story. Wishing to illustrate that the gout may intermit, he relates that a person subject to gout won the race in the Olympian games, during the interval of the disease. And he closes his chapter on melancholy thus: "A story is told, that a certain person, incurably affected, fell in love with a girl; and when the physicians could bring him no relief, love cured him. But I think that he was originally in love, and that he was dejected and spiritless from being unsuccessful with the girl, and appeared to the common people to be melancholic. He then did not know that it was love; but when he imparted the love to the girl, he ceased from his dejection, and dispelled his passion and sorrow; and with joy he awoke from his lowness of spirits, and he became restored to understanding, love being his physician."

Aretaus shows himself a true physician by his concern and sympathy for the patient, in small matters and great: "Inunctions are more agreeable and efficacious than fomentations; for an ointment does not run down and stain the bed-clothes-a thing very disagreeable to the patientbut it adheres, and, being softened by the heat of the body, is absorbed. Thus its effects are persistent, whereas liquid preparations run off."

Elsewhere occurs this noble phrase, rarely equaled and never bettered: "When he can render no further aid, the physician alone can still mourn as a man with his incurable patient: This is the physician's sad lot."

Some authors call their work "a confession." This is unnecessary, as all writing is autobiographical. Write, and in spite of your best efforts at concealment, your feelings, passions, prejudices, predilections, your good qualities, wisdom, sympathies, will become apparent; where you least expect it, you will give yourself most away; your true self will lurk between the lines, and it will peep from the pages.

I am confident that, from the excerpts here given, the reader has already formed a high opinion of Aretæus. If ever a man cast credit on the art of healing, it was this lofty-souled Cappadocian. He was a disciple who not only followed in the footsteps, but caught the spirit of the immortal Father of Medicine. Aretæus should not be a forgotten physician, for no one better than he could repeat with decorum the soul-testing Hippocratic oath:

"With purity and with holiness I will pass my life and practice my art. Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further, from the seduction of females and males, of freemen and slaves. Whatever, in connection with my professional practice, or not in connection with it, I see or hear, I will not divulge, as reckoning that all things should be kept secret. While I continue to keep this oath inviolate, may it be granted to me to enjoy life and the practice of my art, respected by all men at all times. But should I trespass and violate this oath, may the reverse be my lot!"

There's autumn in the air.
I do not know from where
It comes, nor why I know,
But the full winds that blow
Are done with summer rest;
The colors in the breast
Of the strong hills grow deep
With shadows that slow creep
Toward winter. There's a mirth

Which laughs across the earth
Too wildly, lest the grief
Of summer find relief
In tears.

Whence comes the word
The startled gardens heard?
Who whispered 'neath his breath
Of that white silence-death?
-Emery Pottle in "Success Magazine.”

IN

N my preceding paper, entitled "Scarlatinal Nephritis," published in THE AMERICAN JOURNAL OF CLINICAL MEDICINE for September, I mentioned the classification I have adopted for diseases of the kidney after long study and examination of numerous cases which have been closely followed during life and morbid changes carefully examined after death, on organs most carefully hardened before sections were made and stained. It is only by observing all these details that a pathologist can speak positively as to the nature of the morbid change before him, always supposing that he has a thorough knowledge of its normal histology. No man has any right to pass an opinion on any morbid lesion who is not a thorough master of normal histology.

Classification

My classification of nephritic disorders adopted is as follows:

1. Scarlatinal nephritis, a simple inflammation, already described in the September number.

2. Acute parenchymatous nephritis, with subdivision of chronic parenchymatous nephritis-the subject of the present paper.

3. Interstitial nephritis, or Bright's disease the subject of the next, and concluding, paper.

There are, of course, many minor changes which might be and are taken to establish other forms of disease, but I cannot see their utility. The classification I have adopted is simple and appeals to the worker by its simplicity. Each division embraces a distinct lesion. The interference with function is clearly shown in each division; and the interference with function and its consequences is so clearly exhibited by its very simplicity that the general practitioner cannot fail to realize

what he is up against in every individual case, excepting of course those complicated cases where a positive diagnosis is almost impossible.

The lay public are keenly alive to disease of the kidneys, and they come with a history of pain in the small of the back which has lasted for some time and is getting worse. These are the cases where the quack gets in his deadly work, and we often meet people who have been paying a dollar a bottle for some advertised rubbish which they acknowledge has done them no good. When I get one of these cases, I give the patient a pill consisting of blue mass, rhubarb, and ipecac, to take at bedtime, this to be followed by a saline laxative on rising next morning. Many cases will be cleared up by this treatment, while all will be benefited.

