with 10 m. of tincture of iron, to be taken three times a day. After taking this for a month all traces of the disease disappeared, and it has not since relapsed.

CASE VII. A. L., aged 6, m. came to St. Mary's Hospital in August, 1878. Has had constant attacks of pemphigus since the age of three. She had several times been ordered arsenic, but had not persevered regularly with it. Ordered 3 m. of Fowler with 3. of Vinum Ferri, twice a day. This she took till the attack subsided, but she constantly returned to the hospital in consequence of fresh outbreaks. In July, 1879, I gave her the arsenic without the iron in 3 m. doses, three times a day. When given alone it seemed to have a more rapid influence on the disease, and since last September she has not had a single relapse.

How arsenic acts in pemphigus is difficult to say. Whether it is through its effects on the blood or by its direct influence on the nervous system, I do not venture to offer a theory. I will now briefly mention one or two other diseases of the skin in which arsenic appears to act with benefit.

Chronic urticaria when unattended by an intestinal irritation is greatly relieved and often cured by a course of arsenic. Though an attack of zoster is not cut short by it, yet the severe pain in the course of the nerve which often lasts a long time after the eruption has disappeared, especially in elderly people, is greatly modified. This is mentioned by Trousseau in his Clinical Medicine.

Acne may be benefited by arsenic, but I have no evidence my self to offer on the subject. Dr. Bulkley says, "Of the value of arsenic in certain forms of acne, or rather in certain cases, I can speak with considerable positiveness."1

Since arsenic has been found to be effectual in such different diseases as psoriasis, pemphigus, and urticaria, I cannot but think with Mr. Hutchinson that they must have some common cause, in spite of the variety of their external manifestations. Whether arsenic acts upon them all equally through the blood, or on the nervous system through the blood, or by some peculiar action on the epidermic cells themselves, cannot be positively determined with our present knowledge.

1 The Use and Value of Arsenic in Diseases of the Skin. New York, 1876, p. 23.

In conclusion, let me remind you that though arsenic is a valuable remedy in some, it is by no means a universal cure in all, skin diseases; but at the same time there need be no necessity for fear of ill results if the drug be given in moderate doses. It must also be borne in mind that some individuals have an intolerance for arsenic, under which circumstances I should advise that the various preparations be tried before the drug is abandoned; that it should never be combined with any other drug, even iron; that it should always be taken during or after food; that it should never be pushed to produce the slightest constitutional symptom; and that it should be continued to prevent relapses for a great length of time after all traces of the disease have disappeared.

I am indebted to Dr. Cheadle of St. Mary's Hospital for his kindness in allowing me to publish the notes of the cases that were treated in his clinique.

CITRATE OF CAFFEIN AS A DIURETIC.

BY D. J. LEECH, M.D., M.R.C.P.,
Physician to the Manchester Infirmary.

(Continued from page 412.)

IN three cases of abdominal dropsy of obscure origin, but probably dependent on chronic peritoneal changes I have had evidence of the diuretic effect of caffein.

Case XVIII. A. D., aged 60, was admitted into the Chorlton Union Workhouse in October, 1879, with a history of abdominal pain, commencing some few months before admission, and followed by dropsy. She was much emaciated; the abdomen contained a considerable quantity of fluid and measured thirtysix inches. No physical evidence of disease of any of the organs could be obtained. When I first saw her, she had been in bed several days, passing but little water, and not decreasing in size. Mr. Orchard, the Resident Medical Officer, very kindly offered to administer citrate of caffein and keep a record of its effect on the woman.

I am indebted to him for the following table:

In this case profuse salivation always followed the administration of the caffein; no fœtor accompanied the flow of saliva, which amounted to from twenty to 50 ounces in the twenty-four hours. The salivation always ceased within twenty-four hours after the caffein was discontinued. The drug produced no headache or sickness. The fluid entirely disappeared from the abdominal cavity and she appeared to be cured. She died some months after, apparently from an acute attack of peritonitis.

Case XIX. E. E. was under my care in the Manchester Infirmary in the latter part of 1879. She suffered from ascites, which followed on prolonged abdominal pain. From the patient's account of herself, it would seem that fluid had been present in the abdominal cavity some eighteen months before admission. Four times during the past nine months she had been tapped, and from twelve to twenty-eight pints of fluid removed, but on each occasion the fluid had returned in a few weeks. The last tapping had been performed three weeks before admission. After trying copaiba and other diuretics, I gave citrate of caffein in three-grain doses every three hours. When she had taken it two days, she felt sickly, and I suspended its use for a week. The urine only increased slightly in amount, but profuse diuresis immediately occurred when I commenced

again to administer the medicine, and the ascites quickly disappeared. Four months later I saw her in good health. Neither nausea nor headache was produced the second time the medicine was administered.

I am unable to append the urine table, which was accurately kept, but has been mislaid.

Case XX. S. H., aged 13, came into hospital on the 6th of October, 1879, with bronchitis, enlarged liver, ascites, and oedema of the legs. Her features were livid, and the veins of the chest, abdomen, and neck were unduly large. The cause of the ascites could not be determined, and though later on indications of effusion into the left pleural cavity and of tumour in the anterior mediastinum, appeared, the exact nature of the primary lesion was by no means clear.

At her death, which occurred suddenly on the 25th of April, 1880, a mass of caseous material on the right side of the anterior mediastinum was found, whilst on the left side, in a corresponding position, were several enlarged glands. The caseous mass had pressed on the superior vena cava, and likewise on the right auricle and the orifice of the inferior vena cava. The liver presented the ordinary appearance of chronic passive congestion. After the fluid had been removed from the abdominal cavity, the peritoneum was found thick and sodden, and in one or two places scattered tubercles were seen.

Copaiba, juniper, caffein, and digitalis were tried in turn. The first seemed to increase the quantity of urine slightly, but it caused sickness; the other three drugs appeared to have no effect. The caffein was given in one and then in two-grain doses every three hours. The accuracy of the urine record was vitiated by the carelessness of one of the nurses, whose duty it was to see that the urine was duly collected, and on this account the urine table during the greater part of the patient's residence in the hospital is not given. She was twice tapped, the last time on the 27th of March; and subsequently caffein was again given in three-grain doses. From the Sth of April the urine was correctly collected and measured, and the following table seems to show that the caffein influenced the urinary excretion: