render great service in patients attacked with choleraic symptoms. In cases of continued fever, with a typhoidal state and high temperature, cold baths are sometimes

For the comatose symptoms,

when the individual is strong and plethoric and when signs of a severe encephalic congestion are noticed, leeches may be applied to the mastoid processes in order to prevent the consecutive congestion.

Cold applications to the head, counterirritants to the extremities, and drastic purgatives are also useful. Bleeding is universally condemned. Chloral hydrate, in doses of two to four grams, in mucilage, is useful in combating delirium in delirious, pernicious attacks and in alcoholic patients.

When vomiting is present, effervescing drinks, champagne and ice may be given. A hypodermic of one-eighth grain of muriate of morphin often soothes the persistent vomiting that is sometimes so annoying a feature. Opium should be prescribed internally for diarrhea if it is excessive. In bilious fever ipecac and calomel are very useful, but yet the first and most prominent thing is quinin.

Do not give purgatives and laxatives first in any type of the disease.

Arsenious acid has been vaunted by some authorities as a cure for malaria.

It has very little effect, if any, upon the parasite, but is a tonic, and as such is of service in the treatment of the malarial cachexia, particularly in children.

The sulfate of cinchonia is cheaper than the sulfate of quinin, but is weaker in the alkaloidal qualities, and therefore must be taken in larger doses to produce the same therapeutic effect. It has, however, greater toxic effect in doses of the same quantity, and therefore it is dangerous to exceed two grams for the daily allowance. In order to produce the same therapeutic effect as the sulfate of quinin, it must be given in double the quantities, and thus, considering its greater toxic power, it is safe to rule that it must not be prescribed.

Analgesin or antipyrin, and the allied group of coal-tar derivatives have had their advocates, but they do not cure palustral fever. They only lessen the intensity of the cephalalgia and fever. Hence they are of use in the treatment of continued palustral fever. This is only palliative treatment, and while prescrib ing this class of remedies, quinin should not be neglected. Quinin is the only real remedy, especially if the fevers are those

of hot countries, and if pernicious complications are dreaded.

Eucalyptus has found favor with some, taken as the alcoholate or the wine of eucalyptus. The febrifuge properties of these preparations have been doubted, and at any rate they are by no means comparable to those of quinin.

Sequelae.

Among the sequelae to be looked for after an outbreak of the malarial infection are the characteristic anemia, the occurrence of relapses, and the establishment of the chronic malarial cachexia with edema and transudation. Nephritis and amyloid degeneration of the kidneys often follow severe attacks. Atrophy of the gastrointestinal tract has been observed, and malarial hepatitis. Occasionally paralysis, generally local, may occur. This is supposed to be due to pressure on some part of the brain caused by obstruction in the smaller vessels by an accumulation of the parasites.

Persons who have passed thru a severe attack of malarial infection generally show an unusual susceptibility to the effects of high temperature, and are often

the earliest victims to the various forms of heat prostration.

of severe auto-intoxication, this following Occasionally there are all the symptoms upon a localization of the parasite in the intestinal mucous membrane.

Sometimes during the course of an attack the patient may show peculiar symptoms due to an idiosyncrasy against quinin. The unthinking practitioner may lay these symptoms to the charge of the infection, and endeavor to overcome them by increasing the dose of quinin. As the drug in excessive doses acts as a poison to the heart, great danger may result, as well as increase of symptoms, and too much caution and study cannot be used, even in what are apparently the most simple and uncomplicated cases.

Dieting.

Thruout the course of an attack, the diet should as a rule be soft-broths, soups, raw and soft-boiled eggs. In the pernicious types but little quantity should

be given at any time, and that in concentrated form and at frequent intervals.

In case of aggravated thirst, and where the milk diet has not been adopted, the use of lemonade, very little sweetened, has often been found beneficial. This is particularly the case where there is some edema, together with the presence of albumin in the urine.

If the appetite is unimpaired and the digestion good, the patient may generally be allowed his choice of food, and given a rich, generous diet.

Hives.

One of the most annoying of the ailments to which humanity is subject is urticaria or the "hives." Rapid in their onset, causing the most acute discomfort and suffering, and usually attended with general disturbance of the entire system, the person who has once suffered an attack will dread a recurrence as the proverbial burnt child dreads the fire.

Urticaria is usually of short duration, often ceasing spontaneously in a few hours or, at least, in the course of a day or so, altho there are persistent forms due to chronic disease, either gastric, hepatic, renal or uterine. When the acute form is present, it is generally due to disturbance of the digestive tract.

