Therapeutics

Therapeutics (Gr. BEparevruo), Sc. iixvrt, from 6EpaTrEbav, to serve), the name given to that branch of medicine which deals specifically with the means employed to cure disease if possible, or to control and lessen its evil results when a cure is impossible.

The cure which is sought for may either be symptomatic or radical. Various morbid conditions of the body generally may give rise to different symptoms. Thus a gouty condition may manifest itself in one man as eczema of the skin, giving rise to redness and intense itching; in another as neuralgia, causing most severe pain; in a third as bronchitis, producing a distressing cough; in a fourth as dyspepsia, giving rise to flatulence and intestinal disturbance; and in a fifth as inflammation of the great toe, accompanied by redness, swelling and pain. The therapeutic measures employed in these different cases may be directed towards alleviating the symptoms, such as itching, pain, cough and swelling, in which case the treatment will be merely symptomatic; or they may be directed towards removing the root of the disease, viz. the gouty condition underlying them all, and thus effecting a radical cure. It very frequently happens that we do not know what the underlying condition is, and we are forced simply to relieve as best we can the most prominent and most distressing symptoms. In symptomatic treatment we are frequently obliged to use remedies simply because we know they have done good before in similar cases, and we expect them to do so again without having the least idea of how they act. Thus in acute gout the most common and most trusted remedy for removing the pain is colchicum, but at present we do not know what action it has upon the system, or why it gives so much ease in the pain of gout while it has comparatively little effect upon pain due to other causes. This plan of treatment is termed empirical. It is a useful method, and is often very satisfactory, but it has the disadvantage that it admits of but little progress, and when a trusted empirical remedy fails we do not know precisely in what direction to look for a substitute. In contradistinction to empirical we have rational therapeutics, by which we mean the application of a remedy, whose mode of action we know more or less perfectly, in diseased conditions, the nature of which we also understand more or less fully. As an example may be taken the use of nitrite of amyl in angina pectoris. It has been found that in many cases of this disease the pressure of blood within the arteries becomes increased, probably from spasmodic contraction of the arteries themselves. Nitrite of amyl has the power of dilating the arteries; it has consequently been employed with much success in lowering the blood pressure and removing the pain in angina pectoris. But such rational knowledge as this not only enables us to remove pain at the time, but helps us to prevent its recurrence. For on the one hand knowledge of the fact that nitrite of amyl lessens blood pressure has led to the successful employment of other nitrites and bodies having a similar action, and on the other the knowledge that increased blood pressure tends to cause anginal pain leads to the prohibition of any strain, any food, any exposure to cold, and also of any medicines which would unduly raise the blood pressure. Here we notice one of the greatest advantages of rational over empirical therapeutics. In cases of angina, while the resistance opposed to the action of the heart by spasm in the vessels may be great, the heart itself may be feeble, and it may therefore be necessary to give some remedy which will increase the power of the heart. But if such a remedy were given alone it might, and probably would, act on the arteries as well as the heart, and by causing the contraction of the vessels do more harm than good. But if we know what remedies will increase the power of the heart and what will lessen resistance in the vessels, we may combine them and thus obtain the objects we desired, viz. removal of the pain, better action of the heart, and more perfect circulation.

The testing of ideas by observation and experiment which was begun in anatomy by Vesalius. and by Harvey in physiology, was applied by Morgagni to alterations in the. organs produced by disease, by Bichat to the tissues, and by Virchow to the cell. The study of disease in the living body may be said to have been begun by John Hunter, developed by Magendie, Claude Bernard, Brown-Sequard and others. Of late years enormous impulse has been given to our knowledge of the causation of disease by microbes, through the works of Gaspard, who injected putrid matter into the veins of a living animal; by Villemin, who discovered that tuberculosis is infective; by Davaine; and especially by Pasteur, Koch and others too numerous to mention, who have worked, and are still working, at the microbic causation of disease with marvellous success. The natural end of life is that all the organs should become old and gradually decay at the same time, so that at the last the individual should become less and less active, weaker and weaker, and finally die without any definite disease, without pain and without struggle. But this is exceptional, and generally one part gives way before another, either on account of one part being naturally weaker or of one part having been overtaxed or more severely attacked by some injurious external influence, or by some undue preponderance of another part of the body itself. For health consists in a due proportion between the action of all the different parts of the body, and if one part be unnaturally strong it may lead to injury or death. Thus a very strong heart, although it may be useful to its possessor for many years, driving the blood rapidly through the vessels, and supplying all his tissues with such abundant nutriment as to enable him to endure great exertion, mental or bodily, may in the end cause death by bursting a vessel in the brain, which might have resisted the pressure of a feebler circulation for years longer. On the other hand, a heart that is too feeble may cause its owner's death by its inability to carry on the circulation against increased \-  resistance. This may occur suddenly, as when the resistance is increased in the arterial system by a e on f  sudden exertion or strain, and more slowly when the resistance is increased in the pulmonary circulation of the  by inflammation of the respiratory passages. The thyroid gland, which is situated in front of the neck, yields a secretion which passes into the blood and there tends to maintain a state of moderate dilatation in the blood-vessels and of oxidization in the tissues, so that the circulation remains good and the body-heat and muscular activity remain well maintained. When this gland becomes enlarged, and its secretion consequently increases, the vessels dilate, the heart beats more rapidly, the skin becomes too hot, the nervous system becomes irritable, and tremors occur in the limbs. On the other hand, when it becomes atrophied the circulation becomes feeble, the face heavy and dull, the patient suffers from cold, the features glow lumpish, mental processes become sluggish, and bodily vigour diminishes.

Disease of the whole body may thus be produced by overaction or under-action of some part of it, but such causes of disease are slight as compared with the effect of external noxious influences, and more especially the effect of microbes. These enter the body through various channels, and once they have effected a lodgment they grow, multiply and give rise to various poisons which attack and injure or destroy different tissues or organs in the body. Various safeguards are provided by nature to prevent their entrance. On the skin we have a thick epidermis through which microbes cannot pass, although if an entrance is obtained for them by a prick or cut they may readily grow in the tissues below and spread from them throughout the whole body. They pass more readily through mucous membranes, but almost every one of these is provided not only with a coating of mucus, which obstructs their passage, but with some reflex mechanism which tends to remove them. Thus irritation of the eye causes winking and secretion of tears, by which the irritant is removed; irritation of the nose causes sneezing; of the air-passages, coughing; of the stomach, vomiting; and of the intestines, diarrhoea. Even when they have passed through an abrasion in the skin or through the mucous membranes and enter the blood they are met, in some instances, by a toxic action of the blood itself upon them; and in others they are attacked by the white corpuscles, which destroy them, eat them up, and digest them, the process being known as phagocytosis. The greater the number of leucocytes that can reach the spot where the invading microbes enter the more quickly can the microbes be destroyed and general infection prevented. The microbes appear in many cases to attract the leucocytes (positive chemiotaxis), but when very virulent they usually repel the leucocytes (negative chemiotaxis) and excrete toxins which kill the leucocytes. The irritation caused by the microbes generally is followed by dilatation of the vessels of that part and thus more leucocytes are brought up to the fight. This dilatation may be increased by local warmth, and poultices or fomentations are commonly applied to inflamed parts; recently suction apparatus has been used for the same purpose or ligature so as to cause venous stasis (Bier's treatment). Blisters also cause local dilatation of vessels, but are usually applied to the skin for inflammation in deep-seated parts, such as the lungs, though they also relieve pain in the joints in acute rheumatism. Bier increases the blood in a part by compressing the veins and thus producing passive instead of active congestion. The toxins produced by microbes, if too weak to destroy the leucocytes, induce them to secrete antitoxins, which not only act as antidotes to the toxins and are injurious to the microbes, but also increase the phagocytic power of the leucocytes (opsonius of Wright). By inoculation with increasing doses of these the resistance of the organism is greatly increased and the invading microbes destroyed. The vaccine is usually made by sterilizing a virulent culture and the proper dose is ascertained by noting 'the extent to which the power of the leucocytes to envelop and digest the microbes is increased.

