mind and sluggishness of body. Mental depression amounting to extreme melancholy is the natural consequence of so hopeless a malady. Yet the general health, for a length of time, suffers infinitely less than could have been anticipated, the actions of the respiratory and digestive organs continue longer unaffected, and even the cutaneous functions are still tolerably performed, as is evidenced by abundant perspiration.

Progress of the Disease is very slow, and its termination, though it may be deferred for many years, is almost always fatal, the unfortunate patient being in the meantime dreadfully deformed and mutilated, and literally dying by inches. The patches spread slowly till the surface of the whole body may be at length inflicted, and its sensibility lost. There is neither pain nor itching, and usually no swelling. After a few months the internal functions become deranged, the pulse gets very slow and heavy, "as if moving through mud," the bowels grow costive, and there is much sluggishness of mind, and tendency to somnolency. The skin of the extremities becomes fissured and rough, and ulcers appear under the metatarsal or metacarpal joints—the integuments seeming to be simply absorbed —or sloughing off in successive layers of about half an inch in diameter, without any previous tumor, suppuration or pain. A serous discharge ensues and there is loss of sensation and a tendency to ulceration and death of the parts. In the advanced stage of the disease the eyes are fierce and staring, and the voice hoarse and nasal.

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Character.—Leprosy is not a contagious disease, but is propagated by inheritance, depending on some specific taint transmitted from parents to children. The two forms of this horrible disorder are the tuberculated and the non-tuberculated or anesthetic.

Treatment.—The only hope of exterminating this dreadful disease appears to lie in the adoption of hygienic measures tending to improve the general condition, both physical and moral, of the leprous poor. Without this medical treatment is of little or no avail, but with the aid of improved sanitary surroundings, tonics and alteratives, especially preparations of iron and iodine, have a very beneficial effect. Much may be hoped also from the systematic employment of baths, either saline or sulphureted, in this affection.

Leprosy Germ.—A bacteria claimed to be the cause of leprosy, and named the bacillus leprar, was discovered in Norway in 1874, and its existence in the tubercles of this disease has been confirmed, although its causative power has not yet been completely demonstrated.

An external remedy is as follows: 

Corrosive sublimate ............................ 2 grains
Infusion columbse .............................. 5 ounces
    A teaspoonful twice a day.
Arsenious acid ................................ 20 grains
Cosmoline ...................................... 1 ounce
    Make ointment. Over a patch of skin three or four
inches square rub the ointment in well once daily for about
two weeks, then treat a fresh portion until the body is
covered.

SCROFULA.

Causes.—A blood disease manifesting itself in a great variety of organs and characterized when fully developed by the presence of a peculiar unorganized matter termed scrofulous. The causes are chiefly hereditary transmission and deprivation of pure air. It is closely allied to pulmonary consumption.

Symptoms.—The scrofulous habit, when strongly marked, is easily recognized. The skin is usually delicate and irritable; the patient suffers very readily from chilblains, and in childhood is more liable than others to cutaneous diseases. The mucous membranes partake the delicacy and irritability of the skin. The edges of the eyelids are apt to be red and swollen; the eye is very liable to be attacked by inflammations; hemorrhages from the nose, cold in the head and enlarged tonsils are frequent. The muscles commonly want firmness, and the whole system is deficient in stamina.

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Diagnosis.—Scrofula is eminently a disease of childhood, while consumption belongs to a later period, but neither is confined to any age. One of the forms in which scrofula most commonly and earliest shows itself is swelling of the lymphatic glands in various parts of the body, more particularly about the neck. These become enlarged and firmer, and after a time a deposition of the peculiar curd-like matter is found to have taken place in their interior. After a time suppuration occurs, the swellings become softer and the skin over them assumes a dusky red hue, gradually becomes thinner and finally bursts, giving outlet to an unhealthy pus mixed with the curd-like deposit of the disease. The ulcers left heal slowly and with difficulty, and unless great care is exercised produce deformed cicatrices.

Treatment 1.—In the constitutional treatment of these cases of strumous adenitis, nutritious food, suitable warm clothing, attention to cleanliness and residence in pure air are the most important requisites. Iodine in its different forms, especially the syrup of the iodide of iron, is given in doses of twenty-five drops thrice daily, and quinine and iron each in grain doses three times a day, with one-sixteenth of a grain of arsenic, or phosphites and hypophosphites of lime and magnesia, in tablespoon doses of the syrup, are frequently of great service. Also the iodide of ammonium in three-grain doses three times a day.

2. In endeavoring to produce a reduction of the swollen glands by causing an absorption of the contents, the tincture of iodine painted on with a camel's-hair brush, or small feather, so as to smart severely but not to raise a blister, and repeated daily for a week or so until the skin peels off is a valuable resource. A milder application of the same remedy is by the use of the ointment of iodine rubbed into the skin over the enlarged gland, night and morning, for weeks and even months if requisite.