Structure and Function of the Kidney

Before going further, I will give a slight sketch of the structure and function of the kidney in its normal aspect, which will help to an understanding of the changes. produced by disease.

In the first place, it is the function of the kidney to produce the urine, a watery fluid which carries a large amount of effete matter out of the body, and any interference with that function is rapidly shown by some changed condition incompatible with health.

The kidney has two functions, one being to produce the urinary water; the other, the urinary solids, or extractives. The first is formed by the glomerulus, which is the expanded end of a uriniferous, or collecting, tube. One closed end of this tube is expanded into a small sac, or bladder. The renal artery sends a small arteriole to each glomerulus which, when reaches this expansion of the collecting

Now, the arteriole which has broken up into tufts of capillary blood-vessels is the afferent vessel, that is, it brings the blood to the expanded end of the collecting tube and pours the urinary water, which carries some substances that are in solution with it, into it. These capillary blood-vessels are then merged into a vessel which carries away the blood that has given up the urinary water and other matter, and this is the efferent vessel; and this ef-ferent vessel is always of smaller size than the af-ferent vessel, thus increasing the blood pressure in the glomerular tufts. When this efferent vessel is first formed, it resembles a small arteriole, but it soon breaks up to form with all the other efferent vessels a capillary network which ramifies throughout the convoluted portion of the uriniferous, or collecting, tubes, so that their cells may remove from the blood, by a process of secretion (which in this case becomes an excretion), those substances which are the solids of the urine. From this rough sketch it will be seen how intimately all the different parts are associated and how little the derangement may be that can upset the whole scheme.

A Case in Point

Now to our case in point. We will suppose the patient has taken the pill of blue mass, rhubarb, and ipecac, with perhaps a little nux vomica, and this has been followed by a saline laxative in the morning. He feels better, but the pain in the region of the kidney still persists. We find he has some fever, we notice also that the urine is scanty, high-colored and smoky. We test with sulphosalicylic acid and find albumin. We now have to make our diagnosis, as it evidently is an acute case and the sooner the treatment is begun, the

better for a good result. The grafter with one idea will at once say, "Appendicitis" and, if he can persuade the patient and his friends, will operate and perhaps get his fee. A check for $150 in one's pocket will soothe the qualms of an elastic conscience.

We will, however, take another view of the case. Elimination has been perfect, but the pain and tenderness still remain; there is a considerable amount of albumin, the eyelids become puffy, there may be persistent vomiting and dyspnea, the skin becomes dry and harsh, the puffiness of the eyelids is soon followed by dropsy of the lower limbs and scrotum.

With these symptoms well developed, a mistaken diagnosis is hardly possible. If, however, a doubt exists, collect the urine for twenty-four hours, mix well, and send four ounces of it to a clinical laboratory for analysis.

The Beginning Treatment

Having decided then that it is a case of acute parenchymatous nephritis, proceed with the treatment and do not wait for the laboratory report.

Without any further delay, send the patient to bed and keep him there; put him on a strictly milk diet to start with; keep the bowels open with laxative salines, compound jalap powder or else elaterium in 1-6-grain doses repeated to effect. Give him all the water he wants, but allow no tea, coffee or stimulants. Drycup over the kidneys and follow with poulticesone made with jaborandi leaves and hemp seed, equal parts, is most effective. Diaphoresis is indispensable in this condition, while magnesium sulphate in small repeated doses is a valuable cathartic, as it acts on the kidneys as well as the bowels. One of the characteristic features of acute parenchymatous nephritis, and the most common, is exposure to damp cold, as has been well proved by arctic expeditions, where the cold is intense but dry, and this form of kidney disease has seldom been met with. Another feature is that it is a disease of the young-under fifty.

The prognosis is decidedly favorable in mild cases when taken in time and properly treated.

In describing the normal histology of the kidney, I mentioned the convoluted tubes as containing secretory epithelium, that is, epithelium that takes something from the blood and passes it into the lumen of a gland-tube forming the secretion of that gland, whatever that may be. But here the action is different. I have pointed out that the efferent vessel, after it leaves the glomerulus, joins other vessels and, forming a capillary plexus which is in close relation to the cells of the convoluted tubes, these cells remove something from the blood which has already been deprived of the urinary water and pass into this urinary secretion, which consists of the extractives, or solids, of the urine.

In acute parenchymatous nephritis, the convoluted tubes are the parts affected by a peculiar form of inflammation, which causes the cells to swell up, annihilating their function, while at the same time destroying the cement-substance which binds the cells together and to the basement-membrane, in consequence of which desquamation takes place and the cells are thrown off in dumps, and a condition of desquamation is produced. In this way numerous cells are unable to perform their function, and consequently the extractives that should have been carried away with the urine accumulate in the blood.

