ment would result in the absorption of the exudate and the restoration of their function, but it should be remembered that when inflammation occurs at the end of the tube, it is not always closed, by the folding in of the mucous surfaces and closing of the peritoneal surfaces over it. In the closure of the tube, one or two fimbria may be only partially retracted, leaving small mucous surfaces protruding, which during the acute inflammation may permit leakage and cause the subsequent recurrence of peritoneal attacks.

The existence of a large exudate does not absolutely indicate the presence of pus. It is to be expected that the occurrence of such a collection would lead to increased secretion within the tube and where its ends are obstructed a collection of fluid gradually forms which may be purulent, bloody, or watery, according to the degree of inflammation or virulency of infection.

The plan of treatment must necessarily depend largely upon the circumstances of the patient. An individual in affluent circumstances can afford to pursue a course of treatment not possible to one dependent upon her own exertions for maintenance of herself or her family.

In the introduction and application of uterine massage we have a procedure of wonderful therapeutic value in the treatment of many forms of pelvic inflammation. In chronic non-suppurative cases it may be practiced by inserting two fingers into the vagina and placing the hand. over the abdomen, we raise up and move the uterus in different directions, thus stretching bands of adhesions and promoting the absorption of exudation until the organs are again free. Such a plan of treatment may follow and supplement vaginal incision and drainage when it is evident that pus is present.

We would present the following plans for treatment :

1. Chronic endometritis associated with irritable appendages should be an indication for dilatation, curettage and drainage. The precedure should be performed under thorough aseptic precautions, and the patient should be kept

in bed for at least ten days. Subsequently the patient should have semiweekly intrauterine applications of astringent or alterative agents and a vaginal tampon of gauze medicated with ichthyol and glycerine. The tampon supports the uterus at a higher level and through the medicament depletes the pelvis. When the tampon is not worn a hot douche should be used twice daily.

2. Uterine displacements and fixation, unless pus can be demonstrated, should be treated by pelvic massage and the use of tampons and hot douches. Massage is just as serviceable and as much indicated in pelvic infiltration as in inflammatory anchylosis in any of the joints. It is surprising how rapidly exudates will be absorbed under careful manipulation.

3. The existence of pus in quantity sufficient to permit of its demonstration should be considered a positive indication for its evacuation. As has already been stated, the isolation of the mass by the barriers nature has provided should be respected and the cavity, where possible, drained through the vagina. In many cases this plan of procedure will result in the preservation of appendages which would otherwise be sacrificed. The subsequent fixation of the pelvic organs may be overcome by a course of pelvic massage, hot douches and mild counter-irritants.

4. A class of cases in which there has been profound destruction of the organs will still remain, in which no hope for health can be afforded so long as they remain. Such cases demand thorough removal of every vestige of diseased tissue. This may be accomplished in some cases through the removal of the appendages, in others the extirpation of the womb is equally demanded.

PRESERVATION OF URINE.Urine can be kept for an indefinite period if to the contents of the vessel there be added 2 c.c. (3ss) of the following solution: Mercuric cyanide, 10.0 (5ijss), water, 100.0 (3iijss). The addition of this salt does not alter the acidity of the urine, nor does it invalidate the results of the analysis.

MALARIA, bad air, or marsh miasm, are synonymous terms according to medical nomenclature; and malaria has been the term used for more than a century to designate the disease caused by the entrance of a certain specific poison into the human system. That it is one of the so-called germ diseases is now pretty well established, the microscopists having found small bodies belonging to the order of protozoa, or lowest living organism, invariably present in the blood of patients suffering with the different forms of malarial diseases.

Six different species of these parasites have been described and their relation to the different symptoms and types of the disease has been worked out by one observer, who reports certain definite cycles of evolution in the development of the parasite in the blood; its gradual increase in size until a process of segmentation or sporulation takes place, causing the paroxysm of chills. This same observer describes a rapid destruction of the red corpuscles of the blood by the micro-organism, which destruction we know does take place, as evidenced by the pallor and anemia of malarial patients. This fact, together with the fact that such organisms are not found in any other disease and of their rapid disappearance on the administration of quinine, makes the theory plausible.