3. Cod-liver oil is an anti-strumous remedy of great power, and is more readily taken by the young than by adults, generally sea bathing and sea air are mostly the best of remedies.

Ophthalmia.—Strumous ophthalmia occurs in children between the time of weaning and the end of the ninth or tenth year. Its chief symptoms are redness of the white of the eye, with the formation of little blisters or pustules, often ending in minute ulcers on the cornea or clear portion. The eyes water very freely, and the intolerance of light is excessive, so much so as almost to be indicative of the disease.

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Treatment.—The management of these cases will tax the skill of both nurse and doctor to the fullest extent, although internal remedies are often also required, the nursing and outward applications are the most important. Great attention must be paid to cleanliness, and warm bathing of the eyes with anodyne fomentations are very serviceable. Applications of the wine of opium or of a solution of nitrate of silver, of a strength of from five to ten grains in an ounce of water, although they smart severely at first are often of very great benefit.

Diet.—Good diet is indispensable in strumous affections. Hence the invalid should have all the advantages of an abundance of good mutton and beef, vegetables and ripe fruits in season, raw eggs, milk and cream, tepid or cool baths and sea air. 

                PRESCRIPTION 1.

Rx.---Cod-liver oil .......................... 5 ounces 
      Phosphorus ............................. 3 grains
         A teaspoonful once a day.

                PRESCRIPTION 2.

Rx.---Citrate of iron and quinine............ 10 grains 
      Cod-liver oil .......................... 1 ounce
      Glycerine .............................. 1   "
         Take a tablespoonful three times a day.

RICKETS.

Causes.—The cause of rickets seems to be anything which induces enfeebled assimilation of food and impaired nutrition of body. Hence this affection is sometimes met with in such weakly children of even wealthy parents as suffer from defective action of the vital forces. Like scrofula, it is, however, especially a disease of the poorer classes. Insufficient and especially improper food, the constant respiration of foul, impure air, residence in dark, damp, cold or filthy dwellings, these and similar circumstances readily serve, in all probability, to generate rickets.

Symptoms.—This disease rarely appears before the seventh month, and most commonly does not declare itself until the child first begins his attempt to walk. When a child is about to be affected with rickets he becomes dull and languid, the appetite is variable and capricious, the bowels are irregular, the stools unhealthy and usually pale. Constitutional disturbance now arises, and a febrile state is soon established; the limbs become emaciated; the belly tumid; the face full and the head disproportionately large; the forehead projecting, and the sutures of the cranium remaining open or perhaps expanding slightly. The extremities of the long bones which are least concealed by muscle, as those of the wrists and ankles, and the sternal ends of the ribs, particularly these last, are swelled out into knobs. The legs begin to bend outward at the knee, giving rise to the deformity of bow-legs, or less frequently the knees are thrown forward and the feet outward, making the child what is called knock-kneed, and usually crippling it more or less for life. The bones of the arms and the collar bones may also become very much curved and twisted, showing that the popular delusion as to the cause of bow-legs has little foundation in fact. The deformity of the chest is often very great, the back being flatttened, the breast bone pushed forward and the natural curve of the ribs lessened. In such cases the child is said to be pigeon-breasted.

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Diagnosis.—This, of course, must be difficult in the early stage, as the symptoms closely resemble scrofula at that time, but after the curvature of the bones commences there can no longer be any doubt, as such softening of the bones during childhood only occurs in rickets.

Treatment.—The medical treatment of rickets must be subordinate to the hygienic, since far more depends upon good food, proper clothing and pure air than on drug medication. Milk diluted with lime-water, Liebig's food, and, if the infant is old enough, beef tea, extract of beef, raw meat, eggs, and so forth, should be given in abundance. The phosphates or hypophosphates of iron, lime, quinine and strychnia, as recommended when treating of scrofula, are very useful, and if the child is capable of digesting cod-liver oil it ought also to be administered. Should the diarrhoea be troublesome a chalk and soda mixture, containing a grain of each as a dose for a baby one year old, or a mixture containing a grain of bismuth in each dose for an infant of that age will probably be of essential service, and after the feverish symptoms are controlled the child, in suitable weather, should almost live in the open air, especially if a seaside atmosphere can be obtained.

Diet.—If the disease has occurred at a very early age it may be advisable to try the effect of changing the wet-nurse; and in general it will be proper to wean the child about the end of the ninth month, for protracted suckling is certainly one of the debilitating causes which dispose to rickets. While the child continues at the breast the diet of the nurse or mother ought to be carefully attended to, in order that the milk may prove nutritious and easy of digestion; or its powers may be assisted by allowing the infant, in addition, small quantities of isinglass jelly, beef tea, or yolk of egg, provided the absence of febrile excitement will permit. After the child has been weaned the diet must be suited to the degree of constitutional irritation which exists; but one leading principle should be to support the strength as much as possible without quickening the circulation or oppressing the stomach.

