undue pulsation at the apex; pulsation in the epigastrium, neck, etc.; thrills, bulging of the chest, depressions, deformities, etc., are observed. Palpation. This includes changes in vocal and respiratory fremitus, displacements, and character of apex-beats. Percussion and auscultation of all organs toward which the symptoms may possibly point. In nearly all cases whose symptoms are the least suspicious of heart-lesions, such as "shortness of breath," the heart is carefully exam ined at all its valves. 3. Special examinations. This includes examination of urine, sputum, blood, and contents of stomach, according to the nature of the case. Urinary examinations are made chemically as well as with the microscope, and, whenever thought of importance, repeated two or three times a month. Sputum is examined in all cases which are suspected tubercular, and rarely is a diagnosis of phthisis made without having found previously the bacillus. Blood count is made when indicated, and contents of stomach examined wherever the diagnosis is made difficult by obscure symp toms. 4 Examination in other departments, such as the eye for cases of nephritis, the throat in tubercular patients, etc. How very important such a procedure is, it may be well to quote a few cases from our case-book, their history and subsequent diagnosis: E. F., male, complains of headache (fron tal), nausea, especially in the morning. No pains, appetite good, bowels regular, tongue good. No palpitation; some dyspnoea on exertion. Urine same as usual,-neither increased in quantity or frequency nor decreased. Color normal. No previous disease. Always healthy up to four or five months ago. No diseases of childhood beyond measles and whoopingcough. Family history good. R. G., female, 28 years, gives negative family history. Previous history negative, except severe headache for past six years. Present history, headache for past week; more severe than usual; at times vertigo. During attack feels nauseated, feverish, and complains of malaise. Bowels very constipated. Appetite fair. Tongue fair. Physical examination showed a marked mitral systolic murmur, and the diagnosis of mitral regurgitation was made. Under bromides and some sulphate of strychnia the heart's action became more normal and the abovementioned symptoms disappeared. M. H., male, aged 57, complains of malaise and general mental depression. Appetite good. Bowels regular. Had articular rheumatism fifteen years ago. Physical examination disclosed a mitral systolic murmur. Reduplication of second sound at aortic valves. H. G., male, 32 years, gives a phthisical family history. Had malaria twelve years ago. For four or five days before admittance complained of pain in lumbar region; general illfeeling; frontal headache; some dyspnoea. Coughs at times; little expectoration of white mucus. Physical examination showed bronchial breathing on both sides. Subcrepitant râles in left apex and subclavicular region. Examination of sputum. Tubercular bacilli. Laryngoscopical examination made by Professor Cleveland. Tubercular deposits. B. G., 16 years, male. Family history negative. Previous history good with the exception of spinal curvature caused by a fall when a baby. Complains of poor appetite, gaseous eructations, headache, soreness at times in right side. Bowels regular, appetite poor, tongue coated white. Physical examination shows weak and intermittent pulse. Mitral systolic murmur. B. G., male, 69 years, complains only of dyspnoea, most marked in the morning. Physical examination showed some changes Perfectly well otherwise. Frequent mictuin mitral valves, but no murmur. Urinary examination: Sp. gravity, 1010; acid reaction; amber color; albumin present; no sugar; hyaline casts and granular matter. Ophthalmoscopical examination: Marked retinitis, but no deposit. Diagnosis. Chronic parenchymatous ne phritis. rition. Urinary examination. Sp. gr., 1015; acid reaction; dark amber; albumin present; granular and epithelial casts; epithelial débris. B. F., female, 52 years, complains of headache at night about 12 o'clock, with flashes of heat. Dyspnoea, but only in the recumbent position. Otherwise perfectly well. Urinary examination showed low specific gravity, the | citated by Nélaton's method. It is rather sinpresence of albumin and casts. gular that these patients were mother and son. Possibly idiosyncrasy of an hereditary character was accountable for this phenomenon. I keep a record of every time I give an anæsthetic, in which are mentioned all the particulars of the case, with the name of the operator. While this record is not very extensive (since I have been in practice but eight years), I have an advantage over those men who boastingly say that they have administered it thousands of times, but yet have nothing to substantiate their assertions. Then, too, I make mention only of those cases in which I myself am the administrator. I have no record of those instances (which are numerous) that I have witnessed, on which occasions others have given the anaesthetic. Ether I have given but twice, and then I did so only because the operator insisted upon Lecturer on Applied Therapeutics in the Baltimore University its use. I would never employ it voluntarily, as its action is slow, it causes great irritation School of Medicine. N the choice of an anesthetic I invariably of the respiratory passages, it frequently pro indefatigable efforts of the advocates of ether to prove its superiority have failed to convince me of any advantage to be derived from its administration. I hold to this opinion notwithstanding the fact that I graduated from an institution (the University of Maryland) in which but one of the professors (that of Ophthalmology and Otology) ever employed chloroform. At that time all the others strongly condemned it and extolled the virtues of sul phuric ether. I do not believe that the latter is safer than chloroform. Many reasons could be given for this view if such were the object of this article. This point has been ably considered in a paper which Prof. J. J. Chisolm, M.D., LL.D, read a few years ago before the Baltimore Academy of Medicine. Like that distinguished gentleman, I believe that any one who is a fit subject for a surgical operation may take chloroform. I lately administered it to a man who had a pronounced mitral regurgitant murmur. During the operation (amputation of two fingers) the action of the heart became weak, but this was easily overcome by the hypodermatic injection of nitroglycerin (gr. Too). I have never seen a death from chloroform narcosis. Twice while I was administering it the patients ceased to breathe, but, the action of the heart remaining