2. The same remark applies to pain produced by the pressure of cancerous, aneurismal, or other tumours. Thus cancerous disease of the lumbar glands is often mistaken for lumbago; so also the pain from aneurismal disease of the thoracic and abdominal aorta, when no pulsating tumour can be detected, is referred to rheumatism.

3. During the course of renal disease, abnormal irritation arises not only in the serous membranes, producing pericarditis, pleurisy, peritonitis, &c., but a similar change happens with the synovial membranes, and a form of disease is induced which simulates rheumatism.

4. In chronic poisoning by lead, vague pains in the fascia, as well as in the joints, have been designated "saturnine arthralgia."

5. We have already referred to periosteal disease as a source of fallacy in the diagnosis of rheumatism.

6. Shingles or herpes zoster may be found in the course both of the cerebral and spinal nerves; and the severe pain which precedes the eruption of the vesicles, and which also follows their disappearance, closely simulates local rheumatism.

7. A more important disease, and one which is attended with fatal issue, is pyæmia. It closely resembles rheumatism; for, with rigor and febrile symptoms, there is fixed pain and swelling in the joints-first one, and then another, being affected, though without subsidence of those parts first attacked. But, whilst there may be some similarity in the symptoms, the prognosis is widely different. The one is generally a curable disease; the other, a fatal one.

We might also refer to the severe pains in the back which precede some of the exanthems, as small-pox; and to the general malaise of fever; but these could scarcely be mistaken for rheumatism. And, lastly, the symptoms described as arising from acute trichinous disease have some resemblance to rheumatism in the pain in the limbs. I have never seen an instance of a patient dying in consequence of this affection, although in numerous cases I have witnessed the trichina spiralis in the muscles after death.

It is an excellent rule, whenever there is local pain, to examine for a local cause; but it is often surprising to notice the strange maladies which are designated as rheumatic, at one part or other of their course, from the character of the pain; and, even when the disease is truly rheumatism, we attach but little value to statistics drawn up without reference to individual peculiarity. The natural result of this disregard of constitutional difference is to follow a routine plan in the remedies employed; in fact, treating the disease rather than the patient. We believe that rheumatism may be greatly relieved, or shortened in its course, by the proper use of means; and we strongly deprecate the treating of mere symptoms, as both injurious and unphysiological. But we would urge that each case be estimated in all its relations; and that a patient having severe rheumatism should not be at once dosed with calomel and opium, or with a certain number of drachms of saline medicine, irrespective of every other consideration.-British Medical Journal, June 30, 1868, p. 603.

5. THE TREATMENT OF ACUTE RHEUMATISM.

By Dr. N. J. BUTLER, Blackrock, Dublin.

As I think many practitioners are not aware of the extraordinary efficacy of valerian, administered in the form of a bath, in subduing the pain and inflammation attending acute rheumatism, particularly of the arthritic form, I consider I am merely fulfilling a duty to the profession and public by mentioning it. It was first introduced to my notice by my friend, Dr. Adriena name known and honoured in the annals of Dublin surgery-since which time I had opportunities of testing and proving its wonderful power of arresting and cutting short the most violent attacks of acute rheumatic arthritis. The bath is made simply by taking lb. i. of valerian root, boiling it gently

for about a quarter of an hour in one gallon of water. Straining and adding the strained liquid to about twenty gallons of water in an ordinary bath. The temp. should be about 98°, and the time of immersion from twenty minutes to half an hour. Pains must be taken to dry the patient perfectly upon getting out of the bath. If the inflammation remain refractory in any of the joints, linseed-meal poultices should be made with a strong decoction of valerian root, and applied.—Medical Press and Circular, August 5, 1868, p. 133.

6. THE REMOVAL OF CANCER BY CAUSTIC ARROWS AND CARBOLIC ACID.

By Dr. J. R. WOLFE, Ophthalmic Surgeon to the Aberdeen Royal Infirmary.

[The favourable termination of the following cases increases the interest attaching to them from the mode of treatment adopted.]

