trated form and instruct them how to dilute it for use. Thus twenty-five cents' worth will run them for a week, tho they seldom have to take it over two or three days.

This is my way of preparing it in the sick room I pour about four ounces of water into a glass, and add to this 10 to 20 drops of specific gelsemium, and 5 to 10 drops of specific bryonia. I direct that a teaspoonful of this be given every hour, excepting when the patient is asleep. If the stomach is very irritable, as it is apt to be for the first few days, I alternate with the above, nux and ipecac. Thus, specific nux, two or three drops; specific ipecac, five or six drops; water 4 oz. The dose of this is a teaspoonful, to be given in alternation with the other if there is a great deal of stomach trouble, otherwise to be given every third hour, substituting for the other at such time. A small proportion of cases break into the intermittent form toward the last. In such cases, I give quinin, two or three grains per day. During the first days of a malarial fever, or of influenza, I have the patient drink a great deal of warm water. It will settle the disturbed stomach better than anything else, and is helpful in many other ways. Of course the patient must have perfect quiet, all company being excluded, and the attendants being careful to talk as little as possible. Impress upon the nurse with iron emphasis how immeasurably easier it is to overfeed than to underfeed the patient. Under this treatment, I have never lost a case of malarial fever. In very malarial regions, there are always a number of quinin-proof cases. They have taken so much of the drug, and taken it so long, that their systems have acquired a tolerance of it which renders it non-medicinal to them. I have never failed to cure these cases by the following method: Say a chill or "molyma" is due at about 4 P. M. At about 3.30 I give the patient a hot sitz bath, so as to have him in a profuse perspiration at the time when he would, otherwise, have been in a chill. This knocks the anticipated paroxysm "h. w. and c.," to classically express it. The oncoming chill finds its site squatted on by its greatest foe, and there is nothing left for it to do but quiesce into dissipation. The operation may have to be repeated several times in veteran cases, tho I have never struck one that required more than three such treatments, dispersed thru six or eight days. Do it this way:

Half fill a tub with water as hot as the patient can bear. Tilt the tub a little, putting a brick or stick of wood under the lifted edge. Half fill a bucket with water a shade warmer than that in the tub. Let patient strip and step into the bucket, and after a few moments sit down in the tub. Throw a blanket about his shoulders, fitting it close around his neck, and so disposing the rest of it that all his person, excepting his head, will be incarcerated. Give him a teacupful of hot spice tea, letting him, after that, frequently sup hot water or "quack." Keep his head cool by cold water affusions; otherwise there is some danger of syncope. After he has been sweating thus for 15 to 30 minutes— according to his strength-put him to bed, closely wrapped with his blanket, other covering being thrown over him according to his need. Let him drink very plentifully of warm stuff all thru the treatment. After sweating from half an hour to an houraccording to his strength-sponge him off rapidly with cool water to which has been added some whisky. After wiping him, let him put on his sleeping garments. He should remain in bed two or three hours before getting up and dressing.

Probably an alcoholic vapor bath would do as well; I have never tried it in malarial cases.

I have cured many cases of chronic malaria-those inexplicable cases that may as well be anything else as malaria-by submitting them to a series of these sweats. The treatment is heroic, but there are cases which nothing else will reach. I have not employed this treatment once within the last fifteen years, because I have been able to cure the worst cases we have in this part of the country by my other treatment. In places where malaria is intenser and more persistent, the sweating method will be found to be very reliable. I should think no curable malarial disease could resist the sweating method combined with a rational medicinal treatment. Cleves, O. W. C. COOPER, M.D.

Treatment of Remittent and Intermittent Malarial Fever.

Editor MEDICAL WORLD:-The treatment of remittent and intermittent malarial fever is the same. The first thing to do is to unload the system from stomach to anus. Nothing does this so well as calomel in two-grain doses with a little soda. every hour, for five or six doses, followed

Quinin sulf. Acetanilid

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ways believed himself to have been cured by the then (1844) new remedy, quinin. In Baltimore and Philadelphia some cases from laboring classes, chiefly from along water frontages, appeared in the hospital wards (we had no dispensaries then). far as I can recollect, rest and a few small doses of quinin resulted in uneventful recovery, so that students, at least those from non-malarial regions, gave such cases no special study. (1849-'52, inclusive.)

The population of the Willamette Val

Treatment of Malaria, Typical and Atypical Cases.

