Outlines of medical treatment : intended as a companion to The student's guide to medical diagnosis

Front matter

I i

i

MEDICAL TKEATMBNT.

Preface

When recently occupying the Chair of Medicine at the London Hospital Medical College it was my custom to devote the last few lectures of each session to a short outline of the treatment of the various diseases which had been described during the course. I found that by so doing I was the better enabled to aid the thoughtful student in preparing for his examinations, and also that the plan served to call to the minds of the class what had been taught them in the wards of the hospital and. in the out-patient clinique. On relinquishing the chair it was suggested to me that the pubHcation of these lectures might perhaps prove useful, and acting on this I have put together the notes from which they were delivered, whUst retaining, as far as possible, the arrangement and conversational style of the original lectures.

Such general rules as are applicable to the treatment of disease in all its forms, and which must, therefore, be ever borne in mind, are briefly laid down viii

PREFACE.

in the first chapter, and reference to them is afterwards rendered easy by a lettered arrangement throughout the book.

Believing that similar pathological conditions, although in diverse organs, present similar indications for treatment, T have in the second chapter shortly delineated such indications as present themselves in the acute forms of disease ; whilst in the third chapter are described those arising from pathological changes of a chronic nature, and in the chapters that deal with separate diseases the remarks as to their treatment are preceded by a reference to the pages in which these indications are to be found.

On many occasions I have been forcibly reminded of one great advantage of the old apprenticeship system, which has somewhat suffered by the change in medical education of recent years. Formerly, when most students had served an apprenticeship before entering upon their hospital career, each one was practically acquainted with the actions and doses of the drugs in common use, even when ignorant of all beside. Now we meet with many who can well describe the course and symptoms of a disease, but who are entirely unacquainted with the remedies employed in its treatment. I need scarcely remark how needful it is that every senior student should not only know his remedies by heart, but

PREFACE.

ix that he ought to be so perfectly familiar with their closes and ordinary combinations that he may be able to write his prescriptions with ease and confidence ; and so, with a view of assisting him in this, I have added a number of formulae, which I would advise him to practise himself in copying. They are simple in character, and are selected from Mr. Squire's valuable collection of the pharmacopceias of the metropolitan hospitals, from the works of Dr. Tanner, Mr. Beasley, and other authors. The arrangement of remedies is that proposed by Dr. Wood.

Notwithstanding that, in all our larger hospitals, the most improved methods for the administration of remedies are in constant use, I have thought that a few hints on this subject might not prove unacceptable to those senior students who have the management of dispensaries and cottage hospitals, and therefore for this purpose a few drawings are inserted.

In conclusion, I must remind my readers that this volume is not intended as a substitute for the more elaborate treatises on medicine. It is only an outline, which must be filled in with the student's own observation and experience. If, however, it should tend to make him more careful and painstaking in the treatment of his cases; if it should make his views more clear as to what he can and what he

X

PREFACE.

cannot effect by medicine; if it teach him when actively to interfere, and when to be content with the mere relief of symptoms ; the purpose of its publication will have been fully answered.

29, IIakiey Steeet,

Cavendish Square ;

September 5, 1879.

Contents

CHAPTER I. PAGE Erroneous views respecting therapeutics. First general rule is to remove the cause of a disease. Second general rule is to watch the condition of the heart in all acute diseases. The state of the circulation varies in the same disease at different times. Third general rule is to watch the state of the nervous system in all acute diseases. Fourth rule is to give rest in all acute diseases. Fifth rule is that in all acute febrile diseases the diet should consist of liquid food. Sixth rule is that in all chronic . maladies attention must be directed to the organs engaged in nutrition. Medicines require time to enable them to act ..... 1 — 13

Chapter II

The same pathological change requires similar treatment whenever it may occur. Indications for the treatment of acute inflammation. Indications for the treatment of hemorrhage. Indications for treatment during an attack of spasm or neuralgia .... 14 — 29

Chapter III

Indications for the treatment of chronic inflammation. Indications for the treatment of dropsy. Indications for the treatment of dilated organs. Indications ior the prevention of spasm and neuralgia . . 30 — 39

Chapter IV

Stimulants of the heart. Uses of alcohol. Depressors of tlie heart. Palpitation. Treatment during an attack. Prevention of palpitation. Fainting. Gradual failure xn

CONTENTS.

