panied by sweating.

With the fever are headache, pros

tration, constipation, and diminished urine of high specific gravity. During the first few days the remissions are well marked, ranging from 2° to 3°, but as the disease goes on the temperature becomes more continuous, although in milder cases the remissions may still be decided. As the disease subsides the remissions become more and more marked, and the temperature may become intermittent. In some cases there may be two daily remissions. The duration is usually from one to three weeks, and the attack may terminate in recovery or in death, or the disease may merge into intermittent fever.

Variations in Type.-(a) In mild cases the symptoms are not severe; the patient is up and about, and recovers in about two weeks. (b) In severe cases the temperature has a high range; the patient passes into a typhoid condition in which he may die in two or three weeks. (c) Hemorrhagic" cases are characterized by a tendency to bleed. The most common sources of hemorrhage are the kidneys and the intestines. Considerable blood in this way may be lost. This form is usually seen only at certain times and in certain places. (d) In some cases there is developed well-marked jaundice, the so-called "bilious remittent fever." This fever is usually developed during the first week of the disease, and is often associated with the hemorrhagic form. The association of fever, hemorrhages, and jaundice closely resembles yellow fever, and the diagnosis is at times difficult, as both diseases are apt to occur at the same time and in the same place. Blood-examination should, however, clear the diagnosis by finding the plasmodia.

4. Pernicious Remittent Fever.--This type corresponds. with pernicious intermittent fever, except that the temperature at no time in the twenty-four hours comes entirely to normal. No further description, therefore, is necessary.

5. Malarial Cachexia.-This form usually follows prolonged attacks of intermittent fever improperly treated. Cases developing without such a history are uncommon except in intensely malarial districts. The general health becomes affected; there is loss of flesh and strength; the blood shows marked anæmic changes; the complexion is muddy or lemon-colored. The spleen is distinctly enlarged and firm on palpation. The temperature may be normal or subnormal, but there is usually an irregular fever of moderate intensity. Digestive disturbances are common. There may be functional disturbance of the liver, gastric or intestinal indigestion, or irregular action of the large intestine. In other patients neuralgia is a marked symptom. Headache is the most common symptom, being frequently periodic. The next most frequent symptom is supraorbital neuralgia. The degree to which the symptoms are developed varies. In rare cases paraplegia or orchitis may develop.

Diagnosis. The diagnosis of all forms of malaria is rendered simple by the finding of the plasmodia in the blood and by the subsidence of the disease upon the administration of quinine. The chills, the paroxysms of fever, and the sweatings of pyæmia, tuberculosis, and ulcerative endocarditis might be mistaken for malarial fever. Intermittent is to be distinguished from remittent fever by the careful use of the thermometer. Remittent fever may be mistaken for typhoid or for yellow fever. The diagnosis of the pernicious form is often difficult, but the examination of the blood, the enlargement of the spleen, the history of an intense tropical malarial exposure, and the results of quinine therapy afford positive diagnostic indications.

Prognosis. The prognosis depends upon the severity of the infection, upon the proper treatment, and upon pro

longed residence or further exposure in a malarial locality. The simple intermittent and remittent fevers do well, although if neglected they may run into malarial cachexia. The pernicious forms are exceedingly dangerous. A patient untreated rarely survives the third paroxysm. If energetically cinchonized, the prognosis is fairly good. The prognosis of malarial cachexia depends largely upon the patient's ability to change his residence to some locality where he will no longer be exposed to the miasm.

Treatment.-Prophylaxis.-Inhabitants of malarial districts should select the situation of their houses, should sleep, if possible, upon upper floors, and should avoid night air. It is well to take from 6 to 8 grains of quinine after breakfast.

The arrest of a paroxysm is important only in pernicious cases. A full dose of opium (grain of morphine hypodermically), grain of pilocarpine hypodermically, or a drachm dose of chloroform is often of service. Quinine is useless unless given hypodermically, as its action otherwise is too slow. In pernicious cases, however, it should be given hypodermically in full doses, the tannate, hydrochlorate, or hydrobromate of quinine being given in aqueous solution. At least 15 grains should be given every two hours in bad cases until the paroxysm yields.

During the paroxysm the chill and the fever should be treated on general principles.

To prevent recurrences quinine is a specific. It may be given in solution or in freshly-prepared capsules or pills. Children take it well in chocolate tablets. The dose depends upon the severity of the attack and the susceptibility of the patient. In mild cases from 10 to 20 grains daily will suffice. In severer cases from 20 to 40 grains will be required. It may be given in divided doses during the twenty-four hours, or in single large doses six to eight hours before the expected paroxysm. In severe cases the latter

form of administration is preferable. Cinchonism may be controlled by phenacetine or sodium bromide. In many cases it is best to precede quinine treatment by a mild mercurial purgative. The effect of quinine is either to prevent paroxysms or to modify their severity or to postpone the paroxysm for several hours. A third paroxysm is not to be expected. In long-continued cases quinine seems to lose its power, and capsules of desiccated Warburg's tincture should be given. Six to eight capsules, each representing 3j of the tincture, should be given daily. Good results frequently follow the use of arsenic, especially if combined with iron and laxatives in small doses, with or without small doses of quinine.

In remittent fever daily doses of from 15 to 20 grains of quinine frequently benefit the patient by the third or fourth day. In other cases, especially if the remissions be slight, quinine does no good, and in these cases it seems best to wait until the temperature becomes more markedly remittent, and then quinine regains its curative power. In bad cases it is best to continue the use of quinine whether it seems to do good or not.

Treatment of Malarial Cachexia.-The hardest cases to treat are those living constantly in some malarial locality. The anemia demands treatment by iron and arsenic, with small doses of laxatives if needed. A good combination is

Ft. pil. No. j. Sig. Take one three times daily.

Digestive disorders are to be met with appropriate treatPeriodical neuralgia may be benefited by quinine,

ment.

arsenic, or Warburg's tincture. Obstinate cases should be sent to some non-malarial locality.

ANTHRAX.

Definition and Synonyms.-Anthrax is an infectious disease caused by the anthrax bacillus. Synonyms: Malignant pustule; Malignant oedema; Splenic fever; Charbon; Milzbrand; Woolsorter's disease.

Etiology.-Anthrax which is primarily a disease of cattle, sheep, and horses, is occasionally communicated to man. It is especially frequent in Russia, Siberia, in parts of Europe, and in South America. The bacillus of anthrax was the first specific micro-organism ever described. It is a rod bacillus two to ten times longer than the diameter of a red blood-cell, non-mobile, with abundant spore-growth. The rods are often jointed together, forming long filaments. The bacilli are readily destroyed, but the spores are exceedingly resistant, and live for a long time in the grass or on the surface of pasture-land. Cattle acquire the disease by eating the infected grass or by inhaling the spores.

In man the disease may be acquired by inoculation, by inhalation, or by the alimentary canal. Inoculation results from handling infected hides, wool, hair, or instruments, or by bites of flies or of mosquitoes. The disease may be acquired by inhalations from infected skins or wool, or the alimentary canal may be infected from diseased meat.

Symptoms.-The disease occurs in an external and an internal form.

1. External Form.-(a) Malignant pustule is the most common form, and it occurs from inoculation of an exposed surface, usually the face. Symptoms begin from a few hours to four days after inoculation, with itching, pricking, or burning like the sting of an insect. A papule is formed, developing into a vesicle which ruptures, dis