Case 1.--Epithelial Cancer.-J. B., aged 51, farm servant, applied for advice at the Royal Infirmary, Aberdeen, in May, 1867, on account of a tumour in the inner canthus of the left eye. The tumour was about the size of a large walnut, rounded in form, hard, inelastic, and nodulated to the touch, immoveable, being firmly attached to, and involving part of both eyelids, affected every now and then with attacks of lancinating pain. He stated that it began about nine years ago, in the form of a small wart at the inner angle; it remained nearly stationary for a considerable time, but some months ago it had begun to enlarge, and continued to progress rapidly. On being told that it was malignant, and would require an operation for its removal, he left the hospital, and did not again present himself till July 3rd, at which time the tumour had begun to break up on the surface by ulceration; being covered with a crust, and having an ichorous discharge, of a slightly offensive smell, spreading and infiltrating the subintegumental tissue. Examined with the microscope, it presented the ordinary characters of epithelial cancer. The awkward situation in which it was placed rendering it difficult of removal by the knife, without producing cicatrices which would have given rise to considerable deformity of the eyelids, I had recourse to the following procedure.

Five openings were made with a broad lance, into which caustic arrows were inserted; one of these was in the centre of the tumour; the other four were in the healthy skin round its margin; and the neighbouring parts were protected by a patch of leather, having an opening cut in its centre of sufficient size to embrace the tumour. The whole was covered with a compress of dry lint and bandage. As the patient complained of no pain, nor any irritation, he was allowed to move about the ward as usual.

On the third day, the whole tumour came away, leaving a grey-c 7-coloured slough, which was detached in the course of twenty-four hours by the use of linseed-meal poultices. The surface now exposed was clean, and presented irregular elevations, which bled very readily. The gap left was so deep as to expose freely the inner wall of the orbit as far back as the middle of the eyeball. The surface was now painted with strong carbolic acid, and the whole covered by wadding dipped in glycerine. This treatment was continued for three days; by which time the bleeding elevations had disappeared, and the whole presented an uniform granulating surface. It was then covered with carbolised wadding dipped in glycerine; the dressing being changed every second day, and the wound washed with a weak solution of carbolic acid. Under this treatment, the gap filled up rapidly; and in a fortnight it was entirely healed.

In August, I exhibited the case at the meeting of the North of Scotland Medical Association; when the skin about the inner canthus and eyelids presented its natural appearance, and scarcely a trace of cicatrix remained to show that loss of substance of such an extent had occurred.

I had an opportunity, quite recently, of examining the patient, and found the cure complete. The only traces (and these only to be observed on minute inspection) are: a slight elevation at the inner angle, as if the periosteum there were thickened, and the obliteration of the tear-duct, which, however, does not give rise to any inconvenience.

Case 2.-Cancerous Cyst.-E. A., aged 68, domestic servant, was admitted into the Royal Infirmary, October 12th, affected with a hard tumour of the left inner side of the lower eyelid and cheek, measuring two inches and oneeighth in its largest diameter; of an oval shape, irregular and nodulated on the surface, and presenting the appearance of small abnormal vessels ramifying on its cutaneous surface, which was completely adhering. On puncturing it, there escaped a quantity of bloody serum and air-globules, which evacuation, however, did not diminish the size and hardness of the tumour. This fluid, when examined under the microscope, presented a mixture of cells and granules, but of so undecided a character as not to make it clear whether these were cancerous, or merely the products of an inflamed cyst; but the bulk of the tumour, &c., showed unmistakeable characters of malignancy. The tumour was removed by caustic arrows, as in the last case, and dressed with carbolic acid. The patient was discharged in eighteen days, scarcely any appreciable cicatrix being left, and still continues well.

Remarks.-The advantages of this mode of treatment appear, as far as two cases prove anything, to be the following.

1. It is painless. Patients walked about the wards as if nothing had been done, and complained of no feeling of pain or discomfort whatever.

2. The tumour is completely eradicated; and, under the action of the antiseptic, which acts in the first instance as a caustic to the diseased tissue, healthy granulations are produced, which completely fill the gap, and leave little or no trace of a cicatrix.

