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nausea and pain in the abdomen, particularly on the left side. The tongue was flabby and covered with brown fur. The abdomen was thin-walled and irregular in contour from the presence of doughy lumps, evidently fæces, which could be felt in the regions of the ascending, transverse, and descending colons. Abdominal wall oedematous. Per rectum, the sigmoid could be felt to contain large hard fæcal masses. She was in for five days, during which four enemas were given without any result. She suddenly became worse, and died from syncope.

Urine: Amount passed was 26 ounces, 34 ounces, 18 ounces, and 16 ounces on successive days. Examination showed sp. gr. 1010, alk., haze of albumen, no blood.

Post Mortem.-Body stout, but tissues flabby.

Heart.-Eleven ounces; slight right-sided dilatation; no valvular disease; no atheroma.

Lungs.-Emphysema, congestion, œdema.

Colon full of

Abdomen.-Small intestines not distended. rather hard fæcal masses. Descending colon compressed between kidney and abdominal wall.

Liver.-A few small cysts scattered over the surface, two or three of which were the size of a billiard ball in the right lobe.

Kidneys. Right weighed 35 ounces; left, 43 ounces. Both kidneys of enormous size, and occupying a large portion of the abdominal cavity.

Ovaries. A few small cysts in right ovary.

CONCLUSIONS.

The second stage of congenital cystic disease of the kidneys lasts for an indefinite period, perhaps for six or eight years. During this time the kidney tumours may be found if searched for. Dull aching and sometimes paroxysmal pains are experienced, especially in the abdomen and back, both during exercise and rest. Pain is often augmented by palpation, pressure, micturition, and during exercise if the kidneys are movable. Tenderness is usually present.

Urinary Symptoms.-There is dysuria, sometimes polyuria, and almost always some degree of hæmaturia, varying from a few corpuscles to a large amount of blood. A large number of leucocytes and even pyuria may be present. Casts are absent. Urea is reduced and albumen present. Symptoms of mild or severe dyspepsia are often felt. Headache and constipation are common. Cardiac enlargement occurs late in the second stage in about 40 per cent. of cases, and arteriosclerosis generally accompanies it.

I am sincerely indebted to Dr. Rickards and Mr. Heaton for allowing the use of the notes in three of these cases, and to Dr. J. F. Atkins for placing two of the cases under my care for observation.

PRACTICAL THERAPEUTICS.

TREATMENT OF CHRONIC DYSPNEA. By ARTHUR FOXWELL, M.A., M.D. (Cantab.), F.R.C.P.

It is very common in my experience to see patients who complain of this and nothing else. The causes of this condition, as seen in the consulting room, are, broadly, five. place them in order of frequency :—

1. Disordered metabolism.

2. Vascular degeneration.

3. Renal cirrhosis.

4. Cardiac.

5. Pulmonary.

It is evident from the above order of precedence that diet must play a very important, often the most important, part in the treatment; in fact, diet alone will not seldom suffice to effect a cure. But cure by diet takes time to show itself and you must appease your patient's haste to be well by the alleviation of drugs. I usually give some such pill as this:

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The patient is often run down and then I add to it strychnine. It may be wise to give a dose of some aperient water before breakfast every other morning whether the bowels be well open or not. I usually speak of the pill as a tonic liver pill, as otherwise it will be looked on as a simple aperient and not be taken unless the bowels tend to constipation; the result will then not be good, and your skill naturally valued at a low price.

If there be much gouty tendency, the capsules of colchisal* are a useful preparation: one should be given six times a day for a week, and afterwards three a day for three weeks more. Or, if the urine be lithatic or deposit uric acid, thialion, a level teaspoonful in a tumbler of water, every morning on rising, acts well.

It is often desirable to bring about a mild diuresis: this can be done by drugs, but is usually better effected by some medicinal water. I find Evian water as useful as any: it contains salts fairly identical in nature and amount with those in the blood; it is in no way depressing, and is very palatable; one to two pints should be taken daily in divided. doses on an empty stomach.

Patients who are in feeble health should be made to rest both before and after meals, with a long rest of not less than an hour after lunch. Such resting is preferably taken in the open air and nowadays it is not difficult to get your patient to agree with you in this. Long-continued or severe exercise is in all cases to be eschewed, but it is most important to insist that four short periods-half to one hour-of gentle outdoor exertion should be taken daily.

As to diet, the two great things are to insist upon no alcohol and very little animal food. I prefer that the meat should be taken at the mid-day meal; but if the patient is accustomed to dine in the evening, it is as well to allow him to continue to do so, forbidding soups made with animal stock, and allowing only fish or meat. Concentrated vegetables, e.g., peas, beans, etc., should not be taken with the dinner, or only very sparingly. According to Dr. Luff, spinach is the best and, luckily, may be obtained during a long period of the year. For breakfast and lunch, milk foods with bread and butter should be the staple diet. Early to bed-not later than ten-is another essential condition; hence the evening meal should be at 6.30 or 7.

Should the patient be prone to wake up with nocturnal dyspnoea, or should the breathing be most difficult in the evening, then mid-day dinner must be insisted on, and the

* Each capsule contains: Colchicine gr. o; Methyl. Salicylas gr. 3. + Thialion is Na O, 3 Li2O, SO3, 7 HO

evening meal be a light tea not later than six. These cases of metabolic asthma are generally due to increased arterial tension or, at any rate, are accompanied by this; hence trinitrin or some similar drug is of much temporary service.

The second and third causes-vascular degeneration and renal cirrhosis-are intimately connected with the one just considered; perhaps most often the three co-exist, but I have placed disordered metabolism first, as the dyspnoea of 2 and 3 is due to the inducement by them of 1, and, if we can correct 1, the dyspnoea usually goes. But not always; vascular degeneration itself is a most potent force in the causation of dyspnoea owing to the constant excessive labour it throws upon the heart. The hearts of vascular degenerates have but little strength to spare; quick exertion easily brings dyspnoea and, if persisted in, cardiac dilatation; but, the dyspnoea coming first, the patient usually slackens his effort before serious damage is done to the heart. It is, unfortunately, different with long-continued exertion, either mental or physical: here, no warning dyspnoea comes to the patient's aid, and he finishes his labour all unwitting of the injury he has done himself. That night he is restless, has some cardiac discomfort; the next day he feels very slack and tires very quickly. The condition does not improve: attacks of dyspnoea supervene: till in a week or so he comes to you complaining of chronic dyspnoea with exacerbations. However slight, these cases should be taken seriously; sometimes they are the beginning of a long downhill with death at the bottom, or the slope ends in a lower level of chronic invalidism; in any case it is seldom that the former standard of health is regained; even if it be, the wisely-advised patient will act as if it were not. Labour of any kind must be at once and absolutely interdicted; breakfast should be taken in bed, and there should be no getting up for at least an hour and a half after breakfast is finished. Before the mid-day dinner there should be an hour's reclining, and two hours' after it; going to bed should be at nine. When up, six gentle strolls of five to twenty minutes each, with good intervals of rest, should be taken; during the periods of rest the patient should be

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