last use, you have not only a clean instrument, but one which you can usually rely upon to work. Since this is always clean, it per se, never produces an abscess.

The use of the hypodermic as a form of medication is being extended daily. Its great advantage lies in its exactness and its rapidity. The resulting abscess and the pain have been the greatest drawbacks. If any one will use proper aseptic and antiseptic precautions and carefully selected drugs there need be no abscess.

Its use frequently relieves the stomach to a most wonderful extent and enables us to give proper nourishment, which is of the utmost importance. Our forefathers neglected this and often prevented a cure by their medicines. Today pharmacology has reached so high a standard that nauseating drugs are rarely necessary. Yet our prescriptions often take away the appetite. Where it is possible to employ the hypodermic the stomach is relieved, (with a few exceptions, as apomorphia) and we can feed the system as well as medicate.

It seems to me that the syringe will be used much more in the future than it has been in the past. But I wish to call your attention to its advantage in malaria.

Malaria is a disease from which the Mississippi Valley has suffered throughout its medical history. Many theories of its etiology have been advanced and a bacillus carefully described, but Lavaran, a French army surgeon, while working in Algiers, was the first to recognize the parasite in the blood, and to believe in its relation to malaria. Lavaran had a long and heated discussion with several Italian observers, which led to much bitter feeling. For a long time Marchiafara and Binani constantly refused to see the parasite, although Lavaran made a trip to Rome to show it to them.

They were contending for the bacillus of malaria. Later their own. investigations proved to themselves that the parasite was the cause of the disease, but even to this day they have never acknowledged the work of Lavaran as amounting to anything, and have never owned that he was right, but have described it as if it were new from their own pens. Their work is of the best and their researches have advanced far ahead of any thing Lavaran has given us.

Today we recognize three forms of malaria: Tertian, Quartan, Aestivo Autumnal.

The life history of the tertian and quartan parasite has been thoroughly studied but that of aestivo autumnal is still in doubt. It may be that later we will find more than one variety of parasite under this division.

Malaria is undoubtedly caused by a parasite in the blood, and it is only by the extermination of this parasite that we hope to bring about a cure of malaria. When the parasite is seen we know at least that part of the trouble is due to malaria. Thus the uncertainty of the diagnosis exists no longer, the doctor ceases to worry as to whether or no he is right and the quinine is increased until a cure is effected.

The question arises as to what time in the life of the plasmodium quinine can do its best work. One would suppose that the younger forms

would be the more delicate. So it is, and we find that if the quinine is in the blood at the time of segmentation it has a much more deadly effect upon the disease than if there at any other time. Segmentation occurs at the time of the chill or just before, and can be predicted by the microscope. The chill is in all probability caused by some toxic property which is liberated at the time of segmentation. In predicting the chill you can judge approximately of the time of segmentation. When you realize that the life history of a tertian parasite is about 48 hours and that of the quartan is about 72 hours. you can see that this prediction presents no great difficulty. But with the aestive autumnal we have an uncertain life history and cannot be so accurate.

Some cases seem to get well without medicine, others only need the assistance of a little quinine; while others produce death in spite of very large doses of quinine. There are a few systems which cannot tolerate quinine, to one of which I shall call your attention. It is in severe cases which do not tolerate large doses of quinine and cases in which very rapid control of the disease is desired, that I recommend and urge the use of the hypodermic syringe.

The form of quinine which I now use is the hydrochloro-sulphate of quinine. It has given the best results and has the fewest drawbacks. It is soluble in equal parts of water. It has the strength of the bisulphate and is decidedly the least painful of all the quinia salts which I have tried. The hydrochlorate with urea is also soluble in equal parts of water, but is much more painful. It is usually used in a 50 per cent solution, and the pain frequently lasts for an hour, while the double salts is easily tolerated even by very nervous patients.

I have always made the injection into the deep muscles of the gluteal region. It is best to wash the part with a 1:20 solution of carbolic acid, as that renders the surface antiseptic and numbs the sensative nerves.