Editor MEDICAL WORLD:-Your invitation in editorial of August WORLD for description of experiences in treatment of malarial disease-"Something New Wanted," gives the writer opportunity to add evidence of the truth that "there is nothing new under the sun.”

During 1854-55-56-'57, opportunity came to me for experiences entirely "new" to myself. A Pennsylvanian and Marylander from youth to manhood, I had no knowledge even by information and rumor, save of but two cases of 66 ague," one, that of my father, who retained what remained of one-grain quinin pills, with a caution label to "stop use if head becomes affected;" and a cousin, who lived upon a mill-dam, whom quinin had failed to cure. The latter recovered by change of residence, but attributed his "cure" to steam baths, while my father (a clergyman) al

immigrants from Missouri, Illinois and Arkansas, and that valley was then about all of Oregon settled at all thickly. A majority of the adults had histories of "malaria" before they came "the plains across." In some localities they remained forever free from attacks of "ague," unless physical or mental depression occurred; while upon the eastern side of the river, running thru the entire valley of the same name, in the years 1853 and '54, a traveler could not find meals nor lodging in a horse-back ride of several days, unless he helped himself, by doing his own cooking, -in fact, attending to all his own wants, and often assisting the sick as well. The sufferers all had the cinchona alkaloid, and used it variously, some in teaspoonful doses; only a few in smaller ones. So sallow a set as those seen, in traveling about sixty miles, I never saw many heard imperfectly; a few had the sight more or less affected; yet almost none spoke of quinin being a factor. Well, they knew no better than to attribute all their ills to what they called "ague."

After eleven years' residence in the above-named valley, I removed to my present residence, then a town of 3,000 inhabitants, now nearly 9,000. Even malarious symptoms were unobserved in disease until 1869, when two young Cornish miners seemed to have remittent fever. The surroundings (August and September) seemed favorable. To my surprise, I ultimately found it relapsing or famine fever, and so soon as a benevolent lady took charge of their food-providing, convalescence became rapid and permanent. They had been without previous experience in preparation of food, came directly from their homes in Cornwall to a mining campsuburb; for economy "caboosed," and with abundance of food, had it been properly prepared, were actually starving-abundance around them, even in their own cabin.

This, and many other lessons in other diseases, has led me to prescribe for my patient as individuals, and base none of my prescriptions simply upon nomenclature of disease, even in intermittent, remittent, nor even typhoid fevers.

Remove the cause first, if found, and if removable; learn the history of the patient, so far as possible, as influencing his present condition of ill-health; study present condition of the patient, and prescribe for him and his condition as found, forgetting the nomenclature entirely, while studying condition of patient.

So in malarial disease; the thought of "plasmodium" may disappear from my mind, but causation and prophylaxis will dwell; the former even to hereditism, if can be; the latter as circumstances of patient permit.

Except in a first attack from first exposure, I do not recollect seeing and examining, out of hundreds, more than three typical cases in the sense described in August WORLD, pp. 324–326. If this description be the type in which quinin is the curative remedy, they have been few in my experience.

In this location, until after 1889, only such cases were seen here as came from the valleys. Our city is not in a valley, but is more than 2500 feet above sea-level, and varies within its corporate limits from 2500 to 2800 feet elevation above sea-level; has good surface drainage, but no sewers proper. Late in November, 1889, while leaves and late fruits were still upon the trees, heavy snow came, and for more than six weeks successive fallings of snow came and no time was given nature nor man to do any cleaning up, for the weight of snow had broken down and off upon the earth all twigs, leaves and fruits, so well as burying under its first fall what of ordinary vegetation had fallen as usual at that season. The weight of one snow-fall coming soon after another, several times, weighted and drained into the soft, unfrozen soil all this immense quantity of woody and vegetable matter. Only surface frosts followed, but the natural winds of the season no longer carried the leaves, etc., into the hollows and ravines where winter rains ordinarily carried them toward or to the valley. They were beaten into and held in the surface soil, making a portion of it, until the temperature permitted decomposition. Many square miles of surface in such condition, during the next summer (1890) gave no apparent malarial

influence upon health, but we observed myriads of insects and beetles and worms we never saw before, and still newer, but smaller ones next summer (1891).