While it is yet somewhat sub judice, and the testimony of more witnesses must be heard, it satisfies more of the conditions of the disease than any other theory thus far advanced.

There are yet gaps in our knowledge concerning it; it is not known how it enters the system or in what form it leaves it, nor how it is propagated and no record of successful cultivation has been recorded. Heat and moisture and

a proper breeding place are necessary for its development. Low, swampy, marshy places and hot weather supply these conditions. It does not follow, however, that all such places are malarious; in fact, sometimes in the same section of the country and exposed apparently to the same conditions, one district will be malarious while another will not. Salt water marshes, as a rule, are free from it, while it prevails around fresh water and mixed fresh and salt water marshes.

Salt water is said to neutralize or absorb it. It does not develop at a lower temperature than 60° and is entirely destroyed at 32°. Infection is most liable at night and the nearer the ground the more liable the infection. It is said to adhere to trees of dense foliage. It is probably transmitted through the air to a locality formerly free from it; in fact, it seems to develop in cycles. Residence is the only way to tell whether a given locality is malarious or not, though probably in time chemistry and microscopy will do it.

That malaria used to prevail on the Eastern Shore is true, though reports concerning it have been greatly exaggerated, and that it has almost entirely disappeared is equally true. Having practiced my profession in Caroline County nearly fifteen years, I speak from positive knowledge and experience. In collecting the vital statistics for my county, I addressed letters to all the physicians, asking their observation as to the prevalence of malaria; each reported it as fast disappearing; one of the oldest and most intelligent reported it as compared with forty years ago at five per cent. This corresponds with my own observation, and at the present ratio of decrease, in a few years malaria

will be an unknown quantity on the Eastern Shore. The few cases that do exist are found around old mill ponds. Cut all the mill dams on "the Shore," and I will venture to say that in a few years it will be an unknown quantity.

There must be some reason for this great change in this section of the State; it cannot be attributed to any one cause but to a possible sum or combination of causes. The old stereotyped reason of "better drainage" will not entirely explain it, as we used to find malaria in some of the best drained sections of country. While no doubt drainage is a factor, the better cultivation of land, which goes hand in hand with drainage, is probably a greater one; with increased cultivation and growing vegetation come purer air. Vegetation has a purifying influence on air, removing the carbonic acid gas and restoring that life-giving principle, oxygen; consequently the more vegetation and the more luxuriant, the purer is the air; the purer the air, the more ozone, with its remarkable powers of oxidation and disinfecting, antiseptic and anti-germicidal properties. To the presence of this agent alone a possible explanation can be found.

Another probable factor is the growth of the pine tree. In the march of civilization the larger oak trees have been cut down for building purposes and the smaller and less valuable pine trees allowed to stand. Pine trees have for ages been supposed to possess some antiseptic power, due probably to the evaporation of the volatile oil which they secrete naturally and the giving out of ozone. The removal of the oak has probably allowed the more thorough dissemination through the air by the winds of the purifying principle of these trees. The planting of the peach tree is another possible factor. Trees with a large leaf absorb or destroy the malaria germ; if not by absorption, possibly by the general rule of vegetation, of giving out oxygen. Climatic changes are probably another factor, heat and moisture being necessary to the development of malaria. From some inexplicable cause the rainfall and heat of the summers have been less than formerly. While I

have not had the means of determining accurately the rainfall, I know from observation and experience that certain fields on my farm which were invariably drowned out a few years since now yield good crops. Why the summers are not so hot, I cannot explain; possibly for the same reason that the pine trees have more room, the cutting away of the larger trees and thereby allowing the modifying and cooling influence of the Atlantic Ocean on one side and the Chesapeake Bay on the other to be better felt. With these two necessary properties for its development lessened, combined with the other possible factors mentioned, it looks as if the "bug will have to skip."