Mr. E. C. Walden and myself reported 21 cases of malaria in which the effort had been made to see how small an amount of quinia could be given and have good results.* We found that by giving small doses as 5 grs. four hours before the suspected and predicted paroxysm, and another 5 gr. dose four hours after or at the time of the paroxysm, the disease could often be checked at once and cured in a few days. Yet it is not always possible to thus so easily control the disease, and I believe that it is much easier to get such control in a place like Cincinnati than in a typical malarial district. Even in Cincinnati we are often compelled to use larger doses and at times to resort to the hypodermic. Hypodermic injections were given daily, six grain doses of the hydrochloro-sulphate of quinia being used. The bisulphate was used twice and only 41⁄2 grains injected. It worked very well but was painful. (I have had Werner & Simonson, of Cincinnati, make hypodermic tablets of the hydrochloro-sulphate. These are readily soluble and are easily preserved.)

In places where there is much more malaria than in Cincinnati and where are oftener fatal cases from this cause, (I have seen only one fatal *Conclusion drawn from 49 cases of malaria in Cincinnati. Kennon Dunham, M. D. and E. C. Walden, A. B., M. S. The Cincinnati Lancet-Clinic, August 28th, 1897, Vol. XXXIX, No. 9.

case in Cincinnati), I believe that the hypodermic could be used to the utmost advantage. In the cases reported I never failed to make the patient feel that he was well or almost so within three or four days. One great danger lies in the fact that you are liable either to be condemned for treating him unnecessarily or, if you lose sight of your patient, to have a relapse follow.

It is seen that the aestivo autumnal is the most persistent. I should advise in treating this form of the disease that little time be wasted with any form of medication except the hypodermic, and that this be pushed ruthlessly. Also the best hygienic surroundings should be given such cases. A relapse is very liable to occur and you are not safely out of the woods for many weeks.

The following cases are given briefly:

CASE I.-White male, aged 32 years, came to me August 17th, 1895, suffering from aestivo autumnal malaria. The crescents were very numerous and chills were occurring every day but with variable intensity. I gave him hydrochloro sulphate of quinia, six grains, hypodermically. After the twelfth injection he had no more paroxysms. Many crescents were seen in the blood but no other form of the parasite. There was much pigment in white blood corpuscle. After the twelfth day he was given quinia sulphate grains every four hours, and was discharged well on the 30th of September, 1895, 44 days.

CASE II-Colored, male, aged 27 years, came to me September 13th, 1895, was suffering from double tertian malaria. He received the hydrochloro sulphate of quinia, grains vi., once. The patient objected strenuously to the injection and did not return to clinic for ten days. I ascertained that until the sixth day after the injection he had no trouble. the seventh day he suffered from a slight paroxysm which increased each successive day. He returned to the clinic on the tenth day, suffering much more than he had before he received the injection. He submitted very gracefully to the injection and had no more chills after the second treatment. After the ninth day of this treatment (hydrochloro sulphate of quinnia, grains vi) he was placed on quinia sulphate, grains ii, every four hours and had no relapse. He was discharged well on the 17th of October, 34 days.

CASE III.-White female, aged 37 years. Patient came to me March 3rd, 1896. She was suffering from double tertian malaria. Injected the bisulphate of quinnia, grains v, for six successive days. (The blood at this time showed no organisms, although searched for carefully.) She felt perfectly well after the third day. All traces of the case were lost after

the sixth day-probably was well.

CASE IV.-White male, aged 57 years. Came to me July 21st, 1896. I prescribed quinnia sulphate, grains v, two doses daily, one at time of chill, the other four hours before, and repeated this for three days. The only effect produced was to nauseate the patient and produce a violent headache. There was quite an eruption and the patient refused to take any more quinnia.

The patient after this received an injection daily of hydrochloro sulphate of quinnia, grains vi, for ten successive days. He made no objection

and there were no constitutional symptoms. After the third injection he felt practically well. When the injections were discontinued he was given quinnia sulphate, grains ii, every four hours until August 18th, 1896, when he was discharged well-28 days.

The patient had been under the care of well-known physicians in St. Louis, Chicago and Cincinnati before he came to me, and had been suffering for two months This is the most protracted and stubborn case of single tertian with which I have ever met. I have suspected that my diagnosis of single tertian might have been a mistake and that it was of the aestivo autumnal type.

CASE V. White male, aged 49 years, came to me August 21st, 1896. The diagnosis of double tertian was made and quinnia sulphate, grains v, was prescribed four hours before attack and again at time of chill. The treatment was continued for several days. No benefit or bad symptoms from the medicine were noticed. Qninnia sulphate, gralns xv, was then prescribed twice daily as above for five days. Patient was a little nauseated but felt slightly better. I then gave him an injection of the hydrochloro sulphate of quinnia, grains vi, on two successive days. The chill ceased after the first injection and he was placed on tonic doses of quinnia, grains ii, every four hours until September 27th, 1896, when he was discharged well-37 days.