In this last summer no paludal district ever experienced more intermittent fever than our mountain city. Above us, higher in the mountains, for thirty and more miles, so-called "ague" was reported, and while now declining in frequency, is heard from occasionally, in the more irregular forms. One might have expected, under similar conditions, many typical cases, but under my personal observations, only a few were so, and they were quite young adults, rarely one beyond adolescence; none in old age. Those who had been in the best general health before attack, were the nearest typical.

In typical cases, for forty years, no quinin nor other "antiperiodic" has been prescribed by myself until my patient was found as result of previous prescribing, or otherwise, in a complete apyrexia (remission) with a moist-clean or cleaning tongue, when usually the sulfate or bisulfate of quinin, in doses of three grains, rarely more, but sometimes six grains, were given; seldom more than twelve grains being required during remission to prevent pyrexia unless some constitutional condition had been overlooked. The typical cases are most frequently gastro-enteric and depend on diet of a faulty quality or time and method of use.

In an individual patient, with whose history and habits personal acquaintance has given me all required knowledge, a second prescription is rarely necessary.

The atypical cases (occurring in my own practice) may require any prescription from aconite to zine or zingiber. Grass Valley, Cal. J. L. COOMBS, M.D.

[These cases seem to suggest "mountain fever," which is more of a typhoidal than malarial type. It might be well for our readers to look upon this subject with the above cases in mind.-Ed.]

The Indication of Vertigo.

Editor MEDICAL WORLD:-Allow me a few lines for E. E. Reynolds, M.D., on Vertigo, in August WORLD, as follows: To me your case is one of meningitis-perhaps cerebro-spinal, but rather tubercular. You say that you have treated for indigestion, torpid liver and constipation without relief. If the tongue is fairly clean, no albumin or sugar in urine, with loss of appe

tite, you would better treat for meningitis, with ergot and potassium iodid.

I had a case a few weeks ago in which there was a history of some of family dying of "head trouble." Patient was seventy years of age. Had fallen on ice in March, but paid not much heed to it, and got apparently better. Took spells as you mention, and I treated as you did, until acute symptoms of head trouble set in, and patient passed into coma and died in ten days. D. A. KIDD, M.D.

Atwood, Ontario.

Cure for Ringworm.

Editor MEDICAL WORLD:-I think I derive more benefit from reading THE MEDICAL WORLD and the Alkaloidal Clinic than from all my text-books on the practice of medicine, Watson, Wood, Flint, Osler, Hartshorn and Hughes.

Tell Dr. J. L. Watson (July WORLD, page 307) that I cure my ringworm cases (tinea circinata) with a solution of blood root (sanguinaria pulv.) a nickel's worth to four ounces of pure apple or cider vinegar. Two to four applications usually do the work. J. L. CUNNINGHAM.

Edwardsville, Ill.

Treatment of Fracture of the Patella. Editor MEDICAL WORLD:-In my experience I have found the treatment of fractures of the patella with any of the long splints to be very unsatisfactory, the great difficulty being to keep the separated fragments in apposition. This is the complaint of most of my friends who are accustomed to rely on any form of splint or adhesive plaster treatment. Cutting down upon, drilling and suturing the patella exposes the joint to too great danger, and simpler methods give as good or better results. Moreover, opening the knee joint is an operation not without danger, and should only be performed or attempted by the surgeon who has already demonstrated his ability to do aseptic work. I have seen some very disastrous results follow the opening of the knee joint for the purpose of drilling and suturing the fractured patella.

On the contrary, the following operation as employed by me, with summary of cases is one that, I believe, will appeal to the general practitioner. However, I make no claim whatever to originality, altho I am unable to learn who was the author of it. It is at least an operation whose results are eminently satisfactory, and with

All that is required is a straight Peaslee needle and a piece of No. 10 loose twisted silk. Four incisions one-half inch long are made thru the skin, as shown in cut at ABCD. Beginning at A, pass the needle thru the center of the tendon close to the patella, and bring it out at B. Thread the needle and draw it back. Then pass the needle from C to B, again thread the needle and pull the suture to C, and so on from D to C, and finally from A to D, until the patella is completely circled with the subcutaneous suture and with its ends emerging at A. I next have an assistant hold the patella fragments in contact, while I draw the suture tight and see that the parts are in perfect apposition. I then tie the knot over a small roll of gauze at A, all the incisions being closed with two horse hair sutures, sealed with collodion, and the leg extended on a straight, wellpadded splint.