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CRETINISM.

Causes.—A condition of persons in whom partial or complete idiocy is combined with great bodily deformity of the whole body, due to bad water, lack of sunlight, and life in deep valleys like those of the Alps.

Symptoms.—There are three varieties: first, complete or incurable cretinism, which is characterized by idiocy, deaf-dumbness, deficiency of general sensibility and entire absence of reproductive power; second, semi-cretinism, which is a degree of the malady in which the mental faculties are limited to the impressions of the sense and the bodily wants. The general sensibility is obtuse, the head is badly formed and drooping, the speech is rudimentary and the reproductive powers are feeble or absent; third, incomplete or curable cretinism in which the mental faculties, though limited, are capable of development.

Treatment 1.—The first thing to be accomplished is the removal of the young cretin, as soon as possible after the disease exhibits itself, to a pure bracing atmosphere.

2. The treatment requires an abundance of pure water for drinking, washing and bathing; warm and cold baths and douches; friction of the skin with brushes and stimulating liquids to rouse its action; warm clothing; mineral tonics; nourishing food; iodine, cod-liver oil and phosphates. The effort to develop the mind must follow the attempt to restore the body to a healthy condition.

DIABETES OR DIABETES MELLITUS.

Causes.—Twice as many men as women have this disease. It is most frequent among young and middle-aged adults; the mortality from it being greatest from fifteen to fifty-five. It is more common in cities and manufacturing districts than in the open country; occasionally it is hereditary. The exciting causes appear to be exposure to cold and wet; drinking cold water largely when heated; excessive use of saccharine food; intemperance; violent emotion; febrile diseases, and organic affections and injuries of the brain and spinal cord.

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Symptoms.—In this remarkable disease there is an excessive discharge of urine containing grape-sugar, the saccharine principle of grapes and of honey called glucose, being produced in the body in great quantity and eliminated from the kidneys. The exhaustion, which results from the immense loss of fluid, sometimes amounting to several gallons daily, is often accompanied by other disturbances of the system due to the presence of sugar in the other secretions and in the blood and to the modifications of the nutrition thus effected; opacity of the crystalline lens of the eye—constituting diabetic cataract—is occasionally one of the modifications of structure; shrinking of the substance of the brain is another, and a peculiar form of inflammation of the lungs is another. It is a disease which commonly, after a longer or shorter course, proves fatal.

Diagnosis.—The detection of sugar in the urine, not temporarily, but for a considerable time, is of itself sufficient to make out the case.

Prognosis.—Recovery is not impossible in diabetes, but a large majority of cases end in death. Amelioration—keeping the disease in abeyance—is often an attainable end.

Treatment.—The most positive influence in diminishing the disease belongs to opium; but this does not appear to interfere with the progress of the disease. The alkalies, pepsin, iron, quinine, salicylate of soda, alum, iodine, nitric acid, turpentine and the inhalation of oxygen have all been employed.

Diet.—Since it is found that the amount of sugar discharged in the urine fluctuates very much in accordance with the starchy and saccharine materials which are eaten, it is the best for the diet of a diabetic patient to be freed, as far as possible, from substances which can be converted into glucose by the digestive organs. Hence the effort should be, in treating diabetes, to abstain from all starchy food as well as from every solid and liquid containing sugar. That meat and eggs may be taken as a derangement of the liver is not found to be produced by them, and fish is a most important article with which to vary the monotony of the diet. Skimmed milk appears to answer a very good purpose in this disease.

The following prescription is of value in diabetes mellitus: 

Rx.---Salicylate of soda....................... 3     drachms 
      Fowler's solution ....................... 1     drachm
      Glycerine ............................... 1     ounce
      Water ................................... 1 1/2 ounces
          Mix and take a teaspoonful three times a day.

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PURPURA OR LAND SCURVY.

Causes.—It chiefly occurs in individuals of delicate habit or enfeebled by their occupations or mode of life; by confined, low or damp habitations, scanty food, hard labor, grief, anxiety, fatigue and watching. On the other hand purpura frequently occurs where no causes of a debilitating or depressing nature can be supposed to have existed.

Varieties.—The two varieties which are distinguished are the simple and the hemorrhagic, in the latter of which the malady is accompanied by bleeding from some of the mucous membranes of the body.

