what mischief has been there. On Tuesday (14th) the brother's throat became bad, but his case I shall relate in full after that of his sister.

دو

The patient was of medium size, florid, rough skin. The tongue was of a dirty-brown colour. Bowels confined. She had taken "pills on that account. Catamenia irregular ; nothing seen the last two months. Pulse 128, feeble, soft; temp. 103-8°. She has been sick. Is very thirsty, but can scarcely swallow even liquid. The fauces are much congested. The tonsils meet and block up the passage; matter pointing in several spots. She has headache. Calc. Sulph. 12x trit., gr., Bellad. 1, gtt. j, 2 h. alt.

19th.-Throat very much better; can swallow well now. Catamenia came on yesterday and are still flowing (this is the third month since their last appearance). She was very delirious all night, and got out of bed several times. Pulse 112, temp. 102°. Tongue dry, furred. Has been very thirsty. Bowels moved naturally. Skin hot and dry; has had no perspiration. Pupils dilated. Face dusky. No eruption. Tonsils large but much less inflamed. Acon. 1, gtt. j, 2 h.

21st.-Pulse 64, feeble, and rather irregular; temp. 98.4°. She has been very excitable, laughing and talking, but this morning she has slept and is now quieter. Skin dry. Urine scanty. Tongue clean. Bowels regular. Appetite better. The catamenia continue, but scanty. The pupils are still rather dilated. Rep.

23rd. Has slept quietly, and is now herself in nearly all respects. Catamenia over. Appetite good. Ars. 3x, gtt. j, t. d.

25th.-Convalescent. She did not desquamate.

The next case, that of the brother of the last patient, aged 30, had an unfortunate sequel. The patient was an unmarried man, large, extremely powerful, and very well made. He was of a fair, sandy complexion, and of a slow, lymphatic temperament. Without being actually intemperate, he was somewhat careless about himself, and passed a good deal of his spare time at the usual place of public resort in a village, the ale-house. He drank a good deal of beer. He was, like

his father, a wheelwright. I found him on the 16th of April, when I first saw his sister, suffering like her, from sorethroat. It began with him on Tuesday the 14th, the day after his sister was taken ill with her throat. Previously he had been in good health. I found his throat much swollen, the tonsils very large, just as in the case of the last-named patient. I gave him, like her, Bell. 1 and Calc. sulph. 12x, to be taken in the same way.

April 19th.-Is very much better. Tongue much cleaner. Bowels open. There is very little pain in the throat now. He is very weak. I gave him China 1, gtt. j, quarter die.

So.

21st. He appeared to be quite well and considered himself

Beyond giving a few general directions, I did not consider him as requiring further treatment.

On the 21st of May, just a month later, I was not a little astonished to see this patient walk into my dispensary, having come a journey of six miles, looking very puffy about the face, and with his legs oedematous and pitting.

The history he gave was that he first noticed his face and legs puffy a week ago, but that he had felt quite well all the time, and did so on the day of his visit. The tongue was rather dirty. There had been no desquamation. He ate, slept, and worked well; and had no urinary difficulty. He had not taken cold.

He had not brought a specimen of his urine with him, and I had no convenience at hand for testing, and judging by the absence of all constitutional symptoms, I concluded that it was probably one of those anomalous cases of dropsy following scarlatina without any discoverable kidney lesion, such as I have seen, and such as do occur, as pointed out by Niemeyer. In this conclusion, however, I was greatly mistaken, and the case has been a warning to me ever since. I gave the patient Apis and ordered him to be kept warm and quiet, and to send me word how he was in a few days, but not to come himself.

I should have said that, in the limited accommodation usually found in cottages in the country, the patient had occupied a sleeping-room which was little more than a VOL. XLI, NO. CLXIV.-APRIL, 1883.

K

closet, and contained far less than the regulation amount of cubic space prescribed by Government as necessary for each adult.

On the 24th I received word that his legs were no better though he felt quite well in himself. I now gave him Arsenic 3, gtt. j, 2 h.

27th.-No better. Legs not quite so large. He has a cough which causes pain in his head when he coughs. His back is very painful. Appetite good. He sleeps well. Arsen. 2, Canth. 1, 14 h. alt.

31st. Same generally. Not so much headache. The usual quantity of urine. The urine contained two thirds of albumen. Under the microscope a few hyaline tube casts were seen containing yellow granular cells embedded; a few bacteria, micrococci, solitary and in clusters; a mass of yellow granular matter with yellow cells and micrococci scattered about; epithelial cells. I gave him Canth. p, gtt., and Liquor arsenicalis, gtt., 1 h. alt.