The following cases wherein I have employed the operation have demonstrated its utility:

CASE 1. M. Shea, age 34, section hand, tripped his toe on his way to work and fell, striking his left knee on the iron rail. When he entered the Union Hospital two hours later there was great tumefaction of the tissues about the knee. The following day I aspirated the tumor and drew off over a pint of blood and serum. The knee was then firmly bandaged, and hot sterile constant irrigation continued for five days. Then, under ether narcosis, I operated as described in the cut, using a straight

Peaslee needle with Hagedorn paint. At the end of the fifth week union was firm, the suture was removed and he returned to work with the injured leg as useful as the other.

CASE 2.-Fred R, German, age 50, laborer, fell while at work, striking his knee on the floor, sustaining a fracture of the patella which was transverse, near the upper third. The same operative procedure was followed, with corresponding results.

CASE 3.-Jerry McC, Irish, switchman, age 28, very muscular. While switching cars, he eaught his toe under a bar of iron and fell forward. As he did so, he felt something snap in his knee and fell to the ground. When I saw him a few hours later the knee was in a similar condition to Case No. 1. The same operation was followed and with about the same results, tho it was some four or five months before complete flexion was obtained at the knee. This case was especially interesting, as showing that fracture of the patella may result from muscular violence without the knee coming in contact with an object, as the patient insisted that he felt the patella snap while attempting to free his foot, and not after falling.

In conclusion I would say that a needle and suture operation for fracture of patella is described in the American Text Book of Surgery, page 322. It is called Barker's operation, and by consulting the cut the reader will see that the needle is passed under the patella and so, of course, the integrity of the knee joint is not preserved. Hence such an operation appears to me to be unwarranted, when, by operating in the way I have described, the joint is never invaded. J. P. WEBSTER, M. D.

Chicago, Ill.

Chief Surgeon of Chicago and Western Indiana and The Belt Railway of Chicago. Surgeon Chicago and Erie and Monon R. R. Gynecologist and Abdominal Surgeon of Englewood Union Hospital. Professor of Surgery Harvey Medical College.

Poisoning by Opium and by Acetanilid. Editor MEDICAL WORLD:-Permit me to submit the following:

CASE I.-Opium poisoning in a baby five weeks old. I was summoned at 7 p. m. to see a five weeks' old baby that was "awful sick." Upon arrival I found profound opium narcosis. Respirations about 15. Skin blue and cold; features contracted and old looking. Upon inquiry, the mother stated that as the baby was crying, and she had lots of work to do, she gave it, at 4 p. m., a dose of laudanum. She was not

positive just how much. She had given the baby an emetic of ipecac and this only added to its discomfort.

This was my first opportunity for trying the use of permanganate of potash as an antidote. My previous cases of opium poisoning have been treated successfully with strychnin and ammonia.

I gave this baby one grain of the permanganate in solution. It then occurred that a hot coffee enema would help out. Accordingly about one quart of hot coffee was allowed to flow in the bowel. After the bowels moved, a little was allowed to remain. Results: By 9 p. m., two hours after I gave the first dose, respirations were 36 per minute. Pupils normal and skin clear and warm. Complete recovery.

I have every reason to believe that the permanganate was the antidote.

CASE II.-Acetanilid poisoning in seven weeks' old baby. Mrs. L. called with her baby, showing an ugly erythema extending from the knees to the umbilicus. I brought out a bottle of powdered borax, 75 parts. acetanilid 25 parts, and freely dusted the chafed surface, advising the mother to do the same when necessary. This was at 11 a. m. At 4 p. m., I was sent for in great haste, the messenger stating that the baby was dying. I asked the mother if she had given it anything. Nothing, she said, except two more dustings with that powder.

Here was a typical case of acetanilid poisoning. Skin was cold and blue as ink. I simply gave atropin and strychnin as heart stimulants, and advised a hot bath, keeping the child warm, and no more dusting. As a preventive I took the bottle back. În 24 hours recovery was complete.

This case is of interest to show the possibility of acetanilid absorption thru abraded or exposed surfaces. I have used this powder extensively on cuts, wounds. abrasions and in gynecologic cases, but I am sure that I will be more careful in its use in the future, if I use it at all. Normal, Ill.

T. W. BATH.

The Volume of the "Thirtieth Dilution."

Editor MEDICAL WORLD:-I have been a constant reader of THE WORLD for many years, and can only say, I would not be without it. I am getting old, and shall probably not practice very many years more. But when I quit work, I hope to read THE WORLD regularly, so long as I live.