PAGE

of the heart's power. Pain in the cardiac region. Angina pectoris. Acute pericarditis. Endocarditis. Emholi. Hypertropliy of the heart. Dilatation of the heart. Causes of dyspnaja in heart disease. Cardiac dropsy. Diseased valves of the heart. Aneurism of the aorta 40 65

Chapter V

Forms of inhalers. Nebulisers. Laryngeal brush. Laryngeal galvaniser. Laryngismus stridulus. Paralysis of the vocal cords. Acute laryngitis. Acute csdema of the glottis. Croup. Chronic laryngitis . . 66—80

CHAPTER VI. •Use of condensed air. Waldenburg's apparatus. E.xpectorauts. Cyanosis. Dyspncea. Cough. Pains of the chest. Asthma. Pleurisy. Rules for aspiration of the chest. Pneumothora.x. Acute brouchitis. Acute lobar pneumonia. Rules for venesection. Catarrhal pneumonia. Hydrothorax. Emphysema of the lungs. Phthisis. Hemoptysis. Profuse perspirations 81—119

Chapter VII

Different appearances of the tongue. Thrush. Oral catarrh. Aphthffi. Ulcerative stomatitis. Gangrenous stomatitis. Salivation. Catarrh of the pharynx. Chronic pharyngitis. Tonsillitis. Retro-pharyngeal abscess. Inflammation of the ajsophagus. Stricture of the oesophagus. Spasmodic stricture . . 120—132

CHAPTER VIIL Digestibility of different kinds of food. Stimulants to digestion. Sedatives. Acidity. Flatulence. Waterbrash. Vomiting. IIa;matenicsis. Hiccough. Gastric neuralgia. Acute gastric catarrh. Ulcer of the stomach. Dy.s])epsia. Chronic gastric catarrh. Atonic dyspepsia. Cancer of the stomach. Dilatation of the stomach ...... 133 157

CONTENTS. XUl.

Warm and vapour baths. Diuretics. Anuria. Ursemia. Dropsy. Ansemia. Acute nephritis. Pyelonephritis. Pyelitis. Chronic Brigbt's disease. Chronic pyelitis and pyonephrosis. Hydronephrosis. Cancer of the kidneys. Hsematuria. Renal calculi . . 219 — 24-B-

Chapter XIII

Treatment of cerebral excitement. Stimulants. Excito-motors. Sedatives. Nervine tonics. Narcotics. Delirium. Delirium tremens. Convulsions. Neuralgia. Headache. Facial neuralgia. Paralysis. Congestion of the brain. Simple meningitis. Tubercular meningitis. Apoplexy. Abscess of the brain. Cerebral aneemia. Softening of the brain. Sclerosis of the brain. Cerebral tumours. Chorea. Epilepsy. Hydrophobia. Tetanus . . . 244—284 xiv

CONTENTS,

Chapter XIV. Pagr

Congestion and liemorrliage of the spinal corfl. Spinal meningitis. Acute myelitis. Locomotor ataxia. Infantile paralysis. Muscular atrophy. Paralysis agitans. Writers' cramp. Metallic tremors 285 — 292

Chapter XV

Means of reducing abnormal heat. Use of cold baths. Infectious fevers. Measles. German measles. Scarlatina. Smallpox. Chicken-pox. Typhoid fever. Typhus. Relapsing fever. Erysipelas. Diphtlieria. Pyaimia. Acute tuberculosis. Parotitis. Influenza. Hooping-cough. Cerebro-spinal fever. Dysentery. Asiatic cholera. Acute rheumatism. Gonorihoeal rheumatism 292 — 332

Chapter XVI

Malarial fever. Syphilis. Use of Mercury. Gout. Scurvy.

Anaimia 333—348

Chapter XVII

Rheumatoid arthritis. Rickets. Purpura. Diabetes

mellitus 349—355

PORMULiE.

Astringents Tonics

Cardiac stimulants — sedatives Antisjjasmodics Analgesics Mydriatics Excito-motors .

Depresso-motors Alteratives Cathartics

. 358

. 359

. 360

. 360

. 361

. 362

. 362

. 363

. 363

CONTENTS.

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PAGE

Diuretics 366

Diaphoretics • ■ 367

Expectorants • 368

Atomised fluids for inhalation 369

Applications to laryux ....... 369

Gargles 370

Antacids 371

Anthelmintics . 372

Antiseptics 372

CHAPTEE I.

On the Treatment op Disease generally.