In dealing with such a condition, always bear this in mind and look out for uremic symptoms, as they may develop at any time in any variety of nephritis. It is a self-evident fact that if the blood that is supplied for nutrition to the nerve-center is not in itself in a normal condition, but is full of extractives which should have been removed, the nerve-centers cannot be expected to perform their functions in a normal manner; and uremia is always

more or less connected with the nervous system.

Toxemia must be treated promptly and thoroughly, and when a sudden rise of temperature or increased flow of urine is noticed, the onset of uremia may be suspected; and the more prompt and thorough the measures taken, so much less is there likely to be a severe attack.

Absolute rest in bed at the beginning of an attack of acute parenchymatous nephritis was advised, also a milk diet or animal broth where there is much depression and anemia, the regulation of elimination by frequent small doses of magnesium sulphate or of compound jalap powder, night and morning and with these measures one that is as important as any, or more, that is, keeping up the action of the skin. I have already mentioned a good method of doing this. By attending to all these measures, the toxin which has caused the trouble is gradually removed from the system and the desquamated cells in the convoluted tubes are replaced by new ones, developed by the cells remaining in the convoluted tubules. In this way a mild attack can be cleared up, all parts returning to their normal condition.

This happy condition, however, is not arrived at without great care and attention on the part of the attending physician, and in a great measure it depends upon a correct diagnosis in the early stage. If this is not done and the case is treated in a haphazard manner, it readily passes into the chronic condition and irretrievable mischief is done.

The discussion of this chronic stage will be taken up in my next and concluding paper, together with chronic interstitial nephritis. I will add that, when we find that the blood has disappeared from the urine, a course of iron and ammonium acetate and of glonoin will cause the albumin also to disappear, when we may consider that health is restored.

C

ONTRARY to the consensus of opinion expressed by physicians with whom I have talked on the subject and of most of those whose writings I have read, I do not hesitate to say that narcotic drug addiction is as certainly and readily curable as any of the chronic ailments. Another thing that is contrary to the opinion of the majority of physicians as well as laymen is that most drug users are very desirous of being cured. True, there are some who have no particular aim or ambition in life beyond present desire for comfort and dissipation, but these are almost infinitesimal when compared with the great army of drug users whose paramount hope is, in some way, at some time, to find freedom from their slavery. Dr. William J. Robinson of New York mentions a case in point, in his article entitled "Scientific Medicine vs. Quackery," in CLINICAL MEDICINE for February, 1911, page 159, in which he says: "A young man became, unfortunately, addicted to the use of morphine. He earnestly wanted to break himself of the pernicious habit. He applied to several physicians in succes sion, etc."

Turn to the standard textbooks, and here are a few examples of what we find on the subject:

"Opium habitués, differing as they do among themselves in the manifestations of the drug as long as it is freely taken, all alike develop characteristic symptoms upon its speedy or gradual withdrawal. Precordial distress accompanied by cough is followed by convulsive twitching of the hands. These phenomena are associated with a sense of perfect prostration which obliges the patient to take to his bed. Pain in the back and limbs followed by neuralgias occur. . . . The appearance of the patient is now most pitiable: the counte

nance is blanched and pinched, the body occasionally drenched with sweat, the heart's action feeble and the pulse thready and irregular. (Pepper's "System of Medicine," Vol. V., pp. 657-8-9.) The apartments occupied by the patient should be so arranged as to guard against attempts at suicide. (Ibid., Vol. V, p. 672.) This method (Levinstein's sudden withdrawal) is attended in all cases by indescribable suffering and by many serious dangers.. Failure of the circulation may, notwithstanding every effort to control it, reach such a degree as to jeopard the patient's life." (Ibid., Vol. V, pp. 673-5-6.)

"The treatment is manifestly difficult and unpromising. . . . The likelihood of a cure is exceedingly remote." (Anders' "Practice of Medicine," 1900, p. 1216.)

"There is no remedy for the opium habit." (DaCosta: Potter's "Therapeutics," p. 767.)

Quoting again from Dr. Robinson's article: "The morphine habit cannot be treated very successfully outside of special homes or institutions."

Dr. Geo. E. Pettey of Memphis, Tennessee, writes: "I am now able to say without reserve that the morphine habit is the most certainly and readily curable of the chronic ailments."

With the last two authors quoted, I most heartily agree, but I intend and hope to show that there is something better than one would be led to expect from reading the other writers.

Opium has been used for centuries, for the relief of pain and nervousness and to check diarrhea, and the benefits are beyond calculation.

Now, in case a painful ailment requiring the use of opium lasts for weeks or months, the patient is in danger of getting into such a condition that he will require the use of the drug every day.