Moreover, the products of microbic secretion tend to produce fever. The high temperature characteristic of this condition is no doubt injurious to the body itself, but it is frequently more so to the microbe which has invaded the organism; and thus fever, instead of now being regarded as a morbid condition to be suppressed by every means in our power, is considered to be a reaction of the organism tending to protect it by destroying the infection. But it must be kept within limits, lest it should of itself cause death, and here again we see the difference between empirical and rational medicine. Fever is not to be looked upon as an unmitigated evil, to be removed if possible, but rather as a defensive mechanism by which the organism may prevent invasion from noxicus microbes. Nevertheless, as in a campaign the general's plan may be spoiled by too hasty or too eager action on the part of some of his troops, so the defensive arrangement carried to excess may prove injurious or fatal to the organism. Thus too great a rise of temperature in fever may kill the patient; and the aim of therapeutics is to restrain the temperature within proper limits, neither allowing it to rise too high nor to fall too low. The old plan of lowering it by means of cold baths was known to Musa, the physician of Augustus, and by it he saved the emperor's life; but the same treatment killed the emperor's nephew. The introduction of the clinical thermometer, which allows us to ascertain exactly the amount to which the temperature rises in fever or to which it is reduced by antipyretic measures, is to the physician like the compass to the sailor, and allows him to steer safely between two extremes.

After the struggle between the organism and the microbes is over, even when it has ended victoriously for the former, injuries are left behind which require repair. Every one has noticed after prolonged fever how thin and weak the patient is, and both the muscular and nervous power throughout the whole body are sadly in want of repair. Where there has been local mischief due to inflammation the dead leucocytes must be removed, and this is done either by their being converted into pus in one mass, and making their way through the tissues to the nearest surface, whether of skin or mucous membrane, from which it can be discharged, or they may undergo a process of fatty degeneration and absorption, leaving behind in some cases cheesy matter, in others hard connective tissue.

Poisons formed by microbes are partly eliminated by the kidneys, partly by the mucous membrane of the stomach and intestines, and possibly also by the skin. In old days free elimination by these channels was looked upon as a sign of returning health, and was termed a "critical" diuresis, diarrhoea or sweating, according to the channel through which the eliminative act had occurred.

By therapeutic measures we strive to limit as far as possible the entry of injurious microbes into the organism, to expel or destroy them and their harmful products, and to maintain the strength of the organism itself. One of the influences which is most injurious to the body, and favours most the invasion of microbes, is chill. So much is this the case that some diseases which are now known to be due to infection were formerly attributed entirely to the effect of cold. Thus pneumonia is now known to he due to the diplococcus pneumoniae, and yet its invasion occurs so frequently after a chill that it is almost impossible not to look upon chill and pneumonia as cause and effect. The reason of this appears to he that the diplococcus is frequently present in the mouth or air-passages without giving rise to any symptoms; but when the patient is exposed to chill, and the tissues of the respiratory passages are thereby weakened, the diplococcus grows, multiplies and gives rise to inflammation of the lungs. Even what are known as common colds are probably due chiefly to microbic infection aided by a chill, just as in the case of pneumonia. Therapeutic measures which are commonly adopted in the treatment of a cold have for their object, to destroy the microbes before they penetrate fairly into the organism, and to restore the balance of the circulation and increase the strength of the invaded parts. Thus carbolic acid or carbolized ammonia are sniffed into the nose to destroy the microbes there, or the nose is washed out by an antiseptic solution as a nasal douche; bismuth or morphine are insufflated, or zinc ointment is applied, to cover the mucous membrane, and protect it from further irritation; and various antiseptic gargles, paints and powders applied to the pharynx in order to prevent the microbic inflammation from extending to the pharynx and down the trachea and bronchi, for many a severe bronchitis begins first by sneezing and nasal irritation. Sometimes the patient is put to bed and the circulation is encouraged, especially on the surface of the body, by the use of hot spirits and water, or opium and ipecacuanha, while the outside of the nose is protected to a certain extent from loss of heat, and consequent irritation, by smearing it with a tallow candle or rubbing some ointment over the skin. At the same time, if the throat has begun to show signs of being involved, a hot poultice or wet pack is applied to the neck.

Both inflammation and fever are protective processes calculated to defend the organism against the attacks of microbes. But protective processes misdirected or carried to excess may become injurious or even dangerous to the organism. As an instance of misdirection, we may take the irritation which remains in the eye after a particle of dust has been removed, or the itching of the skin which occurs in eczema. The irritation of the conjunctiva caused by dust leads to winking of the eyelids, lachrymation and rubbing, which tend to remove it; but after the dust has been removed violent rubbing tends rather to keep up the irritation; and sometimes, if the particle of dust remains under the eyelid and is sharp and angular, the process of rubbing may cause it to injure the conjunctiva much more than if it were left alone. In the same way itching is often caused by the presence of insects or other irritants upon the skin, and it tends reflexly to cause rubbing, which is useful by removing the irritant. But when the irritation is situated in the skin itself, as in eczema, the scratching tends to increase inflammation, and makes the irritation worse. In the same way, the reflex act of coughing is useful in removing either foreign bodies or excessive secretion from the air passages; but when the mucous membrane of the respiratory tract is irritated and inflamed, it produces a feeling of tickling and a desire to cough sometimes very violently; yet the coughing simply tends to exhaust the patient, because there is really little or nothing to bring up. The same is the case in inflammation of the lung substance itself. As an example of excessive action we may take sneezing, which is calculated to remove irritants from the nose, but when too powerful may cause the patient to burst a blood-vessel. In phthisis also, although there may be some expectoration to bring up, yet a good deal of the irritation is in the lung substance, and the efforts of coughing are far greater and more continuous than are required for the removal of expectoration, and they simply exhaust the patient. In inflammation of the stomach also such continuous vomiting occasionally occurs that the patient's life is in danger by his inability to retain food; and similar danger also occurs from inflammation of the intestines and consequent diarrhoea.

We will next take the various parts of the body, and consider more in detail the therapeutic measures most commonly employed in the treatment of their diseases. The defensive powers of the body against microbes, when actually on or in it, may be classed as means (z) of passive defence, (2) of active defence, and (3) of repair. Besides these, however, we must consider the protection of the whole body from injury caused by (a) inaction, or (b) overaction, or (c)  weakness of any one of its parts. The means of passive and active defence are sometimes so closely associated that it is difficult to distinguish between them. Thus if a little diphtheritic sputum were coughed into a person's eye, or some blood containing anthrax bacilli were to touch a raw spot upon the hand, the removal of microbes in either case by washing with simple water might be regarded as a means of passive defence, whilst washing them away with an antiseptic lotion might be regarded as active defence, because the antiseptic would tend not only to remove but to destroy the microbes. In the same way, washing the skin with spirit would tend to harden the epidermis and thus prevent the entrance of microbes; and the application of an ointment to an abrasion would have a similar action. But by the addition of some antiseptic to the ointment its defensive action would be converted from passive to active, and its power to prevent infection would become greater; and if inflammation had already set up in the skin, the addition of opium, belladonna, or cocaine would lessen local pain; and an astringent, either metallic or organic, would restrain inflammation and accelerate repair. The thickening of the epidermis in the hands and feet, which occurs from constant use, is nature's provision for meeting the extra wear to which these parts are subjected by much use; but pressure is apt to cause the defensive process to be carried too far, and to lead to corns, which give rise to much pain and annoyance. To remove these salicylic acid dissolved in flexible collodion is now generally employed. When this is painted upon the part the corn usually peels off in a day or two, and the patient is cured.

But the object of therapeutics is not merely to cure. It is, in the words of the old formula, Curare, cito, tuto, et jucunde, to cure quickly, safely, and pleasantly. There are therefore in most prescriptions (i) a basis or chief ingredient intended to cure (curare), (2) an adjuvant to assist its action and make it cure quickly (cito), (3) a corrective to prevent or lessen any undesirable effect (tuto), and (4) a vehicle or excipient to make it suitable for administration and pleasant to the patient (jucunde). In the remedy just mentioned the salicylic acid forms the basis; but sometimes chloride of zinc or lactic acid is added to it to make it act more quickly, and these are the adjuvants. Extract of belladonna is added to lessen the pain which might occur during the removal of the corn, and this acts as a corrective, while the flexible collodion forms a means of applying it conveniently, and constitutes the vehicle.

