river. He had worked on the Tennessee side in Memphis, drank artesian water, and slept at home at night.

Inquiry was made as to time of next chill, and 20 grains of quinin so ordered that last dose would be taken an hour before expected time of chill. Patient had the expected chill and began passing bloody urine of a dark appearance, and I was called at once to see him.

Patient was found to belong to that class whose physical condition is described under the term chronic malaria or malarial cachexia. His spleen was enlarged, complexion sallow or ash-colored, with no color to mucous membranes.

Since chill, temperature was 40°C. (104°F.), pulse rapid and weak, nausea and vomiting distressing. Urine dark red color, being passed frequently, but in fairly good amount. He complained of pain over bladder and intense pains in lumbar region. To give quinin or not to give it, was now the question. None was given, it being my intention to administer the drug hypodermatically at the time of the next chill, in case of such recurrence. The patient had no return of chill, fever was of continued remittent type, hematogenous jaundice was intense. The fever ran a remittent course for one week and then dropped to normal, to continue intermittent for about a week. Urine remained dark and bloody for a few days, became a brighter tinge and was clear by the time the remittent fever dropped to normal-one week.

Treatment. This was supportive and eliminative. No quinin after hematuria appeared. In the beginning 10 grains of calomel followed by Epsom salts to free purgation. Strychnin, hypodermatically and by mouth, was given freely. From the second day of the attack sodium hyposulphite in dram doses to full laxative effect was administered and kept up throughout the course of the disease. Water, a glassful every four hours (often given hot on account of nausea) was administered. Five drops of tincture digitalis with one dram of nitre was given every six hours. Patient was freely stimulated with sherry wine, whisky in milk punches and eggnogs. Ice cap was kept to head for fever, hot fomentations to lumbar region, Dover's powders or occasional doses of morphin were given at night. At end of second week the patient was put on Fowler's solution of arsenic and tincture of iron.

The patient finally recovered, but was so anemic that edema of the feet and legs lasted for several weeks.

The next case is very similar to the above, and will be described in connection with temperature record.

Month.

Chir

14 hour

Sodium Hypo sulphite 45.9m dosa as limáti ton nouse. Whiskey as stini u lant

Case No. 2. Illustrating D. J. W. Laws' Article.

Name: Frasch Leslie

September

11 12 13 14 13-16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 3

X. L. M. E. Y. E. M. E. M. E. м. Z. M. E. M. EM. EX. L. M. Z. M. L.M. L. M. L M. I. X. L M. Z

Urin clearing

૫

Recurrence at 40gen

arine clearing

30.

Case No. 3. Illustrating Dr. J. W. Laws' Article.

L

Case II. Wm. S., aged 27, born in Missouri, but reared in lowlands of Arkansas. The patient was a laborer aboard a steamboat on the Mississippi river for two months up to time of admission to hospital, Aug. 28, 1899. His present attack of malaria had lasted him about two weeks, he having had his last chill the day before admission. At first glance one could tell that the patient was a chronic malarial subject, the cachexia being marked. The temperature on admission was normal, pulse weak and rapid, urine high-colored but contained no blood.

By reference to clinical temperature record it will be observed that 8 grains of quinin was given the first day, patient having fever; 20 grains on second day, still fever; 20 grains on third day, during which time patient had a hard chill lasting all day; 16 grains on fourth day, temperature normal in morning and 40°C. (104°F.) in afternoon. It was on the morning of the fourth, after the hard chill on third day, that bloody urine made its appearance. At the first sight of bloody urine the patient was very much agitated, stating that some quinin had been given him, and that over in Arkansas it was said, that in malarial hematuria if you took quinin it "sho' would stop your clock." No more quinin was given, sodium hyposulphite to complete laxative effect, and 3 ounces of whisky was given daily.

The patient was told he must drink water freely to flush out kidneys. This he did most conscientiously, often calling for water and asking nurse if he was "flushing out his kidneys enough." The patient's fever ran a remittent course for several days, then dropped to normal. The urine began clearing up on the second day, and was clear at the end of a week. The patient was put on a tonic of iron and arsenic and discharged recovered three weeks from admission, but he was still weak and anemic.

