acute pain. A small nucleus of induration forms at the level of the puncture. Most generally that nucleus vanishes and becomes absorbed, but sometimes an abscess or dry eschar about the size of a dime or even as large as a quarter dollar may form and afterward slowly separate. Sometimes larger eschars or even diffuse inflammation has been observed; but these are quite exceptional, and not the injection but the way of making it is to blame.

The hypodermic method allows quinin to be introduced into the general circulation pretty nearly as quickly as the intravenous injection. The latter is only allowable in the most grave pernicious attacks when it might be feared that the hypodermic method would not allow the quinin to be introduced quickly enough into the blood.

It has often been considered sufficient to cut short the fever with two or three doses of quinin, waiting for a return of the fever to recommence the treatment. In the opinion of leading physicians the endeavor should be to prevent relapse by the help of repeated treatment. Unless this is done, only a few attacks are suppressed, as the parasites, stopped for a time in their development, very soon increase and all has to be gone over again.

Practice shows that two or three doses are often enough to arrest an ordinary intermittent fever, but that it often reappears at the end of seven or eight days.

After the fever is arrested the first time, treatment should be recommenced six or eight days after the time of the beginning of the former attack. Quinin might with out doubt be administered for a fortnight or three weeks, but that would present enormous inconveniences on account of its producing ringing in the ears, deafness,

etc.

It has not been demonstrated that continued treatment has any advantage over interrupted treatment. Better results are obtained by giving a few fairly strong doses than in prescribing the drug for a lengthened time but in small doses daily. It is evident that if 15 grains of the hydrochlorate of quinin is prescribed in a single dose that the blood at a given time is found much more charged with quinin and as a consequence is much more fatal to hematozoa than if five grains were prescribed for four days.

The type of fever does not require material modification of treatment. After having been assured (notably by examination of the blood) that the fever is really

due to paludism, the following would be correct treatment for an adult man, according to the principles advanced by Lav

eran:

First, second and third days, eighttenths to one gram of the hydrochlorate of quinin. (It will be remembered that one gram equals 15 grains.)

Fourth, fifth, sixth, seventh days, no quinin.

Eighth, ninth, tenth days, six-tenths to eight-tenths gram of quinin hydrochlorate. Eleventh, twelfth, thirteenth, fourteenth days, no quinin.

Fifteenth and sixteenth days, resume quinin as above.

Seventeenth, eighteenth, nineteenth, twentieth, no quinin.

Twenty-first and twenty-second, quinin as before.

If fever reappears in the course of the treatment, it is necessary to prolong it.

Quinin is better tolerated during the period of apyrexia than during an attack of fever. It excites vomiting less often and the absorption of the drug is probably more complete. On the other hand, it cannot be expected to control or cut short the evolution of an attack of fever of normal duration when that attack has already begun.

Let it be ever kept in mind that in the grave or continued fevers the intermissions or even the remissions need not be waited for before administering the quinin. In serious cases, hypodermic injections of 1 to 2 grams daily should be made, without regard to temperature. As soon as the fever has yielded, the treatment for simple fever, as outlined above, should be followed. Hydrochlorate of quinin should be prescribed internally in solutions or in tabloids, preferably the former.

In the grave palustral fevers, accompanied by pernicious symptoms, the first thing to attend to and by far the most important thing of all is to get the quinin taken, but in addition to this there is often occasion to prescribe some further aids to the special treatment. For the patients attacked with the algid form of the fever, friction, either dry or with the evaporating camphor liniment, should be used. Hot stimulating drinks, alcohol in tea, for example, diffusible stimulants, ether, acetate of ammonia in the form of a draught, or better still, hypodermic injections of ether, may be given. Two to four grams of sulfuric ether must be prescribed.

The hypodermic injections of ether also

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 indicated. 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

This is sup

malarial hepatitis. Occasionally paralysis, generally local, may occur. posed 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.

Occasionally there are all the symptoms of severe auto-intoxication, this following 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 increas

ing 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 er, 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.

to the eruption, and in the severe cases The mucous membranes are also subject 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 chil

dren 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 smallpox. A physician of some renown in a near-by city states that to the best of his 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."

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

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

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. In 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 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