The surface of the skin may be invaded by parasitic organisms and may exhibit spots, which are removed by something which will destroy the parasite, such as ointments containing mercurial salts. In psoriasis the epidermis separates in flakes at various spots which have not been subjected to pressure, and to cure it ointment containing tar or other products of the dry distillation of wood is employed. When the true skin is inflamed various appearances may arise, according to the intensity and extent of the inflammation, and the eruption may be papular, vesicular, pustular, tubercular, bulbous or ulcerative. To lessen irritation the skin is protected by dusting powders, such as oxide of zinc, starch, fuller's earth, &c., or by ointments. Irritation is lessened by lotions containing substances that will diminish irritability of the nerve-endings and skin, such as carbolic acid, hydrocyanic acid, morphine or opium, cocaine, belladonna or atropine. Where the surface is ulcerated it may be protected from external violence and placed under favourable conditions for healing by covering it with lint moistened with water and with oil-silk over it to prevent evaporation. If the granulations tend to become too abundant, some astringent, such as sulphate of copper or sulphate of zinc, is added to the water. On the other hand, when the ulceration is old and the circulation through it poor, the aim of the therapeutist is to reawaken the normal reparative process, to bring about increased circulation and increased tissue change, and thereby insure healing. For this reason a blister is placed upon the callous ulcer, which heals with the fresh inflammation thus excited.

The treatment of inflammation of mucous membrane is based upon the same principles as inflammation of the skin, and there too we usually associate means (I) for removing microbes, (2) for destroying them, (3) for lessening the irritation they produce, and (4) for repairing any mischief they have done. Thus in the eye and ear, lotions containing an antiseptic, a sedative and an astringent are very generally used. For inflammation of the mouth a similar combination is used as a mouth wash, in the throat as a gargle, and in the nose as a wash and sometimes as an ointment or spray, the ointment possessing the advantage of protecting the delicate nasal mucous membrane from irritation by stopping the entrance of irritant dust into the nasal cavities. In the stomach we aid the vomiting by which microbes or the products of decomposition of food are usually eliminated by giving to the patient repeated draughts of hot water so as to wash the stomach clean. Frequently this is sufficient; but if the stomach refuses to eject its objectionable contents, we may either give an emetic or wash it out by means of a stomach-pump or siphon. Similar procedures are used for the intestine, and one of the best methods of treating the diarrhoea consequent upon the presence of irritating substances in the intestinal canal is to give a dose of castor-oil together with a few drops of laudanum. By means of the castor-oil the irritating substances are removed, and the laudanum which is mixed with the purgative soothes the intestine. Even in cases of very acute intestinal diseases similar treatment is now pursued, and instead of treating dysentery simply by sedatives or astringents, an eliminative treatment by means of sulphate of magnesia is largely employed. After the irritant has been removed either from the stomach or intestine, a feeling of irritation of the mucous membrane may remain, and sickness, diarrhoea or pain may continue in the stomach and intestine although the irritant is no longer present within them, just as the flow of tears and desire to rub may remain in the eye after the piece of grit which has occasioned it may have been removed. The condition which remains after the irritant has been removed is one of inflammation more or less intense. The process of inflammation is a defensive one, but if carried too far may prove injurious.

For the purpose of checking the inflammatory processes and lessening discharge from mucous membranes astringents are employed. Some of these are of mineral and some of vegetable origin, but they almost all possess one chemical property in common, namely, they precipitate albumin. This power is possessed alike by a glass of brandy, by solution of lime, soluble salts of zinc, copper, or silver, by tannic and gallic acids, as well as vegetable juices and extracts which contain them. The strength of the astringent application and the mode of its administration are varied according to the delicacy and position of the mucous membrane affected. Thus to the eye we may use a solution of sulphate of zinc of half a grain to the ounce, while to the ear, urethra or vagina a solution of four to eight grains or even more may be applied. For the stomach and intestines we employ the same drug in the form of a pill; and when it is desired to act especially upon the intestines, the pills are made of a harder consistence or less soluble preparation, or are covered with keratin, so that they may not act much, if at all, upon the stomach while passing through it before reaching the intestines. The heat which occurs in inflamed parts is chiefly due to the larger amount of blood circulating in the part on account of the dilatation of the vessels. The pain is due to stretching of the nerve fibrils or compression of them by the turgid vessels in the swollen tissues. This latter cause is chiefly observed when the tissues are of a very unyielding character; for example, when the inflammation occurs in a bone or under a thick fibrous and unyielding membrane. The swelling, heat and pain may sometimes be relieved by mere change of position altering the flow of blood to the inflamed part. Thus when inflammation occurs in the finger, as in a whitlow, the pain is not only constantly severe, but it is increased by every pulsation of the heart, and thus has a throbbing character. By raising the hand nearly to a level with the head both the constant pain and the severity of the throbs may be relieved, as the blood is not sent with such great force into the arteries and returns more readily through the veins. In other parts of the body the same relief may be obtained by raising the inflamed part as high as possible. Relief is. frequently given also by both heat and cold, and at first sight it seems strange that agents having such an opposite action should each produce a similar effect. The reason probably is that the application of cold causes contraction of the arteries leading to the inflamed part, while heat by dilating the vessels around forms a side channel through which the blood passes, the tension in the seat of inflammation being thus lessened in both cases. When the inflammation occurs in soft parts where the surrounding vessels can be readily dilated, heat often affords more relief to the pain than cold, but when the inflammation is in a bone or in unyielding fibrous tissues, cold generally gives more relief. For example, the pain of a gum-boil is generally relieved more by warmth, because the yielding tissues of the gum, mouth and cheek can be readily relaxed by heat and their vessels dilated; but when the pain is dependent upon inflammation in the hard unyielding socket of a tooth, cold generally gives greater relief. The removal of blood, either by incision or by the application of leeches, sometimes gives considerable relief to the pain and tension of inflamed parts. Blisters applied at some distance from inflamed parts are also sometimes useful; and probably they produce this good effect by causing a reflex contraction of the arteries in the inflamed part, and thus acting like a cold application. Certain drugs have the power of relieving inflammation by slowing the heart and rendering its impulse more feeble. Amongst those are to be classed small doses of aconite and colchicum; the former especially tends to lessen the process of inflammation generally, when it is not too severe. There can be little doubt that the intensity of inflammation frequently depends very much on the condition of the blood, and that by altering the blood inflammation may be lessened. Thus free purgation, and especially purgation by cholagogues and salines, has long been recognized as a useful means of reducing the inflammatory process. For example, a mercurial pill at night, followed by salts and senna in the morning, will often relieve the pain in toothache or gum-boil, and lessen inflammation not only in the mouth, but other parts of the body as well. Such remedies are termed antiphlogistic. Venesection (blood-letting) at one time was highly esteemed as an antiphlogistic measure, and while it is possible that it has now fallen too much into disuse, there can be no doubt that at one time it was very greatly abused, and was carried to such an excess as to kill many patients who would have recovered perfectly had they been let alone. Although the high temperature in an inflamed part is chiefly due to the increased circulation of blood in it, yet the presence of inflammation appears to cause increased formation of heat either in the inflamed part itself or in the body generally, because we rarely find inflammation exist to any extent without the temperature of the body being raised and a febrile condition produced.