With malaria rapidly disappearing and la grippe run its course, the Eastern Shore of Maryland is now exceptionally healthy and with its temperate and salubrious climate is almost a natural sanatorium. Typhoid fever, a few diarrheal diseases in summer, catarrhal ones in winter and an occasional case of scarlet fever and diphtheria, which, however, under the pure atmosphere nearly always assume a mild and tractable type, are about the only diseases which prevail; in proof of which I present the vital statistics of my county:

Total number of deaths, 120. Population at last census, 13,903, is 8.6 per cent. per 1000.

These statistics, as well as the condition of my visiting list, testify to the correctness of the eulogium of Dr. Chancellor in his work, "The Climate of the Eastern Shore of Maryland;" the recapitulation of which is: 1. A temperature pleasantly warm for eight months in the year; 2. An air moderately dry, rich in oxygen, of excessive purity and constantly in motion; 3. A large number of clear, sunny days and comparatively few days of rain and fog; 4. A rich and luxuriant vegetation, flourishing as in a subtropical climate; 5. The possibility

of almost daily promenades and drives in the open air; 6. The refined social advantages of the country; 7. Its unrivaled dietetics and cuisine; and, finally, in its proximity to the great centers of population.

SOCIETY REPORTS.

BALTIMORE MEDICAL

ASSOCIATION.

MEETING HELD OCTOBER 8, 1894.

Dr. H. H. Biedler, First Vice-President, in the chair.

Dr. E. G. Waters reported an interesting CASE OF PURPURA. One form of this disease associated with rheumatism has received the name of peliosis rheumatica. He called attention to the affinity between purpura and erythema mentioned by Hyde and Pye Smith. On April 23 he was called to see a gentleman one hour after he had returned from Atlantic City. While there he was taken with cholera morbus and the attack lasted all the way home. That was his condition when Dr. Waters saw him. There was some elevation of temperature, not great, lasting five or six weeks. The case was diagnosticated as continued fever. He went out and had a relapse. Owing to heavy pecuniary obligations he was obliged to go out of the house, staying at his office till he was compelled to return home and go to bed. The purpura was in the form of petechiae.

The spots were very small but excessively numerous. There were none on the face but in other parts there were thirty or forty spots to the square inch. There was no headache but some muscular rheumatism. He could not attribute the fever to rheumatism. Kidneys were perfectly healthy. There was no hemorrhage. During June the spots became enlarged like vibices or ecchymoses. On June 17 there was such an exhibition of erythema as Dr. Waters had never before seen. The whole body was, comparatively speaking, aflame. It had come on suddenly. Dr. I. E. Atkinson saw the patient with Dr. Waters the next day but then the erythema had disap

peared and the purpura had reappeared⚫ Towards the middle of July he went back to Atlantic City and when he returned felt perfectly well. In August he had a return of continued fever and of purpura. The patient is about 55 years of age, but of excellent general health. The case is remarkable because of purpura identifying itself with erythema.

Dr. David Streett: Erythema in many cases is very rebellious to treatment, 'while others recover readily. Some cases of purpura are very obstinate. The pathology of purpura is obscure. It is thought by some to be infectious. Symptomatic purpura occurs in Bright's disease and cardiac affections. Some cases of purpura are allied to scorbutus. He mentioned the diagnostic points between purpura and scorbutus.

Dr. Chas. H. Jones: Had seen many cases in army hospital and a few in private practice. It is due to a cachexia; hereditary. In Dr. Waters' case there was rheumatism. He thinks that the liver and spleen are affected. Dr. Waters' was a mongrel sort of case; one day, erythema; the next, purpura. He rather thinks that it was erythema. He once

saw a child with purpura in which case he thinks that there was an hereditary taint.

Dr. E. D. Ellis: Once saw a case of purpura in a girl 17 or 18 years old. It was her third or fourth attack and commenced with a sore throat. The spots were most numerous on the legs and buttocks. The case was obstinate.