After one case of urticaria has been seen

there will never be any difficulty in the diagnosis. The patient is usually found in a state of high nervous tension, often in tears, unable to sit still from the intense itching, and imploring any means of relief. According to the violence of the attack, the body will be more or less covered with raised wheals or blebs, white on the summits and reddened at the bases for quite a large area. The lesions are almost always uniform in their character, and closely resemble the rash caused by the common nettle, urtica urens, whence the name of the disorder, urticaria. These wheals may remain comparatively small, or may become three or four inches in diameter, the so-called "giant hives." Occasionally they have been seen to become confluent over almost the entire surface of the body, and in those cases the

patient may be driven almost to the verge of acute dementia.

The eruption is always accompanied by generally by fever, the temperature someintense itching, stinging and burning, and times reaching 105°. If the eruption comes out on the palms of the hands and soles of the feet, the condition of nervous irritation is generally aggravated beyond endurance.

The mucous membranes are also subject to the eruption, and in the severe cases the wheals may make their appearance in the mouth and pharynx, sometimes with edema, causing swelling to the extent of requiring surgical interference to prevent suffocation.

No age or sex is exempt from the attacks, tho they are more frequent in children than in adults.

Etiology of Urticaria.

A certain predisposition is always necessary to an attack of urticaria, but the exciting cause may vary. Sometimes a dose of quinin may precipitate an attack, morphin occasionally has the same effect, and copaiba also. Atmospheric changes are often responsible, many attacks coming on during or after a heated term.

Perhaps the most common cause is some form of indigestion, or the eating of certain kinds of food. Among articles to be avoided by persons having the predisposition to urticaria are clams, lobsters, sausage, salt pork, strawberries, peaches, nuts, wine and game of all kinds. Sometimes beginning decomposition of the food may

be the cause from the formation of toxins in the intestinal tract, but often in an acute attack the food remains unchanged in the stomach, there being apparently a complete arrest of the digestive process.

Yet perhaps hives are as often as not the symptom of some disorder of the internal organs. They may indicate dyspepsia, worms, constipation, the bursting of hydatid cysts in the abdominal cavity, diseases of the kidneys and of the sexual organs, even menstruation or pregnancy, spinal and cerebral affections of various kinds and malaria. People of the rheumatic or gouty diathesis are most liable to attacks.

Sometimes it is impossible to find any direct cause, and then there can be no

alternative save to assign as a reason a peculiar irritability of the nerve center or of the cutaneous nerves. In such cases mental and psychic conditions play an important part, an attack following upon any emotional disturbance as grief or anger.

Treatment of Hives.

The first step, wherever practicable, must be to discover and remove if possible the exciting cause. To this end, if it is thought that the alimentary tract is involved, it is well to administer an emetic and a saline purge, preferably Epsom salts or citrate of magnesia.

If the irritation is intense, order the patient at once into a full bath, at about the temperature of 90°, to which at least a pound of bicarbonate of soda has been added. Keep this standing, and whenever the irritation gains, immerse the patient again, heating portions of the bath so as to keep the whole at about the temperature directed. The immersion should last

about ten minutes at a time.

After the administration of the purge, inaugurate constitutional treatment, giving sodium salicylate in doses for an adult of 15 grains every three hours. Arsenic also has been of great efficacy. Jaborandi has had good effect.

For the immediate attack, and for the relief of the nervous symptoms it is often necessary to prescribe the bromids, morphia, chloral, gelsemium, atropia sulfate, etc. Any and all of these are good, tho each particular one is likely to fail in some particular case.

Change of scene and climate is generally necessary in the more severe cases, and wherever there is such exciting cause as malaria, or uric acid diathesis, treatment must be directed to these. All causes of worry must be removed, and the mind of the patient kept calm. Tonic treatment is always indicated, as the attacks seldom come unless there is a generally "run down" state, either of the nerves or of the physical system, and this despite the old saying that "hives are healthy."

Freckles and Sunburn.

The summer season will bring to the doctor the usual crop of complexional ills to be treated, and it is a curious fact that frequently the skill of a physician is meas

ured more by his power to cope with such comparatively unimportant matters than by his ability to treat typhoid or smallnear-by city states that to the best of his pox. A physician of some renown in a belief his entire practice, a large general one, is due to the eclat and introduction gained thru his treatment for a society leader of a case of summer freckles.