Two very old remedies for fever are acetate of ammonia and nitrous ether. These were formerly given empirically, simply because they had been found to do good. Now we can see the reason for their administration, because the nitrous ether, consisting chiefly of ethyl nitrite, dilates the superficial vessels and thus allows greater escape of heat from the surface; while acetate of ammonia, by acting as a diaphoretic and stimulating the secretion of sweat, increases the loss of heat by evaporation. When a patient is covered with several blankets, loss of heat from the surface both by radiation and evaporation is to a great extent prevented, but if a cradle be placed over him, so as to raise the bedclothes and allow of free circulation of air around his body, both radiation and evaporation will be increased and the temperature consequently lowered. If his body be left uncovered except by the sheet or blanket thrown over the cradle, the loss of heat is still greater, and it may be much increased by sponging the surface with either hot or cold water so as to leave it slightly moist and increase evaporation. The temperature may be still further reduced by placing vessels filled with ice inside the cradle. When the patient is very restless, so that cradling is impossible, a wet pack may be employed, a sheet wrung out of cold water being wrapped round him, and over this a blanket. The pack has the double effect of restraining his movements and thus lessening the production of heat, while at the same time it dilates the vessels of the skin and produces loss of heat. The restraint which it imposes and the equal distribution of heat over the surface frequently cause sleep quickly in patients who have previously been wildly delirious and entirely sleepless. When the temperature continues to rise in spite of wet sponging and cradling, recourse must be had to the cold bath. The bath should be brought to the bedside and the patient, wrapped in a sheet, should be lifted into it by two attendants. The water should be at the temperature of 90 and gradually reduced by the removal of hot water and displacement by cold, until the temperature of the patient as taken in the mouth is reduced to about 991° or 99°. After this the patient should be taken out and again put into bed. It is inadvisable to lower the temperature quite to the normal while the patient is in the bath, as frequently it falls after his removal, and may fall so far as to induce collapse. In cases where no bath is available a large mackintosh sheet may be spread upon the bed under the patient, the sides and top may be raised by pillows, and cold water may be applied to the surface of the body with large sponges. The mackintosh sheet forms a shallow bath, and the water may afterwards be run off from it at the lower end of the bed. Another way of applying cold is to dip an ordinary sheet into cold water, apply it for three or four minutes to the surface of the body, then remove it and replace it by another sheet while the first one is being dipped in water. By the alternate use of the two sheets, or by the use of one quickly wrung out of cold water as soon as it becomes warm, the patient's temperature may be rapidly reduced.

There are a number of drugs which have a very powerful action in lowering temperature. Most of these belong to the aromatic group of bodies, although one of them, antipyrin, belongs rather to the furfurol group. Carbolic acid has an antipyretic action, but on account of its poisonous properties it cannot be employed as an antipyretic. Salicylic acid has a strong antipyretic action, and is most commonly used in the form of its sodium salt, which is much more soluble than the acid itself. Amongst other antipyretics, the most important are quinine, phenacetin and antifebrin. These probably lessen fever by their action upon the nerve centres which regulate the temperature of the body, and partly by their peripheral action in causing the secretion of sweat. Very high fever in itself will cause death, the fatal temperature in rabbits being 114.6°. Before death occurs the pulse and respiration become exceedingly rapid and weak, and complete unconsciousness sets in. That these symptoms are simply due to heat is shown by the fact that if the temperature be quickly reduced by the application of cold the symptoms at once subside. But the delirium which is common in fever, although it may be partly due to rise of temperature, is very often due to poisons in the blood, for in some cases it occurs with quite a low temperature, 101° or 102°, whereas in others the temperature rises to zoo° and 105° with no delirium whatever. The presence of toxins in the blood not only affects the brain, causing delirium, but also other organs, the heart and lung, and may cause fatal syncope or respiratory failure.

Many years ago Dr S. L. Mitchill (1764-1831) pointed out in America the resemblance which exists between symptoms of Anti- poisoning by snake venom and infective fevers.' toxins S. Weir Mitchell and others have shown that serpent venom consists chiefly of albumoses, and the toxins formed by infective bacilli have a somewhat similar chemical nature. Calmette and Fraser found that when small doses of snake venom, insufficient to cause death, are injected into an animal, temporary disturbance is produced; but after a few days the animal recovers, and a larger dose is then required to produce any symptoms. By gradually increasing the dose the animal becomes more and more resistant, until at last a dose fifty times as great as that which would at first have produced immediate death can be injected without doing the animal any harm. If a horse be chosen for the experiment, a considerable quantity of blood may be withdrawn without injuring the animal. When this is clotted the serum is found to act as an anti-venin, so that when mixed with the venom of a snake it renders it harmless. Although this result is best obtained when the venom and serum are mixed in a glass before injection, yet if they be injected at the same time in different parts of the body the animal will still be protected and the poison will not produce its usual deadly results. What occurs with snake venom takes place also when the toxins are formed by microbes, and a new method of treatment by anti-toxic serums has been introduced of late years with great success. This is most commonly and successfully used in the treatment of diphtheria. This disease depends upon the presence of a bacillus which grows rapidly at the back of the throat and in the airpassages specially of children, causing the formation of a membrane which, by plugging the windpipe, causes suffocation and death. At the same time it produces a poison which causes inflammation of the nerves, leading to paralysis, which sometimes proves fatal. By growing this bacillus in broth a toxin is formed which remains in solution and can be separated from the bacilli themselves by filtration. This toxin-containing broth is injected into a horse in increasing doses, just as in the case of the serpent venom, and after the resistance of the horse has been much increased it is bled into sterilized vessels and the blood is allowed to coagulate. The serum is then removed and its anti-toxic power tested by ascertaining the amount necessary to counteract a given amount of active toxin in a guinea-pig of a certain size, the standard weight being three hundred grammes. The serum, the strength of which has thus been ascertained, is distributed in bottles and injected in the proper quantity under the skin of children suffering from diphtheria. If used at an early stage of the disease, and in sufficient quantity, the results are wonderful. The same method of serum therapeutics has been used in other infective diseases, but not with the same success.

Another therapeutic method which is historically much older than that of serum therapeutics is that of inoculation. The virulence of infective diseases varies in different epidemics, and at different times in the same epidemic. It had been noted that many infective diseases did not attack an individual a second time, the first attack appearing to protect from subsequent ones. The idea of inoculation, therefore, was to infect an individual with a mild form of the disease, so that he should escape infection by a more virulent one. This was tried largely in the case of smallpox, and once at least by Dr Erasmus Darwin in the case of scarlet fever. The worst of this method was that the disease thus inoculated did not always prove of a mild character, and in the case of Dr Erasmus Darwin's son the scarlet fever was exceedingly severe and very nearly proved fatal. To Edward Jenner we owe the discovery that vaccination protects against smallpox, and it is now generally acknowledged that smallpox and vaccine are ' Quoted by Weir Mitchell, "Researches on the Venom of the Rattlesnake," Smithsonian Contributions (1860), p. 97.

probably the same disease, the virus of which is modified and its virulence lessened by passing through the body of the cow. Pasteur found that the germs of anthrax could be cultivated outside the body and their virulence weakened either by growing them at too high a temperature or in an unsuitable medium. By inoculating first with a weak virus and then with others which were stronger and stronger, he was able completely to protect oxen either from the effects of inoculation with the strongest virus or from infection through contact with other animals suffering from the disorder. On the other hand, he found the weakened virus could be again strengthened by inoculating a feeble animal such as a guinea-pig a day or two old with it, and then inoculating stronger and stronger animals: an increase in strength was gained with each inoculation, until at last the virus could attack the strongest. A similar increase in virulence appears to occur in plague, where animals, especially rats and mice, seem to be affected before human beings, and not only increase the virulence of the microbes, but convey the infection. Two methods of protective inoculation have been used. In one, Haffkine employs the toxins obtained by growing plague bacilli in broth for five or six weeks, and then heating the whole to 65° or 70° C. so as to destroy the bacilli. This preparation is prophylactic, but does not seem to be curative. Yersin has prepared a serum from horses in the same way as diphtheria anti-toxin, and this is said to have a curative action during the attack. In the same way sterilized cultures of typhoid bacilli have been used to protect against attacks of typhoid fever, and an anti-typhoid serum has been employed with intent to cure. Protection does seem to be afforded, but the curative action of the serum is still somewhat doubtful. Although the anti-toxins which are used in the cure of infective diseases are not dangerous to life, yet they sometimes cause unpleasant consequences, more especially an urticarial eruption almost exactly like that which follows eating mussels or other shell-fish. Sometimes the swelling of the skin is much more general, so that the whole body may be so swollen and puffy as exactly to resemble that of a person suffering from advanced kidney disease. These disagreeable results, however, are not to be compared with the benefits obtained by the injection of anti-toxic serum, and this method of treatment is likely to maintain its place in therapeutics.

