it is well to be provided with a number of remedies which can be changed from time to time; for in taking physic, as well as wine, it is to the advantage of the patient to change, since it is certain that many a remedy which may be very useful if taken for a short period of time loses its effect if taken for long, and that benefit may be obtained by substituting for it another, although this last was not efficacious when it was previously given. Preparations of potash, soda and lithia may be ordered alternately with advantage. The practitioner will find that some patients receive most benefit from one alkali, others from another. Soda seems to suit some people better than potash, and although lithia is often beneficial it does not do some patients as much good as soda or potash, or the two combined. In many cases, I find that carbonate of ammonia is a valuable remedy if given in sufficiently large doses. Ten grains of Howard's volcanic carbonate of ammonia dissolved in an ounce or more of water may be taken every three hours, for a week or longer at a time.

So, too, in prescribing alkaline remedies, it is necessary to pay attention to the degree of dilution, and to the time of their exhibition. As a general rule free dilution is desirable, and the best time to take the remedy is about an hour after meals and at bedtime, but sometimes the patient finds that this plan does not suit him, and it is necessary to alter the time to midway between two meals. Free dilution with cold water often disturbs the stomach and may even stop digestion. In that case warm or tepid water should be given, and the patient should be directed to swallow the draught by small mouthfuls, one at a time, and he should not drink off the whole dose, of a quarter of a pint or more, at once. Sometimes a few drops of essence of ginger, or a little peppermint water, or a few drops of chlorodyne added to the mixture, will enable a patient to take the alkaline remedies who was unable to take them in the ordinary form.

But if alkalies as generally prescribed disagree, the proper dose of liquor potassæ, bicarbonate of soda or potash may be added to soda, Seltzer, Vals, or Vichy water, with or without three or four drops of dilute hydrocyanic acid and essence of ginger.

Not unfrequently if the draught be iced and taken in small quantities, or even sips at a time, it will be found to answer, and the patient will no longer complain of its disagreeing with him in any way.

Lastly, it is found that gentle exercise after taking considerable quantities of water, cold or warm, favors its absorption. The experience of centuries at the most celebrated baths here and on the Continent has proved that to be the case, and to this day the practice is carried out. Active exercise and long walks are not advisable, but the gentle walk while the band is playing seems to be just what is required, and there can be no doubt that this sort of easy promenade several times daily in the open air is very conducive to the health of the middle-aged and old people who have spent the greater part of their lives in cities, in sedentary work, with, perhaps, much anxiety and considerable wear and tear of the nervous system. Many work under actual, and frequently severe, pressure, during the greater part of the year, and in order to mitigate the feeling of fatigue and the lassitude they experience, the majority find they cannot get on without wine. Most get into the habit of taking more food than their system really requires if they do not exceed in alcohol; nor indeed is it wonderful that men who work hard and live under pressure and almost constant bother should look forward with cheerfulness and satisfaction to the dinner hour as the chief event and the pleasantest part of the day, especially during the greater part of our year, when the weather is uncongenial and the days are short. Still, it will be found that in the great majority of instances a penalty has to be paid, and unless the same sort of regimen carried out for a month or six weeks in a German bath be adopted cn several days during the week, or for a month at a time, three or four times a year, good living cannot be indulged in with impunity. Important organs and many delicate tissues must suffer and become the seat of degenerations which not only shorten life but make activity and enjoyment of existence impossible while life lasts. Men who have to live under the very disadvantageous circumstances referred to should at the least make a rule of spending a few weeks during the winter months

at Bath or Leamington, and in the summer make a pilgrimage of six weeks' duration to some place abroad where food is restricted, exercise enforced, and the system cleansed by washing out with alkaline waters.

Extractive Matters.-Dr. G. O. Rees more than thirty years ago discovered in the urine, in certain cases, an extractive matter which drained away from the blood, and which is distinguished by producing an abundant precipitate with tincture of galls. Now, although in many cases albumen exists in the same specimens of urine, this blood-extractive sometimes escapes without albumen ; and thus the exhaustion and emaciation in some obscure cases in which there is no hemorrhage or escape of albumen, are to be accounted for. The conclusions at which Dr. Rees has arrived are as follows:

1. That whenever albumen was present in quantity in the urine, it was always accompanied by the extractives of the blood, in large proportion.