Neither freckles nor sunburn require any definition nor description, being too well known and common in their occurrence. The only point of interest is the matter of treatment. No discomfort other than mental attaches to freckles, but sunburn often is somewhat painful to a person of a thin and sensitive skin in the stage when it is still red before it has subsided into "tan."

winter

Summer freckles can be readily removed, but the variety known as but the variety known as "cold freckles," occurring on unexposed portions of the body, and persisting thru the months, are usually obstinate to treatment. Sunburn will yield to practically the same lotions or dusting powders to allay the measures as freckles, after the use of cooling primary irritation. For this purpose a borated talcum powder or lotion of lemon juice is the best.

To remove the discoloration of the tan or the freckles, the greatest success has attended the use of the following treat

ment:

Ft. sol. Sig.-Apply with a soft rag three times daily and at night on retiring. After the spots have disappeared, enjoin washing the face in a little 70 per cent. alcohol at night on retiring.

A weak solution of salicylic acid, about 15 per cent., or a saturated solution of the

drug in alcohol, used in the same general way as the treatment above is also of great avail. Both of these will produce some scaling of the epidermis, but the unsightly effect of this during treatment can be in some degree removed by the use of cold cream, rubbed gently on the spots where the scaling is most noticeable.

Tincture of benzoin put daily in the water in which the face is bathed is also useful in preventing a return of the discoloration.

ORIGINAL COMMUNICATIONS

Short stories on the treatment of diseases and experience with new remedies are solicited from the profession for this department; also difficult cases for diagnosis and treat

ment.

Articles accepted must be contributed to this journal only. The editors are not responsible for views expressed by contributors.

Copy must be received on or before the twelfth of the month for publication in the next month. Unused manuscript cannot be returned.

Certainly it is excellent discipline for an author to feel that he must say all he has to say in the fewest possible words, or his reader is sure to skip them; and in the plainest possible words, or his reader will certainly misunderstand them. Generally, also, a downright fact may be told in a plain way; and we want downright facts at present more than anything else.-RUSKIN. COMPARE.

READ.

REFLECT.

RECORD,

Some of My Failures. Editor MEDICAL WORLD:-We doctors like to put on record our successful experiences, but rarely mention our failures; and yet we all have them. Don't we? I hope so; for I like to be in good company, and assuredly I have mine.

Every man has his limitations, and most of us fall into the grooves that nature designed for us. Only exceptionally do we find the possible master in art hoeing corn, or the mechanical genius occupying the bookkeeper's stool. In devoting myself to consultative, operative and literary work, I do so not more because such things are congenial to me than because I am not as well fitted for other departments of medical practice. A certain slowness of thought has characterized me from boyhood; a certain absent-mindedness, or negligence as to detail, does so now. my operative work I must go over my list with an assistant, or some essential will be forgotten. How many times I have been compelled to wait while we sent out for a razor ! It has been my good fortune generally to have the most admirable of assistants, who attended to these details for me, leaving to me the operation and the patient to occupy my whole attention. But this week I have been caught in a state of unpreparedness that causes me to hang my head in grief. I have been moving, and everything needed at either end of the line was at "the other house." Suddenly in rushed a number of excited people shrieking for the doctor, one woman holding in her arms a golden-haired baby, two years old. It had been playing on the floor, and was supposed to have got a collar-button into its larynx. Its teeth were tightly clenched, so that I could scarcely pry them open. I passed my fingers into the throat, felt the epiglottis to be free and

open, inflated the lungs, without meeting any obstruction. Could not make up my mind at once if it were asphyxia or a convulsion-and within one minute the babe was dead.

In my thirty years' active practice I have carried three sets of tracheotomy tubes, replacing them when lost, and this is the first time I have ever been confronted with a case where their instantaneous use was perhaps required. And I had neither tubes, instruments, nor so much as a pocket-knife that would cut, in my reach. I thought of inverting the child, some hours later. Dr. Abbott came in within half a minute of the child's arrival, but the speediest tracheotomy possible would hardly have been quick enough to save the child. Nevertheless, I shall always regret that I was not ready to make the attempt. For the rest of my life I shall never let my pocket instrument case and tracheotomy tubes be far from my hand.

