I have been asked this question, "If, as you suggest, nature has pointed out the indications for treatment, by filling the stomach and bowels with bile and irritating and decomposed material, and by copiously ejecting it from the stomach, why has not nature continued in the same line, by setting up a hypercatharsis and emptying the bowels?" I might reply in the first place that if nature could accomplish everything, there would be no need of a physician; but in the second place a hypercatharsis induced by nature is debilitating and exhausting. Look at what occurs in cholera morbus, when it only lasts for a very short time, and yet the patient is almost exhausted, and if it were continued through three or four days no patient could live. This excessive action by nature is too closely allied to that of cathartics, viz., in exciting the glands all along the immense surface of the alimentary mucous membrane; but the action of enemata are analogous to the action of the stomach. It simply expels its contents without exciting the intestinal glands and induces no exhaustion, beyond that occasioned by the mere effort of vomiting. And so enemata produce even less exhaustion, because there is no excitation of the glands and even less exertion than in vomiting.

MALARIAL HÆMATURIA.

Read before the Tri State Medical Society, November, 1885,

BY M. J. ALEXANDER, M.D., AUSTIN, MISS.

It is not my intention to discuss the nomenclature of this disease, nor will I trouble this learned body with fine theories. We meet here annually to exchange opinions based on practical experience, and it would be superfluous to speak of what might or could be.

There is no difference of opinion as regards the primary cause of malarial hæmaturia. It is a disease of miasmatic origin. The exact manner in which malarial poison affects the human economy is as yet a matter of theory. From clinical experience we find, however, that the large glands, and more especially the liver, are generally disturbed, when the malarial virus infects the human body. It acts upon the

liver as an irritant, causing congestion and often overaction of that organ. All who live in a malarial region know only too well how often we meet these hepatic derangements, and how constantly we are called upon to treat these primarily, before we can successfully combat the malarial diseases. It is indeed discouraging that such an important organ as the liver is so readily and powerfully impressed by this miasmatic poison, and I charge it against this susceptibility that many of our most useful fellowmen have perished with this much spoken of disease, malarial hæmaturia.

When a person voids dark colored or bloody urine, he loses no time in sending for a physician. We learn that he had been "bilious" or feeling badly for a day or two, and at last had a severe chill, followed by this bloody discharge. The bowels are constipated, but may have been perfectly loose the previous day; the tongue is heavily coated with a yellow, and soon afterward with a brownish or black fur. The patient. presents a perfect picture of what is commonly called "biliousness." The skin is found dry and jaundiced, sometimes having a glistening, greenish yellow hue. Excessive sick stomach and great prostration are early symptoms. The urine is generally scant. There is great restlessness and disability to sleep. The patient has more or less pronounced rigors during the day, which come on irregularly, and are not followed by any febrile stage. All secretions are torpid, and we have a true asthenic condition. In some fatal cases we have coma, but the greater majority are conscious till almost the last moment. The hæmaturia and jaundice being the prominent symptoms, I will examine their cause and refer to the others as they appear.

As inferred above, the miasmatic virus having caused a congestion and thickening of the lining of the hepatic ducts,. their caliber is very much diminished and often entirely occluded. The hepatic cells, however, are still performing their duty in secreting bile, which is, however, not carried into the intestines, but remains in the cells to be carried into the small hepatic blood vessels by osmosis, and thence into the general circulation. The bile pigment is deposited into the tissues, staining them yellow, and becomes in time visible in

the skin. The kidneys are at once made aware of this biliary obstruction, and carry off large amounts of bile before attention is called to the real trouble by the dark colored secretion. They perform that office which nature has put upon all excretory organs, namely, vicarious action. The work undertaken, almost single-handed, by the kidneys, soon becomes greater than the glands can perform; the rapid accumulation of bile products is so great that they are over-distended, congested, and can only perform their duties partially. The urine becomes saturated with bile, and the watery secretions are not sufficient to dissolve it, which therefore remains: in the kidneys, irritating the same to such an extent as to cause an extravasation of blood. It is this fact which causes. the dreaded suppression, which soon carries the patient off, if not promptly relieved. In my opinion it is the saturated condition of the urine with bile which gives it that dark port wine color, and when blood corpuscles are found present, it is. the result of extravasation caused by the renal. irritation as mentioned above. It is nothing strange that the bowels are constipated, and obstinately so, for want of the natural cathartic "bile." The great prostration is accounted for by the fact that the bile present in the blood destroys a large number of red blood corpuscles, and materially interferes with their manufacture. The troublesome restlessness indicates some brain irritation, and this can be accounted for by the presence of bile products carried there in the cerebral circulation. The frequent rigors I attribute to the impoverished condition of the blood.