The treatment of a disease is mucli more difScult than its diagnosis. In diagnosis you have, for the most part, only to discover what is the state of the organ affected, and by attention to the symptoms and physical signs you may generally arrive at a correct conclusion. But you have to take into consideration the age, sex, condition, and previous state of the health of the patient, and whether other maladies coexist, before you can determine on your lino of treatment. Again, diseases vary greatly in severity at different times, and, even in the same disease, what may be useful at one period may be positively injurious at another. You will, therefore, understand that close and accurate observation is essential to the formation of a good practitioner, and that no amount of reading, however valuable this may be, can compensate for a want of clinical experience.

Most students commence their career with very cn-oucous ideas respecting the aim of therapeutics. They imagine that there are particular drugs that have power over certain diseases, and that it is only necessary to discover the complaint, and then a medicine proper for it may be readily found. They look, in fact, upon drugs as antidotes to the diseases for wliich they are administered. It is quite true that there are some that prove, in most cases, bcnc-

TREATMENT OF DISEASE GENEEALLY.

ficial in particular diseased conditions of the system, sucli as mercury in syphilis and cmiuine in ague. But that these medicines are not antidotes for such complaints is proved by the fact that syphilitic iritis may commence whilst a patient is under salivation, and ague may attack a person exhibiting the symptoms ^of cinchonism.

Another very general mistake is that the treatment of a complaint consists solely in the administration of drugs. The student looks upon a physician as ignorant or neglectful who does not introduce into his patient's system various vegetable or mineral substances whenever he is called upon to prescribe for him. But, in reality, drugs are only a part of the treatment of disease, and are often inferior in value to rest, position, diet, and such like measures. Nay, sometimes they positively do mischief. Take, for example, a case of acute gastric catarrh. In many cases every drug that is prescribed acts only as an irritant to the inflamed stomach, and the vomiting does not sul )side until both drugs and food have been abandoned, and the organ has been left in a state of perfect rest.

The ideas of students are often very vague upon another point: they imagine that when a disease has ended in recovery it is in consequence of some remedy that has restored the injured part to its normal condition The fact is that all cures are the result, not of the drugs administered, but of the rej.arative power that is inherent in every animal Iwdy. Why an iniured part should be restored to its former condition we are no more able to explain than we can understand the mysterious processes of growth, secretion, or re- Di-oduction. But we know there is a power in every stmcture that tends to maintain its normal state, and to restore it, when injured, to such a condition as will best enable it again to discharge its

functions. , .,, , „n ,^

There are some general rules you will do well to

TREATMENT OF DISEASE GENERALLY.

bear in mind in the treatment of all diseases. The most important of these is — A. Always maJce it your first object to ascertain and, if possible, to remove the cause of a disease.

This rule will prove invaluable to you in practice, and by it you will be often enabled to obviate or cure diseases rebellious to all medicines. For example, a gentleman had suffered for some years from severe attacks of asthmatic bronchitis, for which he had been treated without success by various practitioners. It was, however, observed that the attacks generally occurred once a fortnight, and very often on a particular day of the week. Further inquiry elicited the fact that on the previous day he generally attended a cloth market, the atmosphere of which was loaded with dust. As particles of wool are very irritating to a sensitive bronchial membrane, he was recommended to give up this part of his business, and as soon as this advice was followed the attacks disappeared. The irritating effects, not only of dust, but even of animal exhalations, are often seen in medical practice. Some asthmatics suffer if they come near dogs, horses, or monkeys, and, by bearing this in mind, you may often obviate attacks over_ which drugs seem to have but slight control. Again, nothing is more common than to meet with a •catan-h of the stomach, which the most careful treatment is unable to relieve, because it is kept up by a habit of secret drinking. Here, nothing but inducing your patient to abstain entirely from all kinds of alcoholic stimulants will have the slightest effect; but if you can prevail upon him to do so there will be no necessity for medicines. These are but examples of what you will meet with daily, and your success will greatly depend on the acuteness with which you detect the causes of a malady, and the tact you employ in removing them.

But where you fail to discover a cause for a disease m the habits or occupation of your patient, you may

TREATMENT OF DISEASE GENERALLY.

often, especially in. chronic cases, hit upon some constitutional ailment that has given rise to the local disorder. Thus, you may obtain a history of syphilis in an obscure disease of the brain, or of gout in a case of chronic dyspepsia. By the exhibition of iodide of potash or of colchicum you may then rapidly relieve symi)toms which other medicines have failed to remove. Or you may be able to trace a disease to an affection of some distant organ. For example, convulsions in children often arise from teething or from intestinal worms, and the use of the gum lancet or the administration of an anthelmintic may at once relieve the nervous irritation.