Symptoms.—Various symptoms denoting general disorder of the system precede the appearance of the spots in purpura, generally for some weeks. In most instances languor, weariness on very slight exertion, faintness and gnawing pains in the stomach are complained of. The appetite is variable, generally poor, but sometimes there is an inordinate desire or craving for food. The tongue is yellowish and coated with a viscid fur, the countenance sallow or dingy, or the face may have a pale and bloated appearance with swelling beneath the eyelids. The purple spots usually appear upon the legs and afterward without any certain order on the thighs, arms and trunk of the body, and their formation is attended with great weakness and much depression of spirits. Deep-seated pains are felt about the region of the stomach as well as in the chest and loins. One of the most distressing and dangerous symptoms is when the patient becomes of a sallow complexion, waxy-colored and dingy, dropsical swellings of the feet and legs with deep and gangrenous sores appear, general dropsy often prevails and the sufferer dies exhausted.

Diagnosis.—The diseases with which purpura is most likely to be confounded are typhus fever attended with scurvy. The origin and course of the complaint, the period at which the petechiae appear, the extent and variety of the accompanying hemorrhages will make its diagnosis clear.

Treatment 1.—In the treatment of this disease we are not to be guided by the name or external appearances, but by diligent attention to the symptoms and especially to the state of the functions and the habit and constitution of the patient. Where high excitement prevails with strength of pulse and vigor of constitution, and we have reason to suspect inflammation, purging, with a suitable antiphlogistic diet, are the appropriate remedies.

2. Where a quite opposite state exists all active depletion must be abstained from and the strength supported by beef-tea and other meat nutriment; at the same time tonics, such as quinine or Peruvian bark, the diluted mineral acids in five- or ten-drop doses, iron and strychnine, must be administered.

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The following offers a good treatment: 

Rx.---Syrup of the superphosphate of iron........ 1 1/2 ounces 
      Liquor of peroxide of hydrogen............. 1 1/2   "
      Glycerine ................................. 1 1/2   "
      Water ..................................... 1 1/2   "
          Take a tablespoonful three times a day.

Or, 

Rx.---Oil of turpentine ......................... 3     drachms 
      Fluid extract of digitalis................. 1     drachm
      Mucilage gum-arabic ....................... 1 1/2 ounces
      Peppermint water .......................... 1     ounce
          Make an emulsion. Take a teaspoonful every three hours.

SCORBUTUS OR SCURVY.

Character.—This is a disease allied to purpura, but attended with a spongy condition of the gums, and livid patches under the skin of considerable extent, which are harder than the surrounding structure. It has been stigmatized as the great plague of the ocean, and has been denominated sea scurvy to distinguish it from land scurvy or purpura.

Causes.—That the essential cause of scurvy is deprivation of fresh food, and, in almost all cases, of fresh vegetable food, is proved. Fresh meat will retard it in the absence of vegetables, but neither this or oranges and lemons will altogether prevent it through long periods. Additional promotive causes are severe cold, fatigue, exposure and mental anxiety or home-sickness.

Symptoms 1.—Languor, debility and lowness of spirits first occur; then swelling, sponginess and bleeding of the gums; the teeth loosen, and the breath is offensive. Palpitation of the heart and dyspnoea may be present. Spots (from subcutaneous extravasation of blood) appear on the limbs. Diarrhoea and dysentery often come on. Death may take place by a gradual exhaustion or by sudden syncope.

2. A remarkable peculiarity of scurvy is the readiness with which all parts of the body suffer from pressure, and the slightest possible blow may produce an extensive bruise, a small eruption like flea-bites is often to be seen on the legs, and about the same time the muscles of the legs and thighs are apt to become hard and painful, and in a day or two the skin over the painful part grows yellow and then purple. These purple spots may be as large as the palm of the hand at first, and are liable to extend until they cover half of the limb.

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3. As the disease advances all the symptoms become aggravated. The loss of physical power increases, the purple spots have a tendency to ulcerate, and the resulting ulcers are especially distinguished by their putrid fungoid appearance, and their great, tendency to bleed.

Diagnosis.—Purpura hemorrhagica is undoubtedly not identical with scurvy, although "purpuric" extravasations are common to both. Purpura does not depend, as scurvy does chiefly, upon a fault of diet; nor are the gums affected in purpura.

Treatment 1.—The great remedy for scurvy is lemon or lime juice; in seemingly desperate cases the most quick and sensible relief has been obtained from lemon juice, when no other remedy seemed to avail. When the acid operates violently upon the stomach and bowels of those who are much weakened, the addition of wine and sugar is strongly recommended.

2. A solution of nitrate of potash in vinegar has been most advantageously made use of in the proportion of two ounces of nitrate in one quart of vinegar, and a tablespoonful of this given two or three times a day.

3. Fresh vegetables alone will restore what is wanting. Potatoes, tomatoes, oranges and lemonade are the most generally available articles. If any medicine is useful as an adjuvant, it is the tincture of the chloride or iron in moderate doses. Sometimes citric acid does good. For the gums a wash of tannic acid or tincture of myrrh in diluted glycerine will be useful, or alum, brandy and water. Salt and whiskey rubbing of the skin will aid in dissipating the petechiae.