2. That the cases in which the extractives of the blood were in the urine in large proportion were generally those marked by debility.

3. That cases of anasarca with disease of the heart, and unconnected with albuminuria, also showed the extractives of the blood to be excreted by the urine in quantity.

4. That cases of chlorotic anæmia and hysteria give copious precipitates.

5. That when, in albuminuria, the albumen became deficient in the urine, which we know often happens in advanced cases, the blood-extractives also decrease in quantity.

6. That, in cases of anæmia, the proportion of blood-extractives observed in the urine diminished as the cure was proceeding, under the use of ferruginous tonics (Lettsomian · Lectures, "Medical Gazette," 1851).

In many cases where the urine contains an abnormal quantity of water, the proportion of blood-extractives is unusually great. Schotten proved that in uræmia there was a large increase of extractives in the blood, and I have found this also to be the case in many forms of febrile disease. The elimination of this

excess of extractive matter has to be promoted. In cases of kidney disease, the relative proportion of extractive matter to the urea is very much greater than in healthy urine. It would seem that extractives merely filter from the blood in certain cases, and these substances might escape into the urine when the structure of the kidney was impaired; but that for the separation of the urea, a healthy condition of the secreting structure is necessary.

The extractive matters are not capable of being converted, by further oxidation, into urea, carbonic acid, or ammonia; and must, therefore, be regarded as excrementitious substances. Scherer ("Würzburg Verhandl.," b. II, Heft III, s. 180) found that the urea salts, etc., in the urine of a madman who took no food, were very much diminished, while the extractive matters, although less than in healthy urine, were not diminished in nearly the same proportion as the other urinary constituents.

We have much to learn concerning the circumstances under which the extractive matters may be formed in greater quantity than in health, and the precise changes which would result from their accumulation in the blood. In cases of uræmia, in most of the severe fevers and probably even in slight febrile diseases and in pneumonia and other acute diseases, the quantity of extractive matters is increased.

I have no doubt that the benefit following the use of many remedies which promote the removal of excrementitious matters is in many cases due to the discharge of extractive matters from the blood. Seeing the large increase of such substances in the blood in cases of fever, low pneumonia, acute rheumatism, and many more in which derangement of the blood has existed for a considerable time, and considering the long period required for convalescence from these diseases, and the re-establishment of the healthy state-it is only reasonable to suppose that during the prevalence of the morbid state, and very probably for some time before its accession, extractives were accumulating in the blood and interstitial fluids of the tissues and organs, and that the presence of these had something to do with the symptoms, and that their elimination was necessary for the restoration of the blood to its normal healthy condition. If the removal of these

offending extractive matters can be facilitated and expedited, then return to health will probably be hastened. As regards the means, it is probable that the various medicines and methods of treatment already recommended for promoting elimination and exciting the emunctories to increased action, are also effective in causing the discharge from the blood of extractive matters which have perhaps been accumulating in the circulating fluid as well as in the interstitial juices of the tissues for a considerable period of time.

EXCESS OR DEFICIENCY OF THE INORGANIC CONSTITUENTS.

In certain morbid conditions, the inorganic salts vary much in quantity, and in some they are very deficient. In cases of diabetes, there is sometimes but a mere trace of fixed salts. This deficiency may depend upon the nature of the food, or it may be due to the formation of a reduced proportion of some of the salts in the organism.

In some states of the system, when much disintegration of tissue or red blood corpuscles takes place, a greater quantity of sulphur and phosphorus is oxidized, and sulphuric and phosphoric acids are formed in unusually large proportion, and afterwards removed in the urine. In certain inflammatory conditions, it would appear that the common salt is required in considerable quantity at the seat of the inflammatory change, and does not pass away from the system in the urine. In some states of renal disease, in which the secreting structure of the kidney is so much impaired that the separation of urea and organic matter is interfered with, the solids consist almost entirely of saline matter, and in most cases of prolonged structural disease the proportion of the saline to the organic constituents is very much increased.

Chloride of Sodium-Deficiency or Absence in the Urine in Pneumonia.-The fluctuations observed in the quantity of common salt excreted in the urine are very great, even in health. The circumstances which influence the amount of chloride of sodium are very numerous and varied, but it will be generally observed that when inflammatory exudation takes