And what else should the doctor keep in readiness for emergencies? The means of checking hemorrhage he has in his pocket-case, and he should see that his ligatures, needles, forceps, pins and tenaculum are always ready for use. Ammonia or amyl for syncope, the lancet for cerebral congestion, chloroform and ether, with dressings for surgical accidents, a stomach pump or tube for poisonings, and a few such remedies as anodynes, emetics, heartstimulants, alcohol, a hypodermic syringe (in order), with tablets of morphin, atropin, nitro-glycerin, apomorphin strychnin are most likely to be required. Antidotes for poisons are rarely of any use, as the time for their exhibition is usually past when the doctor gets to the patient.

and

But, above all, the doctor should familiarize himself with the clinical aspect of all emergencies likely to arise, so that he will be prepared to grapple with them with promptness.

During my whole professional life there has been a singular fatality about my first essays at any task. I always fail with my first case. I always bungled when I first attended a new family. If they waited patiently until the awkwardness wore off and I felt at ease with them, we were friends for life; and as one of them remarked once, "You can't drive us away if you take an axe to it." With such patients the doctor grows to be one of the family; they put their whole trust in him

and he deserves it; and the years that whiten his head only confirm these relations.

But the habit of weighing, of going profoundly into every question submitted to one, to a certain extent interferes with the "nimbleness" of the intellectual move ments. Every new emergency is a new problem to be looked at from all sides, to be tested and tried in various ways; and when this process has been once gone thru with, the next case of the sort will be easily and quickly dealt with.

How well I recollect the first time I tried to extract a molar. I failed. Shown how it should be done, and how to select the proper forceps, I never again failed in hundreds of instances.

My first case of choking failed. I found a man lying back, cyanotic, etc. I passed a long pair of forceps down his throat and got nothing. I then sent for a doctor. He arrived, passed his index finger into the man's pharynx, hooked out a huge hunk of beef that was paralyzing the constrictors, and the man was relieved. I never failed after that.

An old lady was bleeding from a tooth cavity. I applied alum, copper sulphate, Monsel's solution, etc., etc., but still it bled. So I sent for my preceptor (I can recollect yet the sardonic grin displayed by these doctors who knew), who plugged the hole with wax and stopped the bleeding.

And so I might go on, enumerating a long list of my failures, especially on my first essays at treating any diseased conditions. But possibly some others of the WORLD family have had similar experiWILLIAM F. WAUGH, M. D.

ences.

103 State St., Chicago.

[We hope that this will encourage others of the "brethren" to be as open and frank concerning their experience as Dr. Waugh has been. We learn much more from such articles than from the ordinary kind.-ED.]

Recurrent Measles.

Editor MEDICAL WORLD:-In answer to Dr. Aspinwall's question, May WORLD, page 210, "if a patient could have more than one attack of measles, in the same epidemic or season, or at a subsequent time," I cite the following case: About twelve years ago I was called to see Mrs. L. M., and readily diagnosed her case as measles. She said, "Doctor, that surely can't be true, as I had measles five years

ago and have been taught persons could not have them the second time." I said, "Well, if you ever had them, you have them again; but you may be mistaken about the former attack." She assured me that she had the measles at the time she mentioned. I said, "I know you have them now."

In about three years from that time I was called to see her and found her with another unmistakable case of measles, which ran the usual course, recovering in about one week. There was no mistake in diagnosis.

Here is one who has had measles three times, and runs or dodges them, thinking she will have them every time she is exposed. She is now as fearful of them as our negroes are of small pox. If she has another case I will report it in my consultant, THE MEDICAL WORLD. Newport, Ark.

J. M. JONES, M.D.

Why Chronic Otorrhea Does Not Get Well. Editor MEDICAL WORLD:-In the list of questions of the more careful life insurance companies invariably appears the query "have you ever had a discharge from your ear?" If the answer to this question is not negative, it is often impossible for the applicant to secure a life assurance policy. The fact that the life assurance companies recognize chronic otorrhea as a common cause of death, altho recent, is now so well known as scarcely to require explanation or comment. The fact that death as the result of intracranial complications of otorrhea may occur is better understood than that ill health is not unfrequently the result of the slow absorption of the products of inflammation from otorrhea. That this is the case appears from the fact that patients not unfrequently gain in weight and health after the cessation of otorrhea.

Only a somewhat limited number of cases of chronic otorrhea completely recover. The portion of drum-head destroyed is replaced by a cicatrice, which while it does not improve hearing, serves almost as well as the original drum-head to exclude cold, dirt and other irritants from the sensitive mucous membrane of the middle ear, and thus tends to prevent a relapse with renewed suppuration. It should be borne in mind that the principal function of the drum-head is not to increase the hearing power or act as a check ligament to the malleus; but to afford protection to the delicate structures of the middle ear. The writer has observed