Diet.—Medical men in charge of expeditions to a distance, for ordinary supplies should always insist on measures being taken to furnish enough fresh vegetables, or, next best, dessicated potatoes; after the latter onions, tomatoes, turnips, and so forth, and oranges and lemons rank. Wine is also decidedly though not infallibly anti-scorbutic.

The following is a good anti-scurvy remedy: 

Rx.---Common salt ............................. 10  scruples 
      Chlorate of potash ...................... 1/2 ounce
      Rochelle salts ..........................  5  scruples
      Phosphate of soda .......................  3     "
      Lemon juice .............................  6  ounces
      Syrup of lemon .......................... 14     "
      Water ...................................  7  pints
          To be used as a drink several times a day.

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CONSTITUTIONAL SYPHILIS.

Weeks or months after the primary disease, secondary syphilis may show itself. Once produced, although sometimes readily curable, it often impairs the constitution for life, and transmits the taint to offspring.

Symptoms.—The affections belonging to secondary syphilis are peculiar copper-colored eruptions, rupia especially; warts about the genitals, ulcers of the throat, iritis, loss of hair, affections of the testicle or uterus. These last, as well as periostitis and osseous tumors or nodes, cutaneous tubercles, and chronic degenerative inflammations of the brain, spinal marrow, liver, spleen, lungs, and so forth, are often called tertiary syphilis. It has been our experience that constitutional syphilis is not transmissible by inoculation.

Treatment.—Mercury is available in the treatment of secondary as well as primary syphilis, but its power over it is less absolute. After moderate trial of its impression (especially of the iodide of mercury) iodide of potassium may be given, from ten to thirty grains thrice daily. It is an almost certain cure for syphilitic rheumatism or bone pains, with or without nodes; over ulcers of the throat, also, it has great power. Such things, however, often do not stay cured, they break out again, as may also the cutaneous eruptions, requiring the same treatment over again.

The following are excellent remedies: 

Rx.---Iodide of potash......................... 2   drachms 
      Carbonate of ammonia..................... 1/2 drachm
      Compound tincture ot cinchona............ 4   drachms
      Syrup of orange peel..................... 1 1/2 "
      Glycerine ............................... 1   ounce
          Take a teaspoonful after each meal.

Rx.---Iodide of potash......................... 3   drachms 
      Iodine .................................. 1   drachm
      Corrosive sublimate ..................... 2   grains
      Water ................................... 3   ounces
          Take a teaspoonful three times a day.

ANEMIA.

Causes.—Poverty of blood. This is a special, morbid state, in which there is fullness of the surface of the body and deficiency of the red corpuscles of the blood. It is a common affection among women, and persons of both sexes who are ill-fed, or from any cause badly nourished, in crowded localities. It is occasioned by loss of blood, from disease or injury causing hemorrhage, from excessive suckling in a mother or wet-nurse, severe or protracted diarrhoea, or (more rarely) leucorrhea, typhoid or other forms of fever; the malarial influence, sustained for a considerable time, deficiency of food, light, warmth, or fresh air.

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Symptoms.—The face, the hands, and the general surface are pallid and slightly waxen or icteroid in their hue. There are vertigo, faintishness, palpitation and an impaired action of the organs generally, especially of the stomach and bowels; digestion being deranged, with flatulency, constipation, and so forth.

Diagnosis.—This is very much aided by the detection of various murmurs, as the watery blood passes through the heart and larger veins. The jugular veins of the neck are often the seat of a well-marked venous hum in profound anemia.

Treatment 1.—In almost all cases it is essential to put the patient on nourishing diet, and especially where the anemia has been caused by imperfect nourishment; yet care must be taken in the very impressible condition of the system which exists in these cases, that undue excitement be not induced.

2. Our first effort should be to supply the materials for enriching the blood, and especially those which are necessary to construct the red corpuscles, a deficiency of which appears to be the essential element in this malady. Iron, which enters into their constitution more abundantly than of any other tissues of the body, is hence obviously called for, and should be administered in whatever form can best be assimilated. Where it is well tolerated there is probably no better preparation than tincture of the chloride of iron, in twenty-drop doses three times daily.

3. In cases where the tincture of the chloride of iron is not applicable, or is objected to by the patient, the powdered iron, called also iron reduced by hydrogen, in doses of a grain thrice daily, can almost always be borne, and is frequently of the greatest service. All the compounds of iron require, however, to be used for a long time, usually several weeks and often for several months, in order to cure the anemic condition.