This method appears exceedingly valuable for removing tumours from regions where no skin can be obtained from the neighbourhood; and is also applicable to erectile tumours, nævi, cancer of the breast, &c., occurring in patients, places, or seasons of the year, when the use of the knife is to be dreaded.

On my mentioning the result of my cases to Professor Gosselin, he told me that for the last few years he had rarely used the knife for the removal of cancer of the breast in the Hôpital la Pitié, but regularly resorts to the use of caustic arrows. The result is, that he does not now meet with cases of erysipelas, which used to be very common in his wards. He showed me several cases under treatment; but they were not sufficiently far advanced to enable me to judge of the appearance of the cicatrices, or to decide how much of the beautiful result above detailed is due to the carbolic acid and how much to the arrows; in short, to determine whether the same result might not be obtained by the use of the knife and carbolic acid.

The arrows employed I obtained from the Pharmacien of Hôtel-Dieu, Paris, who prepares them by dissolving chloride of zinc in a little water, making a saturated solution, and mixing it with sufficient starch to make a stiff paste, which is rolled into a thin cake, cut into shape, and dried at 212° Fahr. Although elsewhere I have claimed priority in the use in this country of carbolic acid as a dressing for wounds, yet I by no means wish to undervalue the great service rendered by Professor Lister to surgery in the systematic employment of it. Having seen its employment in Professor Lister's wards in the Glasgow Infirmary, I may be allowed to bear testimony to the skill, care, and originality, with which his experiments have been carried out.-British Medical Journal, Sept. 19, 1868, p. 303.

7.-A READY MEANS OF APPLYING CHLORIDE OF ZINC IN CANCER.

Mr. WEEDEN COOKE sends us an account of a process he has devised for this purpose, and which he finds most useful. Following a plan adopted in

some hospitals, of steeping lint in solution of sulphate of copper and liq. ferr. perchlor., and afterwards drying it, he has been substituting chloride of zinc for these substances, and finds this preparation most convenient for application. "The chloride of zinc, being a highly deliquescent salt, requires scarcely more than exposure to the air to render it liquid; at least a very few drops of water will quickly produce this effect. The lint is thoroughly soaked with this liquid, and hung up for a short time. It does not dry so completely as the iron or blue lint, owing to the deliquescence of the zinc. It preserves its active properties for weeks, if kept in a wooden or pasteboard box, such as a seidlitz-powder box. An old pair of scissors should be kept for cutting it, and forceps coated with vulcanite may be employed in its application or removal. The great convenience of the chloride of zinc lint is that the smallest pieces may be used, even to a wart or pimple, or to parts such as the eyelids, to which it would be almost impossible to apply the old paste. There is also the advantage of confining the caustic effect absolutely to the part to be attacked. I have used it to those stubborn indurated ulcers at the inner canthus, be they lupus, rodent ulcer, rodent cancer, or what not, as well as the upper and lower lip, and other parts of the face, with the greatest advantage; and have obtained better results than formerly, because of the power of adapting the application exactly to the size of the eschar required, and the ease of keeping the lint on as long as need be, and re-applying it as often as may be necessary, with very little discomfort to the patient. It being always ready, the surgeon in going round his wards may himself apply this lint to a commencing slough, either in a cancerous breast, or an ulcerated leg, or a bed-sore, or a phagedæna, and at once check that which otherwise may give much trouble to stay. I had occasion to enucleate a large epithelioma, from the parts about the umbilicus, which dipped down so deeply as to render it probable that it had reached the inner wall of the abdomen. An eminent surgeon advised removal by the knife, but the patient objected, and I set to work with some trepidation to remove it by the means of the chloride of zinc. There being a large surface to destroy, I used at first the paste, taking away every other day the dead portions; some little bleeding occurred when these were removed, but by means of the iron lint it was readily checked. It was not possible by any amount of packing round the diseased part to prevent very troublesome excoriation of the healthy parts, and so, at the latter part of the treatment, it occurred to me to use the lint as I have above described. It answered perfectly, and the whole of the cancerous mass was removed, leaving a red healthy granulating surface, which soon healed by the application of resin cerate. In a very curious case, which seemed to combine the appearances of keloid and encephaloma, I have recently been able to discharge from the hospital to resume her usual occupation, after a twelve months' residence there, a patient upon whom I had twice operated by means of the écraseur for large growths of a soft spongy character, having an extended horny base. These soft excrescences reappeared, and I finally attacked them with the zinc lint so successfully, that for a time at least there seems a prospect of immunity. For uterine purposes also, this convenient method of using chloride of zinc is much to be commended. Passed up through the speculum to the diseased part, and covered by a further plug of dry lint, it does its work, if properly measured for the part destroyed, without injury to the healthy tissues."-Practitioner, Sept. 2, 1863, p. 181.