Experience will soon prove to you that a circumstance that in a healthy condition would exert no injurious influence may act most seriously upon an orfj-an when it is diseased. For instance, food that would ordinarily produce no ill effects may excite incessant vomiting if taken into an inflamed stomach, and an amount of light or sound that would be grateful to a healthy person will often act most iniuriously upon one suffering from delirium.

You see, then, that it .is the first and most important duty of a physician to detect and remove any circumstance that has produced or may be keeping up a disease. In no particular do practitioners more completely differ than in the constancy with which they keep this principle before them. Attention to it often compensates for a lack of scientific knowledge, whilst its neglect will render the most accurate' acquaintance with pathological and therapeutical science comparatively useless.

Most acute diseases are the results of some morbific material imported from without, or formed within the animal body. For example, scarlatina is produced bva iJoison communicated from one person to another, whilst gout is the consequence of an accumulation ot urate of soda generated within the system.

In the majority of acute disorders there is a ten-

TEEATMEilT OP DISEASE GENERALLY.

deucy to recovery after a certain time lias elapsed, in case there is no failure in the function of any of the organs that are essential to life. Now, the heart is especially necessary for the contintiauce of existence, and on this fact is founded the second general rule which is applicable to the treatment of all acide diseases, viz.: — B. In allaciite disorders vKitcli carefully the condition of the heart and circulating system.

You must have remai'ked how a careful physician examines the pvilse, and often the heart, ia every acute disease, at each visit. This is to enable him to ascertain the state of the circulating system, for he knows that any undue excitement or any failure of the heart's power will give rise to serious consequences. In the early stages its force is often greatly increased, and if there be a coexisting contraction of the smaller arteries and capillaries, the tension of the arterial circulation will be augmented, and an embarrassed state of any organ that is especially liable to disease may result. In this case he directs his efforts to moderate the undue excitement. But in the later stages, and sometimes also in the early periods of an acute disorder, he has generally to combat a failure in the power of the heart. This may arise in difierent ways. The heart, like the other muscles of the body, is often enfeebled from the first by the cause producing the disease, or it may be the result of the increased rapidi ty of its action. In each revolution of the organ a certain time is allotted to repose, during which its power is recruited ; but when its frequency is augmented, the period of rest is, of course, diminished, and, as in the case of all other muscles, the effects of over- work are shown by exhaustion. But from whatever cause the failure may arise, there is no doubt it is your first duty to watch the state of the heart from day to day in every acute disorder, and to employ appropriate treatment at the earliest indication of feebleness.

In the present day some practitioners would

TREATMENT OF DISEASE GENERALLY.

object to the statement, that you may ever be called' upon to moderate the action of the heart by the employment of energetic treatment. Such persons, I believe, take a limited view of disease, and do not make sufficient allowance for the variations arising from different conditions. Let me show you how the necessity for changing the ordinary practice indifferent circumstances Avas impressed upon my own mind.

After a lengthened hospital experience as a student, I had arrived at the conclusion that bloodletting and all other depressing measures, were always injurious in pneumonia, and that we should either allow the disease to run its course, or should support the strength by stimulants. With such impressions I entered upon practice in an agricultural district, and one of the first important cases that came under my care was one of pneumonia. I coidd not fail to remark that the breathing was more oppressed, the pulse harder, and the general disti-ess greater than I had been accustomed to see. I, however, abstained from all active treatment, and hoped the patient would go on favourably. Day by day the sym^jtoms increased in severity, and in the second week she succumbed to the disorder. Mortified at my want of success, I called upon a medical friend and asked him how he was in the habit of treating pneumonia. " Oh !" replied he, " in the ordinary way, free bleeding, tartar emetic, &c." To all my offers to prove to him that bleeding could never cure any inflammation, he only replied that the practice was successful. Shortly afterwards another case presented itself. Here, again, the symptoms were so urgent I felt that active treatment of some sort was rerpiircd, but prejudice stood in the way, and the patient was only ordered a saline aperient. At the next visit he was much worse, and in desperation I opened a vein, intending to abstract only a small quantity of blood. It spurted out, however, so freely lhat a considerable quantity was lost before its flow could be arrested. The patient was at once relieved, and recovered witliout a bad symptom.