4. The citrate of iron or the citrate of iron and quinine, in doses of from three to five grains, possesses one great advantage over many other preparations of this useful metal in the fact that while perfectly soluble they produce upon the organs of taste little of that styptic or ink-like impression which to many persons is so exceedingly disagreeable. The beef, wine and iron is also a most valuable remedial agent.

Diet.—The best food which the stomach can digest, and there is no doubt that the iron which exists in beef and mutton and gives much of its red color to the muscular fibres of the flesh, is in the most favorable state for assimilation into the human system, and often has a large share in the improvement which we are perhaps too ready to attribute to the chemical compounds prescribed.

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Rx.---Corrosive sublimate ................... 2   grains 
      Liquor of chloride of arsenic.......... 1   drachm
      Diluted hydrochloric acid.............. 1/2 ounce
      Tincture chloride of iron.............. 1/2   "
      Syrup ................................. 3   ounces
      Water ................................. 2     "
          Take a dessertspoonful in a wineglass of water after       
      each meal.

BERI-BERI.

This is a very fatal but obscure disease occurring in Ceylon, the Malabar coast and outer ports of British India.

Causes.—The causes are very obscure. It is a disease of debility, arising from a want of stimulating and nourishing diet, impure air and exposure to a moist and marshy atmosphere while the frame is debilitated by residence in an unhealthy station.

Symptoms.—It commences with the symptoms of anemia and proceeds to the development of acute dropsy.

Diagnosis.—The paralytic symptoms, together with the dyspnoea and dropsical effusions are sufficient to distinguish it from other diseases. In no disease is internal congestion so strongly marked, doubtlessly due to the congestion of blood in the brain and spinal marrow.

Treatment 1.—Mercury here appears to be the sheet-anchor, but must be administered to produce ptyalism. Saline and antimonial medicines will be called for and the strength supported by cordial liquors. Stimulating liniments should be applied to the extremities and a tonic plan of treatment pursued.

2.—In the more severe cases where the dyspnoea, vomiting, spasms and other symptoms are violent apply blisters to the breast, hot fomentations and hot baths, and exhibit the strongest cordials and antispasmodics. 

Rx.---Muriate of pilocarpine ................. 3   grains 
      Water .................................. 1/2 ounce
      Inject 10 to 20 minims with hypodermic syringe.

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GENERAL DROPSY.

Definition.—A morbid collection of fluid in one or more of the serous cavities within the body or in the areolar tissue beneath the skin and in other situations.

Causes.—A dropsical. accumulation is to be distinguished from the effusion of liquid which takes place in certain inflammatory diseases, pleurisy, peritonitis, pericarditis, and so forth. In other diseases the effusion is due to inflammation, whereas in dropsy transudation takes place intact, the part where it occurs being inflamed.

Local Dropsy.—Dropsy may be local or general. It is local when the effusion of liquid is confined to a single serous cavity or to the areolar tissue within a limited space.

General Dropsy.—Dropsy is said to be general when effusion into the areolar tissue beneath the skin exists more or less over the whole body, accompanied with effusion into certain serous cavities, especially the pleural and peritoneal.

Symptoms.—The symptoms of dropsy vary somewhat, according to the primary disturbance which has been the original cause of the effusion. If the blood is deteriorated by an undue proportion of water or is charged with excrementitious materials, such as urea, which ought to be eliminated by the kidneys in the urine, or contains a large excess of white corpuscles, its circulation through the capillary vessels is much impeded. The dropsy in these cases often, begins in the form of odema or swelling about the feet and ankles. The reproductive organs often become enormously swollen and ascites or dropsy of the abdomen soon sets in. After a time the increasing ascites, by pressing up the diaphragm, interferes with the respiration, causing distressing dyspnoea, which is more urgent in proportion as the blood is watery from anemia. The urine is often scanty and apt to contain an excess of urates, but it is only markedly albuminous when, as frequently happens, the kidneys become secondarily implicated. Among the latter symptoms are palpitation of the heart, deficient perspiration, mental distress, thirst, constipation, daily increasing weakness, and so forth.

Symptoms of Cardiac Dropsy.—Disease of the mitral or aortic valves in the heart is the most common cause of cardiac dropsy. The injured valve, sooner or later, interferes so much with the circulation that serious disturbances become manifest. At first, perhaps, there is only shortness of breath on going up a steep flight of stairs, or other active exertion, with some palpitation and debility, but after a few weeks or months the feet and ankles may begin to swell, the skin putting on a peculiar white and glistening appearance. As the effusion extends upward rest in the recumbent posture becomes impossible, and even in the sitting position only unrefreshing snatches of slumber can be obtained. The heart's action grows daily more and more embarrassed, the lungs more or less congested and a frothy expectoration sometimes streaked with blood appears.

