quirements of the case, completely fail, and cannot be persisted in without the risk of actually starving the patient, and doing more than would have resulted if ordinary food had been taken.

But even in cases in which it is not possible for the patient to have the advantage of the special system of diet which would seem to be most suitable to his case, it is, nevertheless, important that the practitioner should be well acquainted with the principles by which, as far as is practicable, he should be guided in his treatment. A little consideration will enable him to suggest an approach toward the proper diet in cases in which the diet most desirable cannot be borne. For instance, although pure milk cannot be tolerated by some, it will be found that few will object to milk puddings and various dishes which contain milk in large proportion. Some patients may be persuaded to take warm milk, and even if pure milk, hot or cold, will not suit the stomach, it often happens that the addition of a little lime water will cause the milk to agree, and to digest quickly without producing pain or discomfort.

That the so-called milk treatment is a great advance, and that by it great improvement may be obtained in bad cases of disease, is undoubted; and we ought to feel grateful to Dr. Donkin, who was, I think, the first to carry out this plan of treatment systematically for many months at a time, and those who have advocated and practiced the system, not only on account of the good to be obtained in special cases, but also because our knowledge of what may be done in many others has thereby been much increased. Until within the last few years we should have hesitated to have advocated a purely milk diet for many months; but now we know, not only that this one fluid may be substituted for the varied diet usually taken, but that people may live on it, gain in strength as well as in weight, and that while taking it pathological changes which were progressing may proceed much more slowly, and even cease to progress. The milk treatment, it should be borne in mind, is of great value in many other conditions besides renal disease. Now that we are better informed concerning those subtle degenerative changes which take place slowly and imperceptibly to the patient, undermine the health

of some of the most important of his tissues and organs, and slowly or quickly result in impaired action and failure, which can only end in death, we cannot attach too much importance to all suggestions which may reasonably be supposed to be influential in reducing the rate of their progress, or in stopping them altogether.

But in treating certain cases of chronic contracting kidney, it is altogether inexpedient to put the patient upon a purely milk diet. For years, perhaps, he may have been accustomed, not only to live too well, upon the best of food, but every day has looked forward to his dinner with pleasure, if not as the most important event of the day. Such a person would probably at once rebel against carrying out your advice, or if he did not openly object, there would be little prospect of his carrying it into practice. Moreover, the sudden change recommended would effectually derange the most important and gradually perfected arrangements below stairs, over which the cook presides, and if you are to do any good, and to be of real use, you must proceed by degrees. Suggest fish, sweetbread, and such harmless things, and in this way gradually bring the patient to content himself with soup, milk puddings, milk, bread, baked and stewed apples, and prunes. First of all, reduce to some extent the quantity of his wine, and suggest Hock or Chablis, and so lead him by degrees to give up stimulants altogether. In this way we shall effect our object without offending or disgusting our patient. Time will be gained, and he himself will begin to recognize the reasonableness of our suggestions. He will feel better than he has felt for many months, and perhaps, even will have some faith in his doctor, who may then with judgment carry out still further changes toward the simplification of the diet and its restriction as to quantity, so that eventually the patient may be induced to submit to live according to the rational principle that no more is introduced in the way of food than is required to compensate for the waste which results from the action of the tissues and organs, and the chemical changes accompanying the development of animal heat.

Of the Treatment of Albuminuria Dependent upon Syphilis.Of all the forms of chronic renal disease, those which are due to

syphilis are the most likely to get well. Nay, though the quantity of albumen in the water may have amounted to as much as a third, present in every specimen passed during the period of a year or more, though there be considerable and persistent oedema of the legs, extending as high as the waist or higher, and the case in many important.respects appears to be grave, improvement may be confidently predicted, and under favorable circumstances complete recovery not uncommonly takes place in the course of a few months. The practitioner will often feel surprised as well as gratified at the change for the better which soon follows the adoption of the proper course of treatment.

In the early stage of renal disease due to syphilis, the patient should be subjected to the usual treatment by purgatives and sudorifics. The warm bath or the hot air-bath should be recommended. If there is any indication of uræmia, free purgation should be promptly carried out and followed by free sweating, kept up for an hour or two daily, or even twice a day if the patient bears it well. As soon as the quantity of albumen has been reduced to about one-fifth, and the urine flows freely at all periods of the twenty-four hours, iodide of potassium, iodide of iron, or some other preparation containing iodine, should be given, and steadily prescribed for several weeks.