June 2nd.-There is now general anasarca but no ascites. No headache. No pain in the back. He feels well. Bowels regular. Appetite good. The urine is normal in quantity. There is not so much albumen; it is clearer to the naked eye. Pulse 76, temp. 99.2°. He told me that he had not felt in the least poorly before the swelling of the face began. He had not caught cold during his convalescence, and though he had taken a little beer, he has not taken much. Before his illness (sore throat) he had had a cough, and it had returned but was better now. When I first saw him he had rather a bloated appearance. I gave him Liq. arsen., gtt. §, 2 h. I put his legs in a pack and instructed his mother how to repeat it.

June 4th. The legs are much less oedematous. Tongue clean. Bowels open. Appetite good. There is a large quantity of urine but the proportion of albumen is not so great. The microscope shows a few micrococci, a few red blood-corpuscles and leucocytes. Pulse 62, temp. 98.6°. Rep.

12th. Is much paler. clean. Bowels regular.

Not so much swollen. Tongue
Appetite good. Has had much

headache lately, but not to-day. Arms and chest swollen. Pulse 64, dicrotic. No cough. Heart-sounds muffled; first at apex prolonged and reduplicated; second at basis impure, reduplicated at times. No pain in the back. Temp. 98.4°. Urine, quantity same; naked-eye appearances same. Microscopical examination showed hyaline and granular casts, studded with round cells, full of granules; leucocytes and coloured blood-corpuscles floating about; vibrios and bacteria; few micrococci; epithelial scales. Rep.

14th.-Swelling same. Tongue clean. Bowels open. Appetite good. Very little headache. Urine contains very much albumen; leucocytes; no coloured corpuscles; no micrococci.

17th. Same generally. Legs more swollen. They do not yield to packing. Has had headache. Urine much better, only one sixth albumen. Phosphorus 2, gtt. ij, Phytolacea, gtt. ij, 3 h. alt. [The latter was given, as far as I remember, under the impression that as Phytolacea is so serviceable in diphtheritic conditions of the throat it might be of use in the sequelæ.]

21st. Had much pain between the shoulders yesterday, also headache. Legs much swollen again. Tongue clean. Appetite good. Bowels open. Good quantity of urine, paler; albumen one half. Liquor arsenicalis, gtt. ijss, Digitalis p, gtt. ss, 2 h. alt.

23rd.-Better generally.

Anasarca less. Rep.

July 12th. He was improving but had an irritable eruption on his legs (Arsenic ?). He went out, contrary to instructions, and took cold. I found him very pale. Has headache. Albumen one fourth, much less than it has been. In my absence he had received Tereb. 1; I now gave him Tereb. 1, gtt. j, and Digit. p j and js, 2 h. alt.

16th.-Breath very short at night, Headache at times. Very feeble. Appetite bad. Urine same. Terebinth 1, gtt.

j, Arsen. 2, gtt. j, 2 h. alt.

18th.-Weaker and paler. Not so much urine. Canth. 3x gtt. j, Ferrum metal 6, gtt. j, 2 h.

He now passed into the hands of an allopath, as I could not give his friends any hope of his recovery. I heard

afterwards that his decline in health became very rapid. He had convulsions, became blind and speechless, but recovered his speech, and died on the 22nd of August.

Whilst in attendance on this family I was asked to see a neighbour of theirs living in a house close by but not adjoining.

Mr. H, æt. 56, an active man, spare, of medium size, was a shopkeeper in the same village. He has suffered. much from palpitation and has been told he has hypertrophy of the heart. In his youth was very active and over-exerted himself. He is still active. His heart has been quieter lately. He is not so nervous as he has been.

I saw him first on the 19th of April, 1879. Three days previously he had been taken with sorethroat and general malaise. He had been getting worse till the day I saw him when he had kept his bed. I found him with a faint scarlet rash over his chest and body, the skin being moist. The tongue was covered with a thick white coat. The fauces and throat were of a dusky red. The tonsils not swollen. The bowels were open. Pulse 107, temp. 101°. I gave him Acon. 1, gtt. j, Merc, sol. 6, gtt. j, 2 h. alt. April 21st.-Pulse 96, temp. 100-8°. legs now. Throat well. Tongue clean. Has slept well.

Eruption all over Bowels not moved.

23rd. Very much better. Pulse 72, temp. 98.2°. The arms have been full of the rash, but now all has gone except a little remaining on the legs. The skin itches. Tongue clean. Bowels open. Appetite good. He has slept well, but has wandered much in his sleep. Ars. 2, gtt. j, quarter die. 25th.-Convalescent. Skin itches, no peeling yet. Rep. He afterwards desquamated freely.

My notes do not say whether this patient had had an attack of scarlatina before, but if I remember rightly he had not. I cannot trust my memory, however, sufficiently to be positive on this point, and must therefore disregard it in drawing conclusions.

These three households were all that came under my immediate notice during the epidemic. They contained altogether ten persons more or less affected by the scarla