8.--RELIEF OF PAIN IN OPEN CANCER.

The field for experience in cancer at the Middlesex Hospital is, as well known, an unusually large one, and opportunity has therefore been afforded for testing fairly the action of remedies in affording relief in this distressing disease. We learn that the exquisite pain which belongs to open cancer is found to be best relieved by the stramonium ointment, which is employed at

this institution. The following is the formula for this in the hospital pharmacopoeia :-Half a pound of fresh stramonium leaves, and two pounds of lard. Mix the bruised leaves with the lard, and expose to a mild heat until the leaves become friable, then strain through lint. The ointment thus prepared is spread upon lint, and the dressing changed three times a day.— Lancet, August 8, 1868, p. 185.

9.-ON THE TREATMENT OF PYÆMIA.

By C. S. JEAFFRESON, Esq., Senior Resident Surgeon to the Royal Free Hospital. [After relating a case of pyæmia which terminated favourably, the writer observes:]

Many persons would, perhaps, feel inclined to doubt this case being one of pyæmia in its most general sense, from the favourable nature of its result. He was throughout kept well under the influence of alkalies, his excretions being fully alkaline; and with this was combined a full allowance of stimulants and support.

This method of treating cases of septic infection has been ably advocated by Mr. Savory. Whether it acts by neutralising or modifying the poison, or whether, by maintaining the blood in a fluid condition, it tends to prevent that first step of coagulation which, in its secondary effects, plays such an important part in the history of embolism and metastatic abscesses, is a matter of speculation. Of this there can be no doubt: that the alkalies, being readily dissolved, are readily absorbed into the blood, upon which they exert a powerful influence, indirectly stimulating the excretions. This action may be summed up under three heads: 1. Direct antagonism of the poison; 2. Protection against coagulation; 3. Promotion of secretion and excretion. Doubtless the stimulants also play an important part in keeping up the circulation; and thus we may say that the indications to fulfil are, to keep the blood fluid, and to keep it circulating.-British Medical Journal, August 29, 1868, p. 219.

10. NOTES ON THE TREATMENT OF CHOLERA.

By Dr. T. M. LOWNDES, Bombay Army.

[In some remarks published in the Transactions of the Bombay Medical and Physical Society for 1860, Dr. Lowndes advocated the use of astringents with one or two full doses of opium at the commencement of cases of cholera.]

With respect to the treatment of the first stage, I have, since the time when my remarks were written, omitted entirely the use of astringents, finding that a draught containing fifteen or twenty minims of chloroform, with ten or fifteen minims of tincture of opium, with a drachm of spirit to render the chloroform miscible with water, was exceedingly efficacious. During several years, when cholera was more or less prevalent, I have treated a large number of patients by this method, and can only call to mind one case where the disease progressed to collapse, and two cases where diarrhoea went on to rice-water purging and vomiting. It may be objected to this, that these cases were not choleraic purging; but the vast majority of them occurred during the time when cholera was present, and the symptoms supervened between midnight and five in the morning, with crampy pains in the stomach and bowels. These cases in India are specially suspicious, the patient going to bed quite well, and being awakened at the time named. During the prevalence of severe cholera, the same result was observed. The orders issued were, that every person suffering from diarrhoea was at once to come to the hospital for treatment; and this medicine was administered, with the general result that but few required a second dose.