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Further Symptoms.—In the variety of general dropsy, which proceeds from disease of the liver, serous effusion into the cavity of the abdomen is the most prominent symptom. Whether the original hepatic disorder is congestion or hypertrophy of the liver, cancer, contraction or chronic hepatic inflammation, the dropsical symptoms usually commence with exudation of fluid into the abdominal cavity from the surface of its lining membrane, the peritoneum. Dropsy of the feet and legs, however, subsequently sets in.

Acute General Dropsy.—Acute general dropsy from disease of the kidneys, or acute inflammatory dropsy may arise when the functions of the skin are suddenly suppressed, thus allowing certain morbid materials to accumulate in the blood and so set up inflammation in the secreting tubes of the kidneys. Typical examples of this form of dropsy are seen when, from exposure to cold, the action of the skin is checked during the stage of desquamation of scarlet fever, compelling the kidneys to remove the scarlatinal poison from the system when it seems to be particularly obnoxious to the renal tissues. In such cases the urine either gradually or all at once becomes scanty, dark brown in color, and on being tested by boiling is found to be loaded with albumen.

Diagnosis.—The diagnosis of dropsy is usually made with ease, by the fact that the indentation produced on firm pressure with the finger upon the enlarged foot remains for a minute or so before it is filled up by return of the watery fluid into the connective tissue. This evidence of the existence of dropsy is most conclusively obtained when the test is applied over some bone which naturally lies only a little way beneath the skin, as for example, the breast-bone or the shin-bone.

Treatment.—1. The treatment of dropsy, either local or general, involves measures indicated by the diseases which stand in a causative relation to the dropsy. Exclusive of these indications it is often an object of treatment to effect either removal or diminution of the dropsical accumulation. Remedies which produce watery evacuations from the bowels, and those which increase the secretion of urine are chiefly relied upon for this.

2. The liquid in serous cavities may be removed by a puncture or an incision, an operation called paracentesis or, commonly, tapping. In some cases of dropsy of the chest paracentesis is resorted to. Tapping of the abdomen is often employed, and is in many cases useful, not only by relieving suffering but promoting recovery.

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3. In cases of general edema or anasarca, if the effusion be very large, great relief is sometimes obtained by minute punctures of the lower limbs, through which the serum drains away in abundance.

4. Where the acute general dropsy is dependent upon suppression of the action of the skin and kidneys, active purgation and the use of diuretics are to be employed. Jalap and cream of tartar (ten grains of the former with three drachms of the latter) every day or two will answer well for catharsis. A strong cathartic is croton-oil. The dose is a single drop, and this will operate in many instances most violently, producing within half an hour sickness, vomiting and profuse alvine evacuations.

Diuretics.—The diuretics most satisfactory are the infusion of juniper berries (a pint daily), acetate of potash, citrate of potash, squills and sweet spirits of nitre. Colchicum is perhaps the most powerful of remedies, and we have succeeded with it in conjunction with mercurials in acting upon the kidneys in hepatic disease when no other remedy had any effect. Tonics, anodynes, and so forth, may, in visceral dropsy, be of more importance than diuretics. Of course it is desirable to lessen the accumulation of fluid, but the effects of the remedies used must be carefully observed, and one symptom must not be allowed to overshadow all the rest.

Diet.—In general dropsy attention to the diet is very important and efforts should be made to restrict the patient to the smallest amount of fluid with which he can sustain life comfortably. With respect to the nicer question of food, dry articles of food should be selected. It must be varied with the nature of the dropsy and the symptoms with which it is attended, and whoever understands the meaning of a phlogistic (inflammatory) and antiphlogistic (opposed to inflammation) regimen will know how to apply either of these, or to vary from one to the other, as circumstances may require.

For general dropsy: 

Rx.---Powdered jalap .......................... 20 grains
      Cream of tartar........................... 3 drachms
      Powdered ginger .......................... 5 grains
          To be taken at one dose before breakfast, two or
      three times a week.

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Dropsy of kidneys: 

Rx.---Chloroform .................................. 2-1/2 drachms 
      Tincture digitalis .......................... 1     drachm
      Infusion of buchu ........................... 4     ounces
      Water ....................................... 4     ounces
          Take a teaspoonful every three hours.

Heart dropsy: 

Rx.---Bicarbonate of potash ........................ 3 drachms 
      Citrate of iron and ammonia .................. 1 drachm
      Tincture of digitalis ....................... 40 drops
      Infusion of buchu ............................ 4 ounces
      Water ........................................ 4 ounces
          Take a teaspoonful every three hours.

BRIGHT'S DISEASE.

Albuminuria, dependent upon structural change in the kidneys, or to speak more correctly, disease of the kidney, characterized by albumen and dropsy.