During tlie wliole of my residence in tliat part of the country I invariably used bleeding in the first stage of pneumonia, and always with relief to the patient. I returned to a manufacturing district, and one of the first cases I was called upon to treat was one of pneumonia. Finding he had not been bled, I used the lancet, but the blood merely trickled from the vein, and he became so faint that it was necessary to stop it. The man sank rapidly, and from that day I have never had occasion to use the lancet in this disorder. Now, you will remark that the same disease recjuii'ed different treatment, because the condition of the vascular system was different. In the countryman, the reaction of the heart set up by the inflammation was intense, the blood was driven with great force through the limited area of the pulmonary capillaries, and, in consec|uence of the obstruction thiis 23roduced, the right side of the heart and the venous system became overloaded. Venesection at once relieved a condition that might otherwise have jjroved fatal, and gave time for the inflammation to subside and for the powers of nature to repair the mischief. In the latter case the action of the heart was depressed by the inflammation, and stimulants, not venesection, were required to enable it to maintain the circulation until nature could restore the lung to its healthy state. The art of the physician, therefore, consists in watching the condition of the organs essential to life during acute disease. He ought not to treat the pneumonia, but the patient who is suffering from pneumonia, and who presents certain abnormal conditions of his system that may call for his interference.

The third rule you will find useful to remember is — C. In all acute diseases watch carefully the state of the nervous system.

The nervous and vascular systems are so closely con-

TREATMENT OF BISEASE GENERALITY.

uected that an undue excitement or failure in the one is usually associated with a coiTespondiug condition of the other. Thus, a loss in the res^ulating power of the nervous centres over the production of the heat of the body generally coincides with an increased rapidity of the pulse. But this is not always the case, for death may be ushered in with symptoms indicating paralysis of the brain rather than that of the heart. In every acute disease, therefore, you Avatch the state of the nervous system, and are ready either to soothe or stimulate it, as the circumstances of the case seem to require.

The next rule is as important as those just stated. D. In all acute diseases insist iijyon perfect rest.

The greater portion of the body consists of muscular structure, and excepting in the recumbent position, some part of this is in more or less constant action. At each contraction of a muscular filjre the arteries supplied to it dilate; thus, an _ augmented quantity of l)lood is directed through it, and, as a necessary consequence, where the muscular action is to any great extent, the heart is forced to contract more quickly and forcibly to keep up the circulation. Again, we see the effects of muscular action upon the nervous system in a state of health in the production of fatigue, and we may, therefore, be certain that all muscular effort is also associated with expenditure of nervous force. The effect, therefore, of bodily exertion is to excite the vascular and nervous systems, and these we have already seen are more especially apt to suffer injury in all acute maladies. Wlienever a muscular fibre contracts sai'colactic and carbonic acids are produced, and in all prolDaldlity an increase of heat is the result. It is most likely from this cause that the temperature of a ]>atient suffering from fever is often higher on the day of his admission into the hospital than at any subsequent period, and it is probably from the expenditure of nervous force during exertion that many persons sink from exlia,ustion

TREATMENT OP DISEASE GENERALLY.

who have made forced journeys to reach, home whilst suffering from acute disorders. You cannot, therefore, too strongly insist upon your patient remaining in bed, not only as long as the temperature is above the normal point, but also until all the symptoms of acute disease have disappeared.

In most acute disorders, and especially in those attended with fever, there is a diminution in the functional powers of the digestive organs. After death we usually discover a catarrhal condition of the mucous membrane of the stomach and intestines, whilst loss of appetite and thirst are prominent symptoms during life. This repugnance to solid food and the great desire for liquids are probably intended by nature as means to limit the duration of aciitc maladies ; the failure of the digesti^)n checking the introduction of new material into the disordered system, whilst the increased supply of water assists in the chemical changes that take place in the affected structures. You will best then fulfil the conditions as regards nutrition by attending to the following rule : — E. In all acute diseases attended hy fever the diet of the 'patient should consist only of liquid food.

In chronic disorders a much more complex problem is presented to the practitioner than in those that are acute. He has no occasion to watch the heart or the nervous system, uirless these organs be specially affected, but has to determine what are the circumstances that prevent the rejoarative power from restoring to health the injured structures. It is especially in chronic complaints that a knowledge of the causes of disease is of so much value, and the physician is called upon to use all his tact to trace the morbid conditions to their sources. As a general rule, where no removable cause can be discovered, the powers of repai-ation are obstructed, either by some abnormal condition of cell-growth, such as cancer or tubercle, or by some imperfection in the quantity or quality of the Lloocl suppli(!d to the tissues. It is only in the latter case that our remedies are likely to be of much avail, and therefore the next general rule may be laid dowii as follows : —