Case III. Frank L., aged 26, born in Illinois, laborer on U. S. dredge fleet during the past summer. While thus employed he frequently slept out on deck at night during hot weather and was exposed to bites of mosquitoes, and often used Mississippi river water as drinking water.

The man was admitted to hospital on Sept. 11, 1900, with temperature of 39°C. (about 1021°F.), pulse rapid, patient quite weak and nervous. He stated that he was first taken sick four days previously with a rise of fever but no chill; that he had fever every day during the past four days, had pains in back, pains beneath lower border of ribs on each side, and that the bones of his limbs ached. He stated that VOL. XXI-11

his urine was high-colored, and that he thought it contained blood. He had taken no quinin, and the only medicines taken had been some compound cathartic pills and 30 drops of nitre the day before for his fever.

The patient was very lightly jaundiced, of hematogenous appearance. He was restless and somewhat nervous, but did not have the anxious, uneasy appearance of most patients with hemoglobinuric fever. His spleen was very slightly enlarged; there was some tenderness on percussion over both liver and spleen.

A fresh blood specimen was examined microscopically before quinin was administered. The examination revealed a few crescent intracorpuscular hyaline bodies. White corpuscles were conspicuously scarce. Little malarial pigment was noticeable. Blood corpuscles were of good color and lacked the expected pale appearance. This examination was made on the morning of admission and the day of decline of fever.

The urine was smoke-colored and of dark red appearance. There was a heavy brown deposit of blood; acid reaction; sp. gr. 1.028. By use of centrifuge all sediment was thrown down and the upper portion of urine examined for albumin by nitric acid contact test. A distinct zone of albumin could be observed. Very little deposit of albumin with heat and nitric acid could however be obtained. The sediment thrown down was then examined under the microscope and found to contain principally hematine, innumerable large phosphate crystals, no distinct blood corpuscles, and no casts.

Treatment. By reference to the temperature record the administration of quinin is rendered more interesting. 40 grains of quinin was given every other day. Under this treatment. the urine cleared up very much, and the patient improved up to the sixth day in the hospital, or about seventh day from the time of first attack of malaria, according to the patient's history. On the fifth day the temperature rose to 38°C. (nearly 1003 F.), bloody urine returned, but there was no suppression. For the next five days quinin was given, 210 grains being given during this time. There was no suppression and the urine gradually cleared up and was clear at the end of five days from the second recurrence. Occasional doses of sodium hypophosphite and seidlitz powders were given as laxatives. Whisky in the form of milk punch was freely given.

The patient's recovery from second recurrence was uninterrupted, he being discharged nineteen days from date of admission.

It will be observed that the last case reported differs very much from the first two in clinical symptoms and treatment.

In the first case, hemoglobinuria following chronic malarial poisoning, quinin was given up to appearance of bloody urine and none was given afterward, while in the last case (III) the hemoglobinuria following acute attacks of malaria, bloody urine was passed before any quinin had been taken, and after its appearance quinin was freely given without aggravating any symptoms.

It seems to me that to intelligently treat a case of malarial hemoglobinuria it is absolutely necessary to determine whether the malarial organism is active-as it most probably is in acute malarial subjects; or whether its activity is spent, which is most probably the case in chronic malarial subjects.

From the few cases I have seen no fixed nor definite conclusions can be drawn, but until my ideas shall be changed by the treatment of a larger number of cases, it shall be my practice to give quinin where there is any probability of remaining active malarial organisms; where the condition is more of a toxemia due to the spent activity of the organism, quinin shall be discarded. As a general rule, where the fever is of an intermittent type, or even of a remittent type with characteristic symptoms of chills, quinin should be given; on the other hand, remittent fever with slight variation in temperature range is not benefited by quinin.

The explanation that when sodium hyposulphite is taken, "free sulphurous acid is disengaged in the blood, and this agent is antagonistic to such an extent that it destroys the microorganism which is the real cause of the disease, and thus arrests corpuscular disintegration," is decidedly theoretical to me. To disengage in the alkaline medium of the blood sufficient free sulphurous acid to kill the malarial organism in the blood may be possible, but I have heard no advocates for curing other forms of malaria by its use.

I believe that the elimination through the bowels and kidneys of the poisonous products of malarial organisms is very essential indeed, and is of prime importance in treatment, whether quinin is given or not.

An expression of one of my old medical college professors