For many years pepsine has been used as a remedy in dyspepsia to supplement the deficiency of digestive juice in the stomach, and it has been used popularly in dyspepsia for a still longer period. From time immemorial thera-  savages have been accustomed to eat the hearts of lions and other wild animals, under the belief that they will thereby obtain courage and strength like that of the animal from which the heart had been taken, but in 1889 BrownSequard proposed to use testicular juice as a general tonic and stimulant. Observations were made on the connexion between thyroid gland and myxoedema, which appeared to show that this disease was dependent upon atrophy of the gland. Accordingly the liquid extracts of the gland, or the gland substance itself compressed into tablets, have become largely used in the treatment of the disorder. The success which has been achieved has led to the use of many other organs in a raw or compressed form, or as extracts, in other diseases; e.g. of suprarenal capsule in Addison's disease, of bone marrow in pernicious anaemia, of thymus and suprarenal capsule in exophthalmic goitre, of kidney in renal disease, and of pituitary body in acromegaly. To this method of treatment the name of organotherapeutics or opo-therapy has been given. The first scientific attempt to employ portions of raw organs in the treatment of disease was made by Lauder Brunton in diabetes in 1873, sixteen years before Brown-Sequard's paper on the effect of testicular juice. From considering the nature of diabetes, he had come to the conclusion that many cases were due to imperfect oxidation of sugar in the body; that this oxidation was normally carried out by a ferment in the muscles, and that probably the disease was in some cases dependent upon absence of the ferment. He tried to supply this by giving raw meat and glycerine extract of meat, but although he seemed to get some benefit from the treatment, it was not sufficiently marked to attract general attention. His attempts to isolate a glycolytic ferment from flesh were also only partially successful. One of the great difficulties in the way of applying this treatment is that in all probability many of the ferments or enzymes are altered during the process of absorption in the same way as the normal ferments of digestion, and unless the tissue enzymes can be isolated and injected subcutaneously the desired results will not be obtained. The most striking of all the results of organo-therapy are those obtained in myxoedema. In this disease the face is heavy, puffy and expressionless, the lips thick, the speech slow, the hands shapeless and spade-like, the patient apathetic, the circulation slow and the extremities cold. Under the influence of thyroid gland these symptoms all disappear, and the patient is frequently restored to a normal condition. When the thyroid gland is absent in children, not only is the expression of the face dull and heavy as in the adult, but the growth both of body and mind is arrested, and the child remains a stunted idiot. The effect of thyroid gland in such cases is marvellous, the child growing in body and becoming healthy and intelligent. In the case of the thyroid the function of the gland appears to be to prepare a secretion which is poured out into the blood and alters tissue-change. When the thyroid tablets or extract of thyroid are given in too large quantities to patients suffering from myxoedema, the symptoms of myxoedema disappear, but in their place appear others indicative of increased metabolism and accelerated circulation. The pulse-rate becomes very rapid, the extremities become warm, so that the patient is obliged to wear few clothes, the temper becomes irritable, the patient nervous, and a fine tremor is observed in the hands. On stopping the administration of thyroid these symptoms again disappear. When the thyroid is hypertrophied, as in Graves's disease, the same symptoms are observed, and these are probably due to increased secretion from the thyroid. At the same time other symptoms, such as exophthalmos, may appear, which have an independent origin and are not due to the secretion of the gland. The whole of the secretion here is poured into the blood and not at all on to a mucous surface, and herein the thyroid gland differs largely from such glands as the pancreas or peptic and intestinal glands. But it seems now probable that all glands which have what may be termed an external secretion like the pancreas, stomach, intestine, skin and kidneys have also an internal secretion, so that while they are pouring out one secretion from the ducts into the intestine or external air, they are also pouring into the lymphatics, and thus into the blood, an internal secretion. In fact, a splitting appears to take place in the process of secretion somewhat resembling that which takes place in the formation of a toxin and anti-toxin. The secretion of some digestive glands would prove poisonous if absorbed unchanged. For example, the trypsin of the pancreas (see Nutrition) digests albuminous bodies in neutral or alcoholic solution, and if the whole of that which is secreted in the pancreas for the digestion of meat in the intestine were absorbed unchanged into the circulation, it would digest the body itself and quickly cause death. The secretion of trypsin by the pancreas may therefore be looked upon as the formation of a toxin. We do not know at present if any corresponding anti-toxin or antitrypsin, as we may term it, is returned into the lymphatics or blood from the gland, but the pancreas, which in addition to secreting trypsin secretes a diastatic ferment forming sugar from starch, pours this into the intestine and secretes at the same time a glycolytic ferment which breaks up sugar, and this latter passes into the blood by way of the lymphatics. Thus the gland not only breaks up starch into sugar in the intestine, but breaks up the sugar thus formed after it has been absorbed into the blood. It is known that several, perhaps very many, if not all glands have also the power of secreting substances to which Starling has given the name of "hormones." These pass into the blood and cause other glands to secrete. Thus an acid in the duodenum causes it to secrete a hormone to which the name of "secretin" has been given. This passes to the pancreas and causes increased secretion from that gland. It is probable that the pancreas in its turn also secretes something which activates a ferment in the muscles. It is evident therefore that the connexion between the different glands of the body is a very complicated one and that the effects of a drug which acts upon any one of them may be of a very far-reaching character. It is by no means improbable that all glands have a double or even triple function, and that sometimes the external may be even less important than the internal secretion. On this point, however, we have but little definite knowledge, and a great field is open for future research. At the same time, there are many indications of the importance of an internal secretion in popular treatment. For example, there are many people who feel very much better after profuse perspiration, and as sweat appears to contain little but water and a few salts, it is not improbable that the improvement in their condition is due rather to the internal secretion from the skin than to the elimination effected by the sweat. It is probable that the kidneys also have an internal secretion, and that the great oedema sometimes found in kidney disease is rather due to the action of some proteid body resembling in its effects the streptococcus anti-toxin, than to accumulation of water due to imperfect action of the kidney. Similarly the beneficial effects of purgation may be due not only to the elimination which takes place through the bowel, but also to the internal secretion from the intestinal glands.

The health of the body depends upon the proper kind and supply of food, upon its proper digestion and absorption, on the proper metabolism or tissue-change in the body, and the proper excretion of waste. We have considered how these may be disturbed by microbes from without and from within. We have also considered in a general way the treatment of local diseases by passive protection, active protection and repair of waste; but both maintenance of health and repair of waste depend very largely upon the condition of the blood. When this is healthy the attacks of microbes are resisted, wounds heal readily, and patients recover from serious diseases which in persons of debilitated constitution would prove fatal. In order to keep the blood in a satisfactory condition it must be well supplied with fresh nutriment, and the products Nutrition  of waste freely eliminated. The food required for and elimi-  the body may be divided into five kinds - carbo- nation.  hydrates, such as starches and sugars; fats; proteids, such as meat and eggs; salts; and last, but not least, water. Water forms almost three-fifths of the weight of the body, so that it amounts to more than all the other constituents put together. Without it life would be impossible, and it is well recognized that death from thirst is more awful than death from hunger. The healthy organism can adapt itself to great varieties both in regard to the quality and quantity of food; but when health begins to fail much care may be required, and many ailments arise from dyspepsia. Imperfect digestion is very often caused by defective teeth or by undue haste in eating, so that the food is bolted instead of being sufficiently masticated and insalivated. The food thus reaches the stomach in large lumps which cannot be readily digested, and either remain there till they decompose and give rise to irritation in the stomach itself, or pass on to the intestine, where digestion is likewise incomplete, and the food is ejected without the proper amount of nourishment having been extracted from it; while at the same time the products of its decomposition may have been absorbed and acted as poisons, giving rise to lassitude, discomfort, headache, or perhaps even to irritability and sleeplessness. Much dyspepsia would be avoided by attention to the condition of the teeth, by artificial teeth when the natural ones are defective, and by obedience to one or two simple rules: (z) to eat slowly; (2) to masticate thoroughly; (3) to take no liquid with meals excepting breakfast, but sip half a pint of hot water on rising in the morning, on going to bed at night, and again about an hour before luncheon and dinner. The object of taking no liquid with meals is that it ensures mastication being more complete, because persons cannot wash the unmasticated food down by drinking, and it prevents the gastric juice from being greatly diluted, and so allows it to digest more rapidly. Should these rules be insufficient, then (4) proteid and farinaceous food should be taken in separate meals - farinaceous food at breakfast, proteid alone at lunch; farinaceous in the afternoon, and proteid again in the evening. The reason for this is that farinaceous foods are digested in the intestine and not in the stomach, where they may undergo fermentation, whereas proteid foods are to a great extent digested in the stomach. When the secretion of gastric juice is deficient it may be excited by gastric tonics, such as ten grains of bicarbonate of soda and a drachm of compound tincture of gentian in water shortly before meals, and may be supplemented by the administration of pepsin and hydrochloric acid after meals. When the nervous system is below par, and both secretion and movements are deficient in the stomach, nervine tonics, such as nux vomica or strychnine, are most useful.