Causes.—It is a grandular disease of the cortical part of the kidney which gives occasion to the secretion of urine, which contains albumen and is of less specific gravity than natural, and which destroys by inducing other diseases. It is one-third more common in males than in females. It mostly occurs between the ages of forty-five and sixty-five. Acute Bright's disease is most often produced by cold and dampness, next by scarlet fever, pregnancy, or violent intemperance. The chronic form is greatly promoted by exposure to cold and wet, and is caused moreover by abuse of spirituous liquors. Other predisposing causes are gout, constitutional syphilis and affections of the bladder and urethra.

Acute Bright's Disease.—After exposure to cold, or a drunken fit, or scarlet fever, the patient is seized with chilliness, headache, nausea, vomiting, pain in the back and limbs, checking of perspiration and oppression in breathing. Fever follows and the face, trunk and limbs become puffy with anasarca. Effusion may also occur in the pleura or peritoneum. The urine is scanty, heavy and dark in color from the presence of blood, and very albuminous. The disposition to void it occurs more frequently than in health. The deposit from it, under the microscope, shows blood-corpuscles, loose renal epithelium, tube-casts and shapeless masses of fibrin. After one, two or three weeks, or even a longer period, the attack proceeds to one of three terminations, recovery, death or lapse into the chronic state. Death results through uremia, secondary pneumonia, pleurisy, peritonitis, hydrocephalus or ascites. Probably two-thirds or more of the cases in the acute form recover.

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Treatment.—Cupping the loins, hot water or hot air or "blanket bath," active purging, as with cream of tartar and jalap, or citrate of magnesium, and diaphoretics, as citrate of potash or liquor ammonia acetatis.

Diet.—Should be liquid and simply nutritious.

Chronic Bright's Disease.—This approaches so slowly as seldom to be detected until after the lapse of months or years. Gradual loss of strength, pallor or puffiness of the face, shortness of breath and frequent disposition to urinate are early signs of it. But they are not always present; the denouement of the disease may be by a convulsion, edema of the lungs, dimness of vision, or some violent local inflammation.

Symptoms.—Albuminous urine, deposits of tube-casts and renal epithelium, dryness of skin, frequent micturition, especially at night; general dropsy, or local effusions into the cavities, indigestion, anemia, uremic effects (headache, dizziness of sight, convulsions, coma, vomiting, diarrhea), enlargement of the heart and secondary inflammations, bronchitis is especially common. The progress of the case is usually interrupted by exacerbations and intervals; each fresh attack leaving the patient manifestly worse than before.

Diagnosis.—The presence of albumen in the urine, with dropsy, not of sudden origin or brief duration, is indicative of this affection. The microscope will show also free renal epithelium and tubular casts in the urine; in advanced cases the casts are sprinkled with oil-dots.

Treatment 1.—Iron will do more good than any other medicine, unless it be cod-liver oil in persons of strong stomach. They may be very well combined. The tincture of the chloride of iron is as good as any other chalybeate as a general rule. With some the citrate of iron in solution, or a carbonate, or the iodide, will agree more readily. As an astringent the ammonia-ferric alum is claimed to possess the power of checking the waste of albumen through the kidneys.

2. For the dropsy warm baths and hydrogogue cathartics are useful. Of the latter cream of tartar and jalap, two or three drachms of the bitartrate with ten or twenty grains of jalap two or three times a week, are the favorites. If serious dropsical accumulations threaten life, elaterium (one-sixth or one-fourth- grain every four hours, in pill, until it acts) may be given.

3. If the warm baths do not agree or fail to produce diaphoresis try the hot-air bath, at 130 degrees to 160 degrees Fahrenheit. This rarely fails to produce free perspiration. For weaker invalids the vapor bath is available. Of diuretics, acetate of potassium, spirits of nitrous ether, and compound spirit of juniper will be least likely to disappoint.

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4. But all will not unfrequently fail. We have as a last resource for the relief of great edema the use of incisions with a lancet or needle in the swollen legs and feet. Care should be taken that erysipelas does not follow, by repeated warm sponging of the limbs and washing them with diluted glycerine.

Diet.—Nourishing diet, of which milk may generally be part, is of the utmost consequence. Regimen or hygienic management is of the utmost importance. Avoidance of exposure to cold, wet or great fatigue; the reform of intemperance, if it has existed, or all other excesses, will be indispensable. Clothing should be sufficiently warm, with flannel next to the skin. Bathing frequently at such temperatures as is borne without either chill or relaxation, and the bowels should be kept regularly open.

The following are approved remedies: 

Rx.---Chloride of soda and gold................. 3 grains 
      Corrosive sublimate ...................... 5   "
      Extract of gentian sufficient to make 60 pills.
          Take one morning and night.

Rx.---Iodide of soda........................... 15  grains 
      Phosphate of soda........................ 1/2 drachm
      Common salt ............................. 3   drachms
      Water sufficient to make solution.
          Divide into three equal parts, and take one part
      every eight hours.

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