liver." African travelers universally testify to the absolute necessity of keeping the bowels regular, and Livingstone reckoned purgative pills the most essential item in his outfit.

And this reminds me of a third point: These same African travelers speak of the certainty of ague attacks following when anyone fell into the water. Wetting the Wetting the skin with malarial water was sure to induce the chills. But this is an experience But this is an experience I have never heard verified elsewhere. Is it true of the waters of our Southern and Western States?

Per contra, a Mississippi doctor wrote to me that when the Yazoo railroad was built the men suffered with ague so that the road was in danger of being abandoned, until the expedient was adopted of drinking distilled water. From that time no more ague appeared, except among those who persisted in drinking the ordinary water.

But within a week I have been told that in Arkansas people have been attacked who drank only distilled water.

It seems that we get bits of truth here and there, but not all. Exposure to night air, especially when the stomach is empty, or when the resisting power of the system has been reduced by indulgence in alcohol, venereal or other excesses, is universally believed to predispose to malarial attacks. Persons residing in malarial localities usually advise visitors to sleep in the upper stories, and not to leave the house until the sun has dissipated the dew, and until a full breakfast has been eaten.

Now these observations are not based upon laboratory experiments, nor are they fortified by the names of illustrious leaders in medicine; but I have more faith in them than in the opinion of any great surgeon who has made a reputation for operating upon appendicitis and never saved a real case of ague in his life.

The British surgeons in India have experimented largely, however, and as one result announced that quinidin is a better prophylactic than quinin; and that anyone who is compelled to sojourn in a malarial district may do so with safety, if he observes the above precautions and takes three grains of quinidin daily.

My own observations have convinced me that ordinary bad hygiene of the premises has much to do with the continuance of malarial poisoning: and that if there is an open drain near the house, or if the

cellar is damp enough for shoes to become moldy in it, malaria will persist there until these conditions are remedied, no matter how much quinin is taken.

Some time ago I had occasion to investigate that curious term, hives. In England it is used as a synonym for chickenpox; here it signifies urticaria, croup, or erythema nodosum. Probably, in certain localities, the pronunciation of the i is short, making it "heaves," and this being the popular term for a pulmonary affection of horses, makes the connection with croup. Erythema nodosum is often known as "bold hives." The eruption occurs as raised lumps, an inch in diameter or more, elevated slightly, but more at the center, red, itching or burning, but not very painful. Relief speedily follows rubbing with wet salt; but the disease is closely allied with rheumatism, and is best treated by laxatives, intestinal antiseptics and salicylates.

Urticaria is a very annoying affection. Thirty years ago I was attacked with it, one summer, after playing base-ball on a very hot day. The eruption went over my whole body, taking forty-eight hours to it, and lingering longest in the palms, soles, prepuce and eyelids. I lay in bed, sponging the itching patches with lead

water.

For a long time thereafter, whenever I became hot enough to perspire, the wheals and intolerable itching would appear. Since I learned how quickly the af fection is relieved by a mustard bath, I have not had an opportunity to apply it to myself, tho I have to many others. "Si jeunesse savait ! Si vieillesse pouvait!"'

The worst attack I have ever witnessed occurred in a lady of my family. She had at a cafeterie eaten an apple pie which had a musty taste. That evening she had an attack of urticaria of the face, chest and body, the burning being intense, the temperature high. In fact, the symptoms were of that form of urticaria known as angio-neurotic edema. The attack subsided in a day or two, but there were threatenings of a return on several occasions afterwards.

Whether there was any connection between this attack and the disseminated cancer that shortly after developed, is a thought that has haunted me since. Of the true etiology of cancer we know absolutely nothing; but among the observations that have been recorded there is one that showed the disease to be especially prevalent in a certain district in France,

where cider is extensively used, and much less prevalent in the neighboring communes where the people do not drink cider.

On page 336, Dr. Jones speaks of second attacks of measles. A family I attended in Philadelphia informed me they had had measles several times, and I subsequently attended the children thru several of these attacks. It certainly resembled measles, in the catarrhal symptoms, the color of the eruption and the desquamation. But it was really erythema, and the body was progressively affected, the eruption beginning to fade on the face before it reached its acme on the feet.

On page 349, "Veritas" asks my opinion. On the face of the case, the boy is becoming an epileptic. But there is no reasonable cause given. The circumcision was wise, but other possible causes of reflex irritation should be looked for. Examine the eyes, ears, nose and throat, in the thoro manner a specialist would do such work. Then examine the abdomen for fecal impaction, the rectum for contracted sphincter, stricture, hemorrhoids, seatworms, etc; the urethra for undue sensitiveness and stricture. If no cause is discovered, strip the boy to the skin and go over his whole body as carefully and thoroly as the most skilful anatomist could possibly do. I could scarcely believe that this could be done and the source of that fever not be discovered. But if not, examine the urine and feces, chemically and microscopically; clear out the bowels and render them aseptic with sulfocarbolates. Lessen the reflex irritability by cicutin hydrobromate, gr. 1-67, six to twelve times a day, but give no bromids, unless it be that of arsenic. Finally, charge him at least $100 for your trouble. It is worth that much; and it is good practice to take such pains and charge for them accordingly, instead of giving a casual examination, a carelessly scrawled prescription and receiving a poorly earned dollar or two. WILLIAM F. WAUGH, M.D.