High tension in the arteries is often associated with sleeplessness, the pressure of blood being such that the circulation in the brain is constantly maintained at a high rate of speed and the brain is unable to obtain rest. The means of producing sleep may be divided into two classes: those (r) which lessen the circulation, and which (2) diminish the excitability of the brain cells. The circulation in the brain may be lessened by warmth to the feet, cold to the head, warm food in the stomach, warm poultices or compresses to the abdomen, antipyretics, which reduce the temperature and consequently slow the beats of the heart in fever, and cardiac or vascular tonics, which slow the heart and tend to restore tone to the blood-vessels, so that the circulation in the brain may be more efficiently regulated. Amongst those which lessen excitability of the brain-cells are opium, morphine, hyoscyamus, chloral, sulphonal, trional, paraldehyde, chloralamide, chloralose, hop and many others. A combination of the two kinds of remedy is sometimes useful, and chloral sometimes succeeds when other things fail, because it depresses the circulation as well as lessens the activity of the brain-cells.

Irritation of sensory nerves tends to cause contraction of the vessels, and to raise the blood pressure, and where pain is ffi, present opium or morphine is the most efficient sedative. The sensation of pain is felt in the brain, and the cause of it may be in the sensory centres of the brain alone, as in cases of hysterical pain, with no lesion to cause it. Ordinarily, however, it is due to some peripheral irritation which is conducted by sensory nerves to the spinal cord and thence up to the sensory centre in the brain. Pain may be stopped by removing the cause of irritation, as, for example, by the extraction of a carious tooth or by rendering the nerveendings insensitive to irritation, as by the application of cocaine; by preventing its transmission along the spinal cord by antipyrin, phenacetin, acetanilide, cocaine, &c.; or by dulling the perceptive centre in the brain by means of opium or its alkaloids, by anaesthetics, and probably also, to a certain extent, by antipyrin and its congeners.

Both sleeplessness and pain are sometimes due to the action of toxins absorbed from the intestine, and both of them may High sometimes be relieved more efficiently by thorough purgation than by narcotics. Another condition which is probably due to toxins is high pressure within the arteries. When this continues for a length of time it tends by itself to cause deterioration of the blood-vessels and leads to death either by cerebral apoplexy or by cardiac failure. It is therefore very important to discover high tension at an early period. It may be diminished or its increase prevented by a diet from which red meat and meat extracts are excluded, by the use of the lactic acid bacillus, by the administration of laxatives and cholagogues to regulate the bowels, and by the use of iodides and nitrites. By such regime and medicines life may sometimes be prolonged for many years.

Deficient nervous action also leads to defective secretion and movement in the intestine, sometimes with flatulent accumula tion and sometimes with constipation. In such cases nux vomica or strychnine is useful. Flatulent distension in the stomach or bowels is partly due to air which has been swallowed and partly to gas which has been formed by the decomposition of food. The stomach may become distended with gas on account of acid fermentation leading to the frequent swallowing of saliva, and both this form of flatulence and that caused by the actual formation of gas are much diminished by such drugs as tend to prevent fermentation. Amongst the best of these are carbolic acid in doses of one or two grains, creosote in one or two drops, and sulpho-carbolate of soda in doses of ten grains. Others which may be mentioned are salicylate of bismuth, salol, 0-naphthol and naphthalene. By preventing fermentation in the intestine these also tend to prevent or check diarrhoea, and they may do good after the irritant has been removed by castor oil. After the irritant has been removed and fermentation stopped, the irritation still remaining in the intestinal wall may be soothed by chalk mixture and bismuth, to which if necessary small quantities of opium may be added. In cases where diarrhoea is very obstinate and lasts for weeks, sulphuric acid is sometimes more efficacious than alkalis; and in chronic colics it may be necessary to treat the mucous membrane by local application of astringent solutions. For this purpose solutions of sulphate of copper or of nitrate of silver may be gently introduced into the bowel in quantities of a quart at a time. It is essential that a large quantity should be used, as otherwise the seat of irritation may not be reached by the astringent. Flatulence and diarrhoea as well as many general disorders are often due to intestinal depression caused by microbes. To these injurious microbes Metchnikoff has given the name of "wild," and he proposes to restore health by giving "tame" microbes, such as lactic acid bacilli. This treatment on the principle of "setting a thief to catch a thief" is frequently very useful. The lactic acid bacilli are given either in the form of tablets or milk soured by them, or cheese made from the sour milk. The most efficient form is soured milk, which acts as a food as well as medicine.

Constipation is so common that it may be almost looked upon as the normal condition in civilized countries. Two of its chief causes probably are (r) improvement in cookery, whereby the harder and more irritating parts of the food are softened or removed; and (2) improvement in grinding machinery, whereby the harder and more stimulating parts of the grain are separated from the finer flour which is used for bread. In consequence of the absence of mechanical stimulant the bowels act more slowly, and constipation is the result. It may be considerably diminished by a return to a more natural system of feeding, as by using brown bread instead of white, by taking oatmeal porridge, and by eating raw or cooked fruits, such as apples, oranges, prunes and figs, or preserves made of fruit, such as raspberry and strawberry jam, marmalade, &c., by vegetables or by dried and powdered seaweed. Should these means fail, aperients may be used. The commonest are senna in the form of compound liquorice powder, sulphur in the form of lozenges, cascara sagrada, either in tablets or in the form of liquid or dry extract, rhubarb, colocynth and especially aloes. The last acts chiefly upon the lower bowel, and forms a constituent of nearly every purgative pill. The medicines above mentioned may be taken either in a moderate dose at bedtime or in the form of a dinner pill, or they may be taken in small doses three times a day just before or after meals. Some sufferers from constipation find that they get greater relief from salts dissolved in water, or from natural aperient water taken on rising in the morning, and others again find that the best way of opening the bowels is to inject one or two drachms of glycerine into the rectum, or use it as a suppository. If these means fail, exercise, massage and electricity may help a cure.

The most common diseases of malassimilation (or "metabolic" diseases) are gout, rheumatism and diabetes. In health most of the nitrogenous waste in the body is eliminated as urea, but in gout uric acid is either formed in too great quantity or too little is eliminated, so that it tends to be deposited as urate of soda in the joints and other tissues. Two means of treating it by diet have been proposed. One is to put the patient on an almost complete vegetarian diet, so as to limit both the amount of uric acid introduced into the body as well as its formation in the body. The other plan is to use an exclusively meat diet, combined with the ingestion of a large quantity of hot water, so as to cause free elimination. Where neither method is strictly pursued it is usual to forbid to gouty patients sugar, pastry and pickles, and to forbid heavy wines, especially Burgundy and port. During an attack of acute gout nothing relieves so much as colchicum, but during the intervals potash or lithia salts taken in water are advisable, as tending to prevent the deposits of urate of soda. In true diabetes, which probably originates in the central nervous system, or in disease of the pancreas, as well as in the glycosuria common in gouty patients, sugar in every form should be entirely forbidden, and starchy food restricted to within narrow limits. The remedy most trusted to in this disease is opium and its alkaloids, morphine and codeine. In acute attacks of rheumatism the remedy par excellence is salicylate of soda, which reduces the temperature, relieves the pain, and removes the swellings from the joints. Rest in bed should be insisted upon for a longer time than appears actually required, because acute rheumatism tends to bring on cardiac changes, and is more likely to do this when the heart is excited than when the patient is kept at rest. In chronic rheumatism the chief remedies are salicylate of soda, and its allies iodide of potassium, guaiacum and sulphur, while massage, liniments and baths are beneficial as local applications.