Dr. W. A. Duvall: Asked Dr. Waters if in his patient there was not constipation before the cholera morbus.

Dr. D. Streett: Had noticed that in many cases the patients are young. It is said by some that the cause of the disease is due to minute emboli.

Dr. E. G. Waters: His patient was predisposed to a laxity of the bowels and frequently had to use astringents. He did not wish to create the impression that Dr. Jones had, that the purpura and erythema alternated. The purpura was persistent until the one attack of erythema appeared. Most of his patients were under twenty years of age. He

had used potash salts (bicarbonate and chlorate) just as in scorbutus. Finally he put his patient on ergot, mineral acids and tincture of the chloride of iron. Once he saw a violent case of urticaria in a similar way.

Dr. Streett: Scorbutic conditions occur probably more frequently than we suppose. He related case of a boy with bleedings from the mucous surfaces, sinkings and convulsions. Inquiry revealed that he ate nothing but meat. A change of diet and acetate of potash constituted the treatment. He never be came robust.

Dr. Duvall: Related a case of urticaria in which no cause could be discovered but the drinking water. It occurred in a mother and her second child whenever they visited the country. The water was hard. The treatment for it was effervescing citrate of magnesia.

Dr. Waters: Dr. Streett's case of scurvy recalls Dr. Kane's experience and that of his men. When they killed an animal and dealt out the liver to the men, the trouble subsided. One of the severest cases of urticaria that he ever saw occurred by stirring up a nest of wasps, one of which stung a servant girl.

Dr. Streett: Has generally noticed indigestion and diarrhea in cases of urticaria. Has seen it occur where it was due to malaria.

Dr. Duvall: For local application has used lead water and a weak solution of chloride of sodium.

EUGENE LEE CRUTCHFIELD, M. D.,
Recording and Reporting Secretary.

CORRESPONDENCE.

THE INDEX MEDICUS. Editor MARYLAND MEDICAL JOURNAL. Dear Sir:-I have learned that The Index Medicus will cease to be published with the February number, owing to lack of support and the fact that a large number of its subscribers are delinquent, unless an effort is made to continue it.

The value of this publication to those who do any work at all in connection with medical literature is so great that I take the liberty of writing to you to

express the hope that you will not only become a subscriber, but will urge other of your professional friends to do so.

It is particularly necessary that The Index Medicus should be continued owing to the fact that after the completion of the supplementary volume of The Index Catalogue of the Surgeon General's Library there will be no record of contemporary medical literature, and he who desires to keep pace with it, or who wishes to study a particular subject, will have to resort to the laborious task of seeking in various journals that which he desires if the publication of The Index Medicus ceases.

It will be possible to continue The Index Medicus if 500 new subscribers are obtained. The subscription price is $10 per annum, which should be sent to Mr. George S. Davis, publisher of The Index. Medicus, Box 470, Detroit, Michigan.

As The Index Medicus can never be made a success from a commercial point of view because of the peculiar scope of its work, I have no hesitancy in making you acquainted with these facts, and I earnestly hope that you will insert a notice emphasizing the importance of this matter in the columns of your valuable journal.

Your truly,

H. A. HARE, M. D. Philadelphia, Dec. 3, 1894.

MEDICAL PROGRESS.

THE TREATMENT OF GONORRHEA BY IRRIGATION.-The prevalence of gonorrhea and the difficulties in its treatment naturally multiply the methods used for cure and each writer sets forth the means which in his hands have been most successful in the majority of cases. Dr. H. M. Christian, in the Therapeutic Gazette, in giving the results of his treatment by irrigation of the urethra, says:

1. That irrigation is a distinct advance in the treatment of gonorrhea; in fact, up to a certain point, it must be considered the proper treatment for that disease. It relieves ardor urinæ and chordee more promptly than any other form of treatment. It is attended with a much