103 State St., Chicago.

[There is not an extensive literature upon the use of the intravenous injection of quinin in cases of malaria, nor has there been any scientific analysis of its effect upon the blood, so far as we can ascertain. The most information in this line can probably be obtained from the writings of Baccelli, who has been the chief advocate of the measure, and has experimented to the greatest extent. Still, even

he gives rather meager details. A fifty per cent. solution would seem to be rather strong for intravenous injection.

In regard to catharsis before the administration of quinin, an analysis of the motive governing its use, particularly in the form of calomel, will disclose the fact that it is generally directed toward the supposed existing jaundice. Further, this diagnosis of jaundice has its basis in the coloring of the skin. Still, so far from there being any obstruction to the outflow of bile, there is generally very little interference with this secretion, the yellowish color so noticeable and characteristic of malaria being due to the disintegration of the blood by the parasite, and the consequent freeing of its coloring matter, the hematin. The reasons for this conclusion are given briefly elsewhere in the consideration of malarial hemoglobinuria and hematuria.

Again, free catharsis will abstract from the blood some of its liquid elements. Researches of Nuttall and Bucher prove that the blood serum has a destructive effect on microbes, and that it certainly is not of assistance in the propagation of the malarial parasite, is proved by the fact that the parasite cannot be cultivated in human blood outside of the body. Hence, catharsis weakens Nature's own defense against the invading element.

Further, injurious constipation is seldom present, so there is not much room for the retention of toxic products in the bowel. In very few cases of malaria is there any interference with the function of the intestine, the habit of the patient remaining normal. Besides, malaria is not the result of intestinal intoxication. The parasite acts thru the blood. Diarrhea predisposes to the attack; then why induce it artificially as a curative measure? A large proportion of cases of the algid type of malaria have been noted as following free catharsis or diarrhea, this possibly because of the general weakening of the patient. The patient should be sustained, not weakened.

If purgatives and quinin are given simultaneously, the dose of quinin given at the same time with the cathartic is more than likely to pass off with the purgative (the drug can be detected in the feces by chemical reaction), hence such simultaneous dosage may be of little practical avail. Free catharsis does increase the absorptive power of the intestinal coat as an immediately following result. Granted.

But as the effect one is waiting for is the cinchonizing of the patient, why wait for intermediary measures? Why not devote the attention at once to this end, discarding routine and rule of thumb procedures?

Years ago not only purgatives, but also emetics were prescribed. The latter have 66 gone out of fashion." It will not be many years until the former also will be obsolete, unless specially indicated. It seems that purgatives may produce harm by weakening the patient-they may do good by promoting the absorption of quinin. The former effect is immediate, the latter causes delay. A certain practitioner in discussing the question says they can do no harm, and may do good. The converse, that they can do harm, and may do no good, seems the truth.

The writer's conviction is purely personal, and is based upon the reasoning outlined. Still, without outlining their reasons, Laveran and Maillot have given the same dictum against catharsis. the writer is open to conviction, and desires to hear all sides before being absolute in conclusions.-ED.]

But,

Administration of Quinin in Malaria. Concerning method of administering quinin in malaria, Dr. A. M. Purdy, of Mystic, Conn. (see his article in August WORLD, page 342), says that he gives it in small doses, so timed that the last dose will be given at the hour of the expected chill. He refers to a physician who gives 10 grains at 6 a.m., 12 m. and 6 p.m. till cured. If the shake is due at 10.30 a.m., the 6 a.m. dose is insufficient, while the 12 m. and 6 p.m. doses are obviously ineffective.

Malaria Cured with One Scruple of Quinin. Editor MEDICAL WORLD:

One scruple of quinin is sufficient to cure a case of true malaria. I follow this plan of treatment: If, for instance, the paroxysm begins at 12 noon, at five o'clock in the afternoon the sweating stage appears. Then at six o'clock in the evening I give one dose of quinin muriate, which I prefer to the sulfate, the dose varying from two to five grains, according to the age of the patient.

On the second day, if the paroxysm occurs every day, I repeat the same dose of quinin muriate at seven in the morning and give one other dose at ten o'clock in the morning. If the paroxysm is not re

peated on the third day, I give quinin in dosage of from two to three grains at ten o'clock in the morning. Finally, on the sixth day, I give two grains of the quinin at nine o'clock in the morning.

But in severe cases of malarial fever, where quinin is not tolerated by the patient, I generally apply a cantharidis plaster over the enlarged spleen for ten hours. At the expiration of this time, I remove the blister and apply ten grains of quinin covered with adhesive plaster, leaving it for three days. Internally I use Fowler's solution of arsenic. If the spleen and liver are enlarged, I recommend a mixture of rhubarb and soda. Brooklyn, N. Y.