F. In all chronic diseases you must direct your attention to the organs engaged in nutrition.

One of the first and most important points to be attended to is the regulation of the diet. In the selection of food you must bear in mind that it is necessary to choose, not only what is nutritious and likely to agree with the digestive canal, but what is appropriate for the complaint you have to treat. Thus, a liberal supply of animal food is essential for the improvement of an angemic condition, whilst you must duninish the amount in cases of feeble digestion. Where there is a tendency to the formation of sugar it is of the iirst importance to exclude all materials of a starchy or saccharine character. Again, I need scarcely remind you that oxygen is as necessary to nutrition as food, and you will constantly find change of air and exercise restore a patient to health when drugs have failed to relieve.

In prescribing drugs for chronic disorders there is no more common mistake than to suppose that the use of tonics is all that is necessary. In the greater number of cases some imperfection exists in the functions of the excretory organs, and, at some period or another, you will find it necessary to pay attention to the kidneys, liowcls, skin, or liver. Indeed it is always wise to ascertain first how these are acting before you commence with strengthening remedies.

You will observe that I have only said you are to watch the condition of the vascular and nervous systems in acaite disorders. You must not suppose that it is necessary tliat you should interfere in every case. If, for example, you are attending a person with measles or pneumonia, and the derangement of the heart, and nervous centres is not greater than

TREATMENT OP DISEASE GENERALLY.

you might reasonably expect, you would allow the disease to subside without any meddling on your part. But if the heart should begin to fail, or the heat of skin become excessive, you must at once adopt such measures as may stimulate the vascular system or lessen the ill effects of the high temperature on the blood and tissues. In order, therefore, to know when to interfere, you must be acquainted with the course of each disease, with the symptoms that necessarily arise from it, and in what order and for what period they usually present themselves. No amount of reading will teach you the natural history of disease ; you can only acquire it by careful and accurate observation.

In every disorder certain secondary diseases or complications are ajDt to arise. Tor examj^le, you meet with pneumonia in measles, sore throat and acute inflammation of the kidneys in scarlatina. These complications often require careful attention,, when it is not necessary to interfere with the original malady. But it is not uncommon for two or three complications to occur at once in the same patient. Thus, a person affected with kidney disease may have dropsy and erysipelas of the legs," and at the same time may be attacked with pleu]isy or pericarditis. Under such circumstances the best rule is to direct your treatment against the affection that seems to be the most dangerous to life and which you are most likely to overcome.

In the use of drugs there are a few points that are especially worthy of notice. Thus, they are always most certain in their action when applied directly to the affected structure. When they have to traverse the circulation in order to reach an inflammation of the skm or mucous membrane they are much less hkely to prove efficient than when brought into immediate contact with the nerves and vessels of a diseased part.

Never forget that most medicines require time ta

TREATMENT OF DISEASE GENERALLY.

enable them to act upon tlie system. Even our most potent, drugs, such as digitalis and mercury, must be given in repeated doses beCore they can influence the nutrition of a diseased structure. There is no more certain sign of a bad practitioner than the constant changing of his remedies. It shows eitlier that he is douljtful of Km diagnosis, or that he is uncertain as to the best mca,ns of subduing the disease he has to treat. An anecdote that used to be related by an old teacher of my own has often been of service to me when I have felt impatient from not attaining ra2:)id results. Dr. S. Avas requested to see a patient along with a young practitioner. When they retired to consult upon the case the physician thiis addressed his junior colleague: — "As we seem quite agreed upon the diagnosis, you had better give him some digitalis." " I i^rescribed it," said the other, " but it did not at all agree with him." " Then have recourse to mercui-y in combination with it," remarked Dr. S. " I did so," was the reply, " and it made him so ill I was forced to give it up." " Give him some acetate of potash," was the next suggestion, but this had also been ineffectually tried. _ Much amvised, the senior recommended various diuretics, but all had been employed in vain. At last Dr. S. addressed the practitioner in these words: — " Tour patient has, I find, been under your care for ten days, and in that time you have employed at least ten powerful drugs, no one of which has succeeded. Now, I only know of one remedy likely to be successful in such a critical case." " I am sure I shall be most grateful to you for any suggestion," replied his colleague, "after so much disajjpointment." "Well, then, sir," rejoined the physician, " try some patience, for I fear that the want of this has been tlie only cause of your failures." " AvA that remedy, gentlemen," Dr. S. used to say, " cured the patient."