Elimination of waste-products is one of the most important points in regard to health, and when this is interfered with by disease of the kidneys, the life of the patient is rendered more or less uncertain and the health frequently seriously impaired. In some cases of chronic inflammation of the kidneys, where the disease is not extensive, the patient may continue in fair health for a number of years, provided attention be paid to the following rules: - (i) The body must be kept warm, and chills must be scrupulously avoided; (2) the digestion must be attended to carefully, so that no excess of poisonous bodies is formed in the intestine or absorbed from it; (3) eliminating channels such as the skin and bowel must be kept active. It is usual to reduce the quantity of proteid food to a minimum, in order to lessen the amount of nitrogenous waste to be excreted by the kidneys. Sometimes an entirely milk diet is useful, but in others it does not agree, and a more liberal diet is essential. Alcohol should be avoided as much as possible. The small contracted kidney, which is so common in elderly gouty people, is usually associated with a very large secretion of urine containing only a minute trace of albumin. The tension within the blood-vessels is generally high, and the patients run a risk of anginal attacks or of apoplexy. A nearly vegetarian diet and a complete abstinence from alcoholic stimulants is the ideal in such cases, but it must be modified to suit individuals, as sometimes very strict limitations prove injurious. The daily use of potash, and especially nitrate of potash, tends to reduce the tension and increase the patient's safety, but if pushed too far may sometimes render him very weak and depressed.

It has already been mentioned that water is absolutely necessary for the body: by taking it hot it does not lie like a weight on the stomach, and by taking it an hour before meals it washes out the remnants of the previous meal; and being absorbed into the blood, it probably renders the secretion of gastric juice freer and accelerates digestion, instead of diluting it and interfering with the digestive processes. Where the stomach and bowels are irritable, all food likely to cause mechanical irritation should be avoided, such as skins, bones, fibres and seeds. In some cases of diarrhoea an entirely milk diet has to be prescribed, and in the diarrhoea of children it is sometimes necessary to alternate a diet of barley water with one of beef juice or white of egg and water, or to give whey instead of milk. The drinking of large quantities xxvi. 26 of whey is used as a means of cure for dyspepsia in adults, and also in cases of chronic bronchitis. The whey is drunk warm, and for this cure it is usual to go to some Alpine resort where pasturage is abundant and fresh milk can be had at all times of the day. The cure is greatly helped by the fresh air and sunshine of such places, among which are Interlaken, Rigi-Scheideck and Weggis in Switzerland; Ischl and Meran in Austria; Harzburg, Reichenhall and Sanct Blasien in Germany. Another therapeutic method is the so-called "grape cure," in which, along with a regulated diet, five or six pounds of grapes are eaten daily. As the grapes contain a quantity of water and of salts, they tend to lessen the amount of food taken, to increase the action of the bowels, and to stimulate the kidneys. The "grape cure" is used both in chronic disease of the stomach and intestines with or without constipation, and also in cases of gout or ailments depending upon a gouty constitution. The chief places where it is carried on are in the neighbourhood of the Rhine, on the Lake of Geneva and in Tirol. Amongst places in the Rhine and its vicinity may be mentioned Kreuznach, Neustadt, Riidesheim and St Goar; on the Lake of Geneva are Montreux and Vevey; and in Tirol Gries and Meran. The socalled "Salisbury" cure consists of living entirely upon minced beef and hot water. It sometimes answers very well in persons troubled with flatulence, since meat does not give rise to the same amount of gas in the intestines as carbohydrates. During its continuance fat is absorbed from the subcutaneous tissue, and patients become very much thinner, so that it not only lessens flatulence, but reduces obesity. It is, in fact, very much the same system as that proposed a number of years ago by Banting (see Corpulence). It is very important for those who are trying this diet to bear in mind the necessity of abundance of water, because sometimes they may be tempted to lessen the water on account of the inconvenience produced either by frequent micturition or too profuse sweats. If the meat diet be continued with too small a proportion of water, a gouty condition may be brought on. This diet has been recommended in gout, and no doubt the essential part of it is the hot water, but there can be little doubt that in fat gouty people it is often useful. An entirely opposite dietary is that in which butcher's meat is completely excluded and proteids reduced to a minimum, as advocated by Dr Haig. This dietary also is very useful in gout, but it answers better in thin gouty people than in fat ones.

The dietaries already mentioned, the whey cure, the grape cure, the meat cure and the vegetarian cure, are all more or less systems of starvation, one or other article of ordinary diet being either reduced to a minimum or omitted altogether. In three of them at least - the whey cure, the grape cure and the meat cure-a diminution in one or other of the solid constituents of food is associated with the ingestion of an unusually large quantity of water. In visiting the most famous wateringplaces, it is curious to note how one finds, in the various waters, here some chloride, there some sulphate, here some potash, there some magnesium, but in all of them we find water. In watching the troops of patients who go to the wells we notice that most of them do more early rising, take more regular exercise, and drink more water in the course of a month at the well than they would do in the rest of the year at home. The watering-places divide themselves, according to the temperature of the waters, into cold and thermal, and according to the composition of the waters, into purgative saline, indifferent saline, sulphur and iron. Amongst the most celebrated saline waters are those of Carlsbad, which contain sulphate of soda and bicarbonate of soda. These salts crystallize out when the water is partially evaporated and may be used with hot water at home, the best imitation of the Carlsbad water being obtained by mixing with hot water the powdered Carlsbad salts (pulverformig), which contain all the constituents of the natural water. Where it is impossible for the patient to visit Carlsbad, half a teaspoonful or a teaspoonful of salt may be taken in a large tumbler of hot water on rising every morning; but when taken at home the treatment is not so effective as at Carlsbad, because at the wells sipping water is associated with early rising, considerable exercise and a very carefully regulated diet. It is, indeed, the care with which the diet of patients is regulated and the difficulty that patients find in obtaining forbidden foods at hotels and restaurants, that make Carlsbad better for the liver than any other watering-place. Amongst other places having a similar action are Marienbad, Franzensbad and Tarasp. The waters just mentioned contain free alkali as well as sulphates, and are employed more especially in cases of hepatic disorder, such as congestion of the liver, jaundice, gall-stone and diabetes. A number of other waters containing sulphides and chlorides are powerfully purgative, and are more often drunk at home than at the springs. Amongst these are the Hungarian waters, Aesculap, Apenta, Franz Josef and Hunyadi Janos; and the Rubinat and Condal waters of Spain. Waters which have a similar composition are drunk at the springs of Leamington and Cheltenham in England, Brides Salins and St Gervais in France, for chronic constipation, dyspepsia, gout and hepatic disorders of a milder character than those usually treated at Carlsbad. The waters in which chlorides form the purgative principle are those of Homburg, Kissingen, Wiesbaden and Baden Baden in Germany, and Bridge of Allan in Scotland. Similar waters, but much weaker, are found at Innerleithen and Pitkeithly. Sulphur waters are chiefly used for painful and stiff joints, chronic skin disease, and chronic catarrhal affections. The most important are Aix-les-Bains, and a number of springs in the Pyrenees in France, Aachen in Germany, Harrogate in England, Strathpeffer and Moffat in Scotland. Iron waters are used in anaemia and the affections which are frequently associated with it. The most important are Spa in Belgium, Schwalbach in Germany, St Moritz and Tarasp in Switzerland. Iron waters are, however, common, and are generally found at all those places which have sulphur waters. Simple alkaline waters containing carbonates, chiefly of sodium along with some magnesium and calcium, are drunk for their utility in gastric and intestinal disorders as well as in rheumatism and gout. They are also employed locally as sprays and douches to the nose, throat, vagina and rectum, for catarrhal conditions of the mucous membranes. The most important are Vichy and Vals in France and Neuenahr in Germany. Alkaline waters containing a little common salt are perhaps even more important than the pure alkaline, as the salt lessens the depressing effect of the alkali. They are therefore used largely in chronic gout, rheumatism and in calculous affections of the kidney. Amongst the most important are Ems and Wildungen in Germany, Contrexeville and Royat in France.

