helpless, and bedridden, and the joints become immovable. The pain may be great and persistent, or slight. Usually the pain grows less as the disease advances. Numbness and tingling of the skin often trouble the patient, and the skin is sometimes smooth and glossy or freckled.

The general health suffers, and weakness, anæmia, and dyspepsia are common. Even though most of the joints become useless, there is often sufficient suppleness in the fingers to allow of their use, as in writing or knitting. In old men the disease is seen attacking one joint alone, as the hip, shoulder, knee, and spine. Children are occasionally sufferers, and in young women it may follow frequent confinements or nursing, and often begins in them like a mild attack of rheumatic fever. The heart is not damaged by rheumatic gout.

It is frequently impossible to distinguish rheumatic gout from chronic rheumatism in the beginning. In the latter, creaking and grating sounds on movement of the joints are less marked, the small joints, as of the hand, are not so generally attacked, nor are there as great deformity and loss of motion as is seen in late cases of rheumatic gout.

Outlook. It often happens that after attacking several joints, the disease is completely arrested and the patient becomes free from pain, and only a certain amount of interference with the use of the joint and stiffness remain. Life is not necessarily shortened by

the disease. The deformity and crippling are perma

nent.

Treatment. Rheumatic gout is a chronic disease in most instances, and requires the careful study and continuous care of the medical man. He may frequently be able to arrest it in the earlier stages, and prevent a life of pain and helplessness. In a general way nourishing food, as milk, eggs, cream, and butter, with abundance of fresh vegetables, should be taken to the extent of the digestive powers. Everything that tends to reduce the patient's strength must be avoided. Cod-liver oil and tonics should be used over long periods. Various forms of baths are valuable, as the hotair bath, and hot natural or artificial baths. A dry, warm climate is most appropriate, and flannel clothing should be worn the year round. Moderate exercise and outdoor life, in warm weather, are advisable, and massage, except during the acute attacks of pain. and inflammation, is beneficial. Surgical measures will sometimes aid patients in regaining the usefulness of crippled limbs.

SCURVY.-Scurvy used to be much more common than it is now. In the Civil War there were nearly 50,000 cases in the Union Army. Sailors and soldiers have been the common victims, but now the disease occurs most often among the poorly fed, on shore. It is caused by a diet containing neither fresh vegetables, preserved vegetables, nor vegetable juices. In the absence of vegetables, limes, lemons, oranges,

or vinegar will prevent the disease. It is also thought that poisonous substances in the food may occasion scurvy, as tainted meat has experimentally produced in monkeys a disease resembling it. Certain conditions, as fatigue, cold, damp quarters, mental depression and homesickness, favor the development of the disease. It attacks all ages, but is most severe in the old.

Symptoms. Scurvy begins with general weakness and paleness. The skin is dry, and has a dirty hue. The gums become swollen, tender, spongy, and bleed easily, and later they may ulcerate and the teeth loosen and drop out. The tongue is swollen, and saliva flows freely. The appetite is poor and chewing painful, and the breath has a bad odor. The ankles swell, and bluish spots appear on the legs which may be raised in lumps above the surface. The patient suffers from pain in the legs, which sometimes become swollen and hard. The blue spots are also seen on the arms and body, and are due to bleeding under the skin, and come on the slightest bruising. Occasionally there is bleeding from the nose and bowels. The joints are often swollen, tender, and painful. Constipation is rather the rule, but in bad cases there may be diarrhea, nausea, and vomiting, and the victim becomes a walking skeleton. Mental depression or delirium may be present.

Treatment.-Recovery is usually rapid and complete, unless the disease is far advanced. Soups, fresh

milk, beef juice, and lemon or orange juice may be given at first, when the digestion is weak, and then green vegetables, as spinach (with vinegar), lettuce, cabbage, and potatoes. The soreness of the mouth is relieved by a wash containing one teaspoonful of carbolic acid to the quart of hot water. This should be used to rinse the mouth several times daily, but must not be swallowed. Painting the gums with a two per cent solution of silver nitrate in water, by means of a camel's-hair brush, twice daily, will also prove serviceable. To act as a tonic, a two-grain quinine pill and two Blaud's pills of iron may be given three times daily.

INFANTILE SCURVY.- Scurvy occasionally occurs in infants between twelve and eighteen months of age, and is due to feeding on patent foods, condensed milk, malted milk, and sterilized milk. In case it is essential to use sterilized or pasteurized milk, if the baby receives orange juice, as advised under the care of infants, scurvy will not develop.

Scurvy is frequently mistaken for either rheumatism or paralysis in babies.

Symptoms. The lower limbs become painful, and the baby cries out when it is moved. The legs are at first drawn up and become swollen all around just above the knees, but not the knee joints themselves. Later the whole thigh swells, and the baby lies without moving the legs, with the feet rolled outward and appears to be paralyzed, although it is only pain which

prevents movement of the legs. Sometimes there is swelling about the wrist and forearm, and the breastbone may appear sunken in. Purplish spots occur on the legs and other parts of the body. The gums, if there are teeth present, become soft, tender, spongy, and bleed easily. There may be slight fever, the temperature ranging from 101° to 102° F. The babies are exceedingly pale, and lose all strength.

Treatment. The treatment is very simple, and recovery rapidly takes place as soon as it is carried out. The feeding of all patent baby foods-condensed or sterilized milk-must be instantly stopped. A diet of fresh milk, beef juice, and orange juice, as directed under the care of infants, will bring about a speedy

cure.

GOUT. Notwithstanding the frequency with which one encounters allusions to gout in English literature, it is unquestionably a rare disease in the United States. In the Massachusetts General Hospital there were, among 28,000 patients admitted in the last ten years, but four cases of gout. This is not an altogether fair criterion, as patients with gout are not generally of the class who seek hospitals, nor is the disease one of those which would be most likely to lead one into a hospital. Still, the experience of physicians in private practice substantiates the view of the rarity of gout in this country.

We are still ignorant of the exact changes in the bodily condition which lead to gout, but may say in