+ Bence Jones lays special stress upon this. A familiar example is the oxidation of sugar in Poolings reaction, which will not occur except in the presence of an excess of alkali.

If these affections do depend upon this or any other diathesis or common constitutional condition, we should expect them to exhibit certain general characteristics indicating a mutual relationship. This they do, and the principal features which they possess in common, and which serve to point to this relationship, are the following:

They are not contagious.

They are frequently general; not, however, by simultaneous invasion of the surface, but by spreading from different foci.

They are frequently symmetrical.

They are usually chronic.

Their natural duration is indefinite.

They are obstinate, and do not readily yield to treatment.

They are frequently observed in different members of the same family.

They are frequently observed in different forms in different generations of a family.

Two or more forms may be present at the same time, or may appear successively.

They do not always preserve their individuality, but sometimes merge one into the other.

Relapses are frequent.

They sometimes alternate with affections of other organs, especially of the pulmonary and gastric mucous membranes, and of the joints.

They itch.

The lesions are always superficial.

They never leave cicatrices.

They are more or less amenable to certain definite methods of treatment, which have little if any effect upon other cutaneous affections.

These many common features, together with the results of rational treatment based upon indications deduced from the supposed nature of the affections, tend, with increasing experience, to confirm rather than weaken the views which I have now for some years held concerning this diathesis, and the propriety of classing these affections among its manifestations.

Treatment

Having now considered the nature of the Rheumic diathesis, it remains to be seen whether we have any means at our command by which it may be counteracted, or its effects in any way modified. The measures which may be adopted for this purpose come under two heads, namely: rational and empirical. The rational treatment will be best understood by taking a retrospective glance at the morbid conditions present and their cause.

1. We have the blood surcharged with insufficiently oxidized excremen-titious principles, less soluble than urea, the substance into which they would be changed if normal action were taking place.

2. The blood is subalkaline.

3. The accumulation in the blood of these excreta is due either to deficient action of the kidneys; or -

4. The kidneys acting normally, these substances are produced in excess.

5. This excess is due either to oversupply of albuminoid food, the surplus not being thoroughly oxidized; or -

6. The nitrogenous ingesta, not being excessive, there is failure on the part of the oxidizing processes to fully perform this function.

7. There are strong reasons for believing that the liver is the organ more particularly at fault in this connection.

The two principal indications, then, are to depurate the blood and to promote oxidation, and these we may expect to fulfil, with more or less success, by means at our command.

Depuration of the blood is to be effected by calling into more vigorous action either the kidneys, bowels, or skin. If the trouble is due to defective renal activity, a point which may be determined by careful estimation of the amount of nitrogen daily discharged in the urea, uric acid, etc., we must treat these organs with some leniency, and be careful not to urge them too much, since by undue stimulation we may increase the difficulties under which they are laboring, and defeat the very object we have in view, to say nothing of the risk of doing more serious damage. We will be obliged, therefore, to depend upon the skin and bowels for the fulfilment of the first indication. The functional activity of the skin is increased by exercise, bathing, and warmth; and is most rapidly and \ orously influenced by the hot-air or Turkish bath. This latter agent, in the abseuce of extensive eruption, is almost always of service, and, when properly managed, is not liable to be followed by injurious after-effects; it may, therefore, be applied frequently, even daily, with the happiest resuls.

If the bowels are to be stimulated, we may employ various cathartics, the most useful in this connection, perhaps, being the ordinary senna and salts, given in sufficient doses to produce one or two loose evacuations daily. Hardy praises very highly an infusion of wild pansy (viola tricolor), combined with senna, in about the following proportions:

Violae tricoloria..................................

Sennae........................

Aq. bullientis...................

M.

One-fourth to one-half of this quantity to be taken daily, and the amount to be diminished gradually as the necessity for its emplo\ lessens. Hardy states that he has given this purgative for two Of three months at a time without ill effect.

In place of these remedies we may employ some of the natural mineral waters, as those of Seidlitz, containing sulphate of magnesia largely, without chlorides; of Pullna, characterized by its richness in sulphates of magnesia and soda, together with chlorides; or of Friedrichshall, containing both soda and magnesia, but less abundantly than Pullna. The native waters which seem to approach most nearly in chemical composition to those above noted are the Estill and Crab Orchard Springs of Kentucky.*

This active purgation, however, I believe is rarely required, the condition necessitating it (defective renal action) being the exception, a by no means the rule, as numerous quantitative analyses have indicated a normal excretion of nitrogen.+