Basing my course of treatment upon the foregoing facts, I submit the patient to eliminative, and from the beginning, supportive medication, and I have found such course successful in all cases under my care, and learn that a similar treatment has proved useful with other physicians of my acquaint

ance.

As long as the secretions from the kidneys are not materially interfered with, I direct my attention to the bowels, through which channel I desire to carry off the accumulated products within the liver. I find nothing that answers better than the mild chloride of mercury, although I do not think

that this drug acts directly upon the liver. Authorities bear me out in the assertion that it stimulates the glands of the duodenum, that it in some way relieves the congested and swollen condition of the bile ducts, and opens a channel for the flow of bile into the intestines. This mercurial should be used unhesitatingly, 3-4 grs. hourly, until bilious action is produced. Griping will be promptly relieved with ext. hyoscyamus. The bowels should, by all means, be kept open, and if necessary, croton oil resorted to. A fly blister over the region of the liver has often a most prompt effect of relieving the congestion of that organ.

The irritable stomach may be relieved temporarily with crushed ice; but I have found nothing which answered as well as hot water and a good deal of it. It washes out all irritating matter from the stomach, and seems to act as a soothing (I might say) poultice upon the irritable mucous membrane. It is also of great benefit in arousing the secretion of the skin. I never have, however, lost sight of the kidneys. The urine is scant and may suddenly be suppressed, and it is in this condition that writers on the subject recommend diuretics, as buchu, turpentine, nitre, &c. I do not condemn this kind of treatment, but I have found it do harm rather than benefit the patient. The suppression of urine is caused by an over-irritation, and is more a strangury than want of proper functional action. It is the watery portion of the urine which is lacking, and water, at blood heat, used in large quantities, is of the greatest benefit. It is nature's diuretic, it is soothing, and dissolves the solid portions of the urine, and dilutes the concentrated bile products accumulated in the kidneys; in a sense, it washes out all irritating particles from their cells and tubes, and prepares these organs to carry off a vast amount of the foreign substances in a diluted state. Warm water is easily retained after the stomach has gotten rid of every particle of irritating matter, and it is rapidly carried into the system, and when eliminated. carries with it much that is deleterious to the economy. But we must give it boldly, and continue in its use until we obtain the end for which we work.

The restlessness will often be promptly relieved by hyos

cyamus in full doses. Quinine is a drug which some give largely and others not at all. I have always given it in the first two or three days in small doses often repeated, and keep the patient under the influence of the same. As to its irritating action upon the kidneys, I have never noticed such effect. Besides its anti-malarial action, it possesses a bracing property, and to a great extent acts as a food to the system.

Stimulants and liquid nourishments are of utmost importance, and must be given under all circumstances. They must not be neglected for even a few hours. As soon as the secretions are established, we may add the chloride of iron to the stimulating and nourishing treatment. The vitalities. being at a low standard in this disease, relapses are very common and generally prove fatal, and it is necessary to watch the patient carefully for several days after convalescence has commenced.

ABSCESS OF THE LIVER-FREE INCISION-RECOVERY. Reported to the Tri-State Medical Society,

BY J. E. BLACK, M.D.,

Surgeon-in-Charge City Hospital, Memphis, Tenn.

The subject under consideration is one of great importance to every medical man laboring in the great valley of the Mississippi, from the fact that the disease is quite common in this territory and that a large majority of cases prove fatal without surgical interference. It is not my object to detail the causes, symptoms, pathology, etc., of the disease, as these are familiar to all of us, but simply to give a brief of the case and operation and exhibit the patient.

The usual operation of aspirating or using the trocar is often followed by success in small abscesses of this organ. In some cases it has been found impossible to completely evacuate the pus cavity, and moreover, the pyogenic process continues, until the patient is exhausted and dies. In properly selected cases, the operation by free incision with appropriate after treatment, is the only one which promises a radical cure of the suppurative process going on in the liver.

The cause, or at least coincidence, so often mentioned by

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