Simple thermal waters are those which contain only a very small quantity of solids, and owe their efficacy chiefly to their temperature. They are used partly for drinking, but even more so for baths. Bath, Buxton and Matlock in England; Mallow in Ireland; Wildbad, Schlangenbad and Badenweiler in Germany; Gastein and Teplitz in Austria; Ragatz in Switzerland; Plombieres and Dax in France; and Bormio in Italy are amongst the best known. When water is dashed against the body with more or less violence, its effects are more powerful. than when the body is simply immersed in it. Thus the stimulating effect of sea-bathing is more marked than simple salt-water baths, for in addition to the effect upon the skin produced by the salt and by the temperature of the water, we have the quicker removal of heat by the continual renewal of the water as the waves dash over the body, and mechanical stimulus from its weight and impetus. Somewhat similar effects are produced by so-called wave-baths, and at Nauheim, although the fresh movement of the water against the surface of the body is much less than in the sea, yet its stimulating effect is greatly increased by the presence of carbonic acid in it. Douches have a still more powerful action than waves. They are generally given in the air, but at Plombieres very simple douches are given under water. These form a more powerful wave-bath, and in combination with intestinal irrigation, are used very successfully for the treatment of abdominal disorders. Douches to the spine are much employed for nervous debility, and good effects are also obtained in such cases from the so-called needle-bath, where small streams of water at high pressure are driven against the whole surface of the body. In the treatment of stiffened joints, massage under water is very serviceable, and in the so-called Aix douche a nozzle from which water continuously streams is fastened to the wrist of the masseur, so that a current of water is constantly playing upon the joint which he is rubbing. While water containing much saline matter, and more especially water containing free carbonic acid, has a very stimulating action upon the skin, mud has a sedative effect, so that in a mud-bath one feels a pleasant soothing sensation as if bathing in cream. These mud-baths are chiefly employed at Marienbad, Franzensbad and Homburg. Sulphur-baths and sulphur waters are chiefly used in combination for rheumatism and gout, and massage, especially under water, is frequently combined most advantageously with baths and drinking water to effect a cure.

Exercises, passive and active, are also used in diseases of the joints, as well as massage and baths, but exercises and training are even more important in cases of cardiac disease. In very bad cases of heart disease, where the patient is unable to go about, the best plan of treatment usually is to make him stay absolutely quiet in bed and have massage, which aids the circulation, tends to remove waste, and increases the appetite. To this is added gentle exercise, beginning with the fingers at first. At Meran walks have been arranged according to Oertel's system, and at Llangammarch in Wales both Oertel's and Schott's systems are employed, and baths according to the Nauheim system are also to be found in London, Sidmouth, Leamington, Buxton, Strathpeffer, &c. Many people who have sedentary employments are unable to get as much exercise as they require because they have not either the time or the opportunity. Such persons may sometimes get a good deal of exercise in a short time by the use of dumb-bells, of elastic cords, or of cords running over pulleys and weighted at one end. The whole system of methodical exercises was started by Ling in Sweden, but it has been developed to a large extent for the purpose of increasing muscular strength by the professional athlete Sandow. A punching ball or rowing machine is even better as being less monotonous. Fencing, boxing or wrestling may also be resorted to. Walking on the flat is of comparatively little use as a mode of exercise, and has become supplanted to a considerable extent by bicycling. Ascending mountains, however, is very different, because in walking up a steep ascent all the muscles of the body are thrown into action, and not only those of the legs. In addition the purer and rarefied air of the Swiss mountains seems to produce a sense of exhilaration which is not felt nearer the sea-level. For those who suffer from nervous depression, exercise in the Swiss mountains is useful, and even living at a height of about 6000 ft. above the sealevel seems to have an exhilarating influence. The nature of this is not very easy to analyse, but as mental depression is closely associated with irritation of the vagus nerve and weakening of the circulation, it seems not at all unlikely that mountain air acts by accelerating the pulse and quickening the circulation, and thus creating a sense of well-being. Indeed, many patients liken its effect to that of drinking champagne. In some persons rarefied air is too stimulating, so that they find difficulty in sleeping, and for those who suffer from insomnia a warm moist air nearer the sea-level is preferable.

It sometimes happens, however, that people cannot sleep at the seaside itself, although they do so perfectly well a mile or two inland. Where the nervous system is exhausted, such warm and moist climates as Malaga, Madeira, Tenerife and Grand Canary are suitable. In these places not only is the air moist, but the temperature is particularly equable, and they are therefore suitable places also for persons suffering from kidney disease. Many such persons also do well in dry, warm places, such as the higher reaches of the Nile, Egypt, Mentone, St Raphael and other sheltered places on the Riviera. The places mentioned are all suitable for persons suffering from chronic bronchitis, who should avoid any irritation of the larynx, trachea or bronchi by air which is too dry or which is liable to great changes of temperature. Some cases of phthisis, therefore, do better in warmer and moist climates, and especially those where the larynx has become affected by the disease. Such patients are apt to suffer much from cough and laryngeal irritation in the cold, dry air of the Alps, whereas they live in comparative comfort on the Riviera, in the Canary Islands, Madeira or at Capri. But warm, moist climates rather favour sedentary habits and tend to lessen appetite, so that the nutrition of the patient is apt to suffer; and although phthisical patients may live in comparative comfort in such climates, their tendency to recovery in them is small. At the Swiss health resorts, on the contrary, during the winter the air is very pure, and has just sufficient coldness to make exercise agreeable to patients. They are thus induced to be out the whole day, and to take food with an appetite which greatly improves their nutrition and aids their restoration to health. The best-known Alpine health resorts are St Moritz and Davos, to which lately Grindelwald has been added. St Moritz is, upon the whole, better for less advanced cases, while Davos is more sheltered and better for cases which are severe. It is a mistake, however, to send those in whom the disease is very far advanced away from home and friends, because when there is no hope of cure it is better for them to die in comfort at home. At the health resorts just mentioned the amount of food taken. is regulated by the appetite of the patient himself, but a system of cure has been inaugurated by Dr Brehmer at Gorbersdorf, by Dr Dettweiler at Falkenstein, and by Dr Walther at Nordrach, in the Black Forest. The most important point in this treatment consists in forced feeding, the want of appetite which is so prominent in many cases of phthisis being regarded as an abnormal sensation not to be regarded; and under the forced feeding, combined with open-air life, many marvellous recoveries are recorded. Numerous other institutions have been started in Great Britain in imitation of Dr Walther's with a considerable amount of success. Even when patients are unable' to stay long at a sanatorium they learn there the advantages of open air and can continue the treatment at home to their great advantage.

In the well-known "rest" cure, which we owe to Weir Mitchell, forced feeding takes a prominent part. The essence of this cure is to give to the patient rest, bodily and mental, by confinement to bed and isolation from the outside world. While this treament by itself would aid recovery from nervous exhaustion, it would lessen appetite and thus interfere with nervous repair; but the want of exertion is supplied by means of massage, which stimulates the circulation and increases the appetite, so that the patient gets all the benefit of exercise without any exhaustion. Where nervous exhaustion is less marked and the Weir Mitchell treatment is not appropriate - for example, in men who are simply overworked or broken down by anxiety or sorrow - a sea voyage is often a satisfactory form of "rest" cure. The lack of posts and telegrams prevents much of the excitement which they would have upon shore, the space for exercise is limited, food is abundant and appetite is supplied by the stimulus of constant exposure in the open air. In order that the voyage should be satisfactory, however, it must be sufficiently long, and the weather must be sufficiently warm to allow the patient to stay in the open air the whole day long. During the heat of summer voyages to the North Cape are suitable, and during the spring and autumn to the Mediterranean, but in the colder months of the year the West Indies, India, Cape Town, Australia or New Zealand forms the best objective.

(T. L. B.)