In Cincinnati few cases of double tertian are as stubborn as this. Most cases succumb to quinnia sulphate, grains v, twice daily.

CASE VI-White male, aged 60 years, presented himself June 17th, 1897, suffering from double tertian. He said that he had been under treatment for several weeks with no effect. I immediately gave him injection of hydrochloro sulphate of quinnia, grains vi, for seven days. He had no chill after the first injection, but on the following day he had a slight fever. When the injections were discontinued he took quinnia sulphate, grains iv, every four hours and was discharged well, June 22d, 1897.-days, 15.

CASE VII.-White male, aged 80 years, double tertian. I called to see him July 4th, 1897. He was in bed very sick and suffering from pain in the head and bowels. He had been passing bloody urine for two days. He complained of his sight being blurred and I attributed this to the great anæmia. His lips were white, conjunctivæ was very pale and the complexion was waxy. He had had a chill every day for two weeks at about 4 o'clock. The spleen was very large and soft and exceedingly tender to pressure. He had been under the care of a homeopathic physician for three weeks. I had none of the double salts of quinnia, and so gave him the bisulphate, grains 41⁄2, and repeated it for seven days. The pain was rather severe but he bore it well and never had a chill after the first injection.

On the following day there was a rise of temperature, 101°, but no chill. After this the temperature remained normal. Later on ophthalmic examination showed a hemorrhage of retina. I know that the treatment with quinnia, and especially hypodermically, is not approved by many when there is any tendency to hemorrhage. It seems to me much more rational to gain as rapid control of such cases as possible, and I know of no method of treatment which does this so promptly and so accurately as the hypodermic of quinnia.

The Treatment of Rheumatoid and Gouty Affections.

R

BY E. C. SCHOLER, M. D., PH. G.,

CHICAGO, ILL.

HEUMATISM may be divided for convenience into the following classications: 1. Acute rheumatism or rheumatic fever. 2. Sub-acute rheumatism. 3. Muscular rheumatism. 4. Chronic rheumatism. In rheumatic fever the prodrome is very short, usually of a few days, commencing with an aching feeling in the larger joints, such as the shoulder, hip, elbow, knee, ankle or wrist, making locomotion very difficult or even impossible. The inflammation having a tendency to be of a flying character, first in one joint then in another, mostly the first symptom is fever, not so high in the start but becoming more so as the increase in the joint involvement develops. Pulse is rapid and intense, sweating follows, decidedly acid in reaction. Urine is usually scanty, high colored, acid reaction with decided sediment mostly of urates. Subacute rheumatism often follows the acute and will cause the patient much suffering, the symptoms continuing not so severe nor the fever quite so high. Cardiac complications often occur at this period.

Muscular rheumatism comes on very suddenly, often within a few hours, mostly without any fever at all and little or no swelling of the muscles. Its involvement is exclusively the muscles.

The lumbar muscles cause what is known as lumbago or "kink in the back."

The intercostal muscles cause pleurodynia.

The pectoral muscles, serratus, and the sterno mastoid muscles cause torticollis or stiff neck.

The temporal and masseter muscles becoming affected making mastication very painful. The abdominal muscles also occasionally become involved. This form of rheumatism is usually of short duration.

Chronic rheumatism is a chronic inflammation of the soft tissues of the joints; its prominent symptoms are stiffness, pain and often marked tenderness with enlargement, always much worse in damp and cool weather and better when dry and warm.

Gout or podagra being both an acute and chronic constitutional affection, is admitted in general that it is caused by an excess or increased accumulation of uric acid in the blood, causing arthritis, which is a distinctive sign, and is mostly inherited but is also acquired.

In the treatment of rheumatism and gout the following essential points must be observed:

1. The elimination of such morbid secretions that cause the ailment. 2. Administration of a remedy to allay the pain and soothe the inflammation in order that the patient may get the necessary rest and sleep.

3. Care must be taken to stimulate the vital functions so as to prevent the excessive weakness that follows the effects of both these complaints, especially in gout two things are necessary, knowing its cause, first to give