Complete recovery is not infrequent after judicious treatment, steadily kept up for two or three months. I often order iodide of potassium three times daily after meals, for a fortnight, and then for a like period of time give syrup of iodide of iron, or Blanchard's pills of iodine of iron, a most convenient and efficacious medicine, which may be persisted in for many months with advantage. It is a good plan to order iodide of iron pills, one or two at 11 and 4 o'clock, daily, for a fortnight at a time, at intervals of two or three weeks.

I cannot help thinking that in former days, when cases of chronic syphilitic disease were treated with biniodide of mercury (bichloride of mercury and iodide of potassium), the class of morbid changes characterized by chronic deposits in glands and in connection with some of the most important tissues of the body, to which syphilitic kidney belongs, was less common than

it is now, although, on the other hand, we do not now see the number of horrible phagedenic sores and dreadful cases of extensive caries and necrosis which used to be by no means uncommon. Not a few facts seem to justify the conclusion that the virulence of many forms of syphilitic poison is less than was the case, but I am inclined to think that the treatment followed out by many practitioners as regards the use of mercury is less pronounced than is wise. My own opinion is that when once well marked secondary symptoms have been manifested, the patient will do well to take mercury and iodides for a fortnight or more at a time, at intervals of a few months, for many years. I have never seen harm result from this course, and it alone affords a reasonable prospect of preventing or curing some of those syphilitic deposits which work such havoc later in life in some of the most important glandular organs of the body and in the nerve centres.

When the urgent symptoms have disappeared and the patient has greatly improved in health, albumen being still present in smaller quantity in the urine, it is very important, if the patient's means are sufficient and his circumstances render such a step possible, that he should take a long voyage and reside in a good climate for a year or more, in order that every chance may be afforded for complete recovery-for recovery does take place in some of these cases. The patient not only increases in weight, and regains his former health and strength, but the kidneys return to their normal state and secrete healthy urine without any further discharge of albumen.

BILE.

When bile is present in urine, it gives to the secretion a yellow color, the intensity of which varies according to the quantity of bile present, and which is more distinct when thin layers are placed upon a perfectly white surface, as on a plate, than when a considerable bulk of urine is examined. The yellow, which is very different from the color of dark and concentrated urine, is almost of a gamboge tint when thin layers of the urine on a white surface are examined. The coloring matter of the bile (bili

verdin) may be completely removed from the urine or any solution containing it, by filtration through a layer of charcoal.

From pressure upon, or obstruction of, the common gall duct, bile, after it has been secreted, is partly or entirely prevented from escaping into the intestine. The gall-bladder and large and small ducts soon become distended by the accumulation of the secreted bile, which, finding no outlet, is reabsorbed, chiefly, perhaps, by the numerous lymphatics which are so freely distributed upon the gall bladder as well as upon the coats of all the large and small gall ducts. The biliary constituents, in a state more or less altered, pass into the blood, and are partly deposited in the tissues and partly carried off in the urine. That scarcely any bile passes into the intestine in many cases of jaundice, is proved by the pale color, offensive odor and claylike consistence of the fæces.

The bile is formed by the cells of the liver and passes directly into the small ducts, and from these into the larger ducts, whence it goes into the gall bladder or directly into the intestine. In jaundice there are impediments to the escape of the bile from the large ducts outside the liver, or from the smaller ducts within the organ. In either case the bile accumulates, the ducts become stretched, a certain quantity passes through their coats, and is taken up by the blood vessels, or is absorbed by the numerous lymphatic vessels, ramifying in the portal canals, and in the transverse fissure of the liver.

In some cases the jaundice, with occasional intermissions, lasts for many years. Oftentimes the skin returns to its normal state, and the patient considers himself well, but after a few weeks the jaundice returns, and soon becomes as bad as ever. The yellowness of the skin and fibrous and other tissues, which varies in intensity, depends upon the staining effected by the yellow serous fluid which transudes from the blood. Variation in the quantity of bile passing into the blood sometimes is due to pressure upon the duct near its orifice, exerted by a small tumor, which changes in volume from time to time, either in consequence of effusion of fluid into its substance, or of alterations occurring in the degree of distention of the vessels which are distributed to it.