H. ROSAHNSKY, M.D. [There is even more effect than the doctor seems to suppose from the application of a cantharidal plaster over the spleen, or the solar plexus. It is highly stimulative and soon produces reaction with its attendant amelioration of symptoms. This is probably the mode of action rather than the production of cinchonism by applying so small a dose of the quinin in direct apposition to the irritated surface. The fact that the muriate or hydrochlorate of quinin has a much greater alkaloidal strength than the sulfate was stated in the August WORLD, in the editorial article upon malaria. Necessarily a smaller dose of the former would be required.-ED.]

Typho-Malarial Fevers.

Editor MEDICAL WORLD:-While discussing malarial fever, it is well to notice that odd mixture of typhoid and malarial fever, in which the diagnosis and treatment is, frequently, far more difficult than in either of the before-mentioned fevers in their typical form.

An attack is usually preceded by more or less malaise, anorexia, aching of head and back, weariness and pain in limbs, frequently light epistaxis, tenderness over stomach and entire abdomen, flatulence, but no tympanites nor iliac gurgling, and usually obstinate constipation. This condition may exist for a week, with slight exacerbations of temperature. Then occurs the chill, altho the temperature would vary from 100° to 104°, and that without regard to the time of day or night.

After this chill, more of the typhoid element develops, as increased soreness in stomach and abdomen, tympanites, diarrhea, and sometimes the typhoid tongue. But still I have never observed in this dis

ease, any sordes on the teeth, no rosecolored eruption on the breast, no subsultus tendinum, no characteristic temperature curve, no hemorrhage, nor that low, intensely prostrated condition from which typhoid derives its name.

Notice the difference in this array of symptoms and that in the editor's description of a typical case of malarial fever, in August number of THE MEDICAL WORLD. On the other hand, most of the physicians in this locality, especially the older ones, call this disease "pure typhoid." Neither is this fever self-limited.

In the treatment, I have found quinin useful until the initial chill, or as long as there were any chills. To use it longer seemed only to aggravate some of the symptoms.

As an antipyretic, acetanilid or phenacetin, and for the heart, at the same time, digitalis, cactus grandiflora or strychnin, cold baths, salol for an intestinal antiseptic, turpentine emulsion, and frequent small doses of calomel, when indicated. The treatment, you notice, leans more to the typhoid "side of the house" than to the malarial.

But such has been my experience in hundreds of cases in this malarial country, and I should be deeply interested to hear from my fellow practitioners, and especially from the editor of THE WORLD, on this disease. B. A. SOUDERS, M.D.

Winterset, Ohio.

[Doctor, is it possible for you to test the Widal reaction or examine the blood? Sure diagnosis would seem to require this, and leading authorities claim there is no typhomalarial fever.-ED.]

Malaria and Cinchonization.

Editor MEDICAL WORLD: -You have added one more stratum to the mountain of debt you are piling upon THE WORLD readers. Of course, this statement has reference to the very exhaustive and scholarly editorial article, in August WORLD, upon paludal diseases. I do not recollect to have ever read a cleaner cut or more elegant paper upon any medical theme. Owing to this fact, any exploitation of my own views and experiences along this line may take on a complexion of audacity. The editor will readily forgive this, however, especially if my article happens to contain anything new to even a few of THE WORLD readers.

With polite deference to germ theorists, I shall have to treat the subject of malaria

as if their conclusions have not been logically and practically sustained. It seems to me that the ease with which cause and effect may be confounded when attempting to study the inter-relations of bacteria and morbid processes contradicts that certainty which raises a theory into philosophy. Germ theorists concede a tertium quid with its necessary priority. Natural consistency and human logic 'inexorably require that a given disease shall have but one commencement. The initial morbid impulse must hold the plan and specifications, so to speak, of the projected malady. Its intensity may be modified variously. but shall its type be changed? Altho "malaise" may seem to depend upon a general impression, its starting point must be specific, unless Nature is capable of self-stultification. The fact is, the primal lesion in any case of sickness is not relationable to the human intellect thru drug exploration alone. It is far out of reach of either chemistry or the microscope. Supreme diagnostic ability is a pretty ac complishment, and it is sometimes helpful in prognosis, but the doctor who has spent months in learning to discriminate between endo- and pericarditis is not nearly so well equipped as the one who has given this time to the study of drug action.

It is a good thing that it is possible to practice without a personal acquaintance with the various microbes, and without an exhaustive knowledge of chemistry. Closet students and theorists tell us to institute certain chemical tests, and make careful microscopic examinations. Not one doctor in ten thousand could do these things, even if he had a complete chemic laboratory and one of the best of modern microscopes. If the expert microscopist, with nothing else to do, can scarcely isolate particular micro-organisms, what could we expect of the busy, practical, every-day physician? It is not a bad thing to remember, in this connection, that the best chemist and microscopist is infallibly the most unsuccessful clinician. This is consequent upon the smallness of the human head, and the shortness of human life.

Please do not interpret the foregoing as a screed against higher education, or against the prosecution of those ultimate studies which, at least, contribute toward the scholasticism and majesty of medicine. The physician should be an all-around learned man, but he must not be expected to equal an expert in the latter's specialty.

The editor has so thoroly described the