good, they were resus At a meeting of the Baltimore Medical Association, held March 25, 1889, I heard Dr. Thomas A. Ashby, then president of that body, report the case of a man in whom the inhalation of chloroform produced a convulsion having the characteristic features of puerperal eclampsia. This was the first case of the kind that he had ever seen or heard of. He was unable to explain the occurrence, especially as chloroform so often relieves this affection in women. In the early part of the year 1886, while a student in this city in the office of Professor Alfred Whitehead, M.R.C.S.Eng., I administered chloroform to a patient upon whom that gentleman operated for the relief of congenital phimosis. The vapors of the anesthetic caused considerable irritation of my throat and much coughing, for which, at the time, I was unable to account. It did not occur to me to attrib- | ment. That the nervi erigentes are sometimes ute this effect to the chloroform, until the night for it produced the same irritation of the PRELIMINARY NOTICE ON THE throat with its attendant coughing. On October 20, 1891, I gave chloroform to an old lady over 80 years of age before sewing up an extensive wound of the scalp. I was again troubled with the same irritation of the throat and coughing. A singular feature in this connection is the fact that chloroform does not always affect me thus. Although I had administered it quite a number of times since February 11, 1889, in no instance since that date had it annoyed me in this manner until this occasion. Although I had given chloroform frequently since the last-mentioned instance, I was not again affected thus by its vapors until Decem. ber 21, 1894. I then administered it for another physician, who operated upon his brother for the cure of an incomplete fistula in ano. I felt the same irritation of the throat, which produced the same amount of coughing. Having experienced this discomfort from chloroform on a sufficient number of occasions to convince me that it is really due to its vapors, I now make it a rule, when administering this anesthetic, to assume such a position that I shall inhale as little of it as possible. THE SOURCE OF MALARIA. BY IRVING H. BACHMAN, PH.D. HE investigation on the source of malaria has had the writer's attention for over two years, and in that time a large amount of clinical testimony has been collected from all known malarial districts in North America; the final report, however, will hardly be ready for publication before next year, but from the work already completed certain facts have been obtained which will be embodied in this short notice. The introduction of artesian wells, first by the railroad companies who desired a larger supply of water than had hitherto been available, and the accidental use of that water by the people in the immediate vicinity soon produced a marked diminution of malarial trouble in those localities. The artesian supplies were, on the whole, so satisfactory to the railroads that their introduction became very rapid, and in a few years most of the South Atlantic lines depended upon this source of water-supply. The evidence that in the exclusive use of the deep-seated waters there was entire immunity from malarial trouble was apparently so incontestible that I determined upon a critical examination of all waters known to produce malaria and those that in malarial districts were proof against it; this examination is not only chemical, but biological and pathological. I am indebted to Dr. Percy Stansbury, of this city, for the following case: In the spring of 1895 he administered chloroform for another physician, who was about to remove a congenitally elongated prepuce. The patient, under the inhalation of the vapors of this anæsthetic, became thoroughly relaxed in every respect In the present state of our knowledge we do but one. The conjunctivæ could be touched not expect to be able to draw a sharp line bewithout the man's flinching, and the arm, tween waters that produce malaria and those when elevated and allowed to fall, was per-proof against it by purely chemical analysis, fectly limp, but there was persistent priapism. nor, on the other hand, can we hope to identify This lasted until the effects of the chloroform by biological examination the protozoa prohad subsided,—about three-quarters of an hour. ducing that trouble; but we may by the former The experiment was tried several times, but succeed in isolating certain toxic products always with the same result. Finally, ether peculiar to those waters only, and by the latter had to be employed before the operation could a certain line of testimony that, in conjunction be performed. This case is unique in that the with the chemical investigation, will yield very erection persisted beyond the stage of excite- | valuable results. The work thus far has proven satisfactory beyond expectation, and, from the work already done and the character and amount of evidence before me, I am justified in stating that the long current belief that the source of malaria is in the air is in error. The germ, which is of soil-origin, is strictly a protozoa and reaches its highest development in low, moist ground with a favorable temperature. Surrounded by the proper soil-conditions, this protozoa passes from one stage of life into another with considerable rapidity; so that in the present state of our experimental knowledge it is impossible to identify it, nor is it probable that by culture we shall be able to produce the accepted Laveran germ outside of the human system. As a rule, the potable water from the malarial districts is derived from driven wells not over twenty-two feet deep, in soil with clay or some other impervious substrata, which water is generally cool and palatable, often sparkling clear, but more frequently a little turbid. This water is filled with an incalculable number of these germs in all stages of development, and if used as a potable water they naturally find their way into the system through the alimentary channel. This protozoa passes through so many forms or stages of life that in some stages it is light enough to float and be transported by the moist air of low grounds, but in this state it is comparatively harmless except under most extraordinary conditions; it is not until the surface-water is used that the real mischief begins, when, by reason of higher development, it has become much more virulent than that floating in the air. A very short period of in cubation is sufficient to develop a severe case of malarial fever in the new comer who uses the surface-water. From personal observation I know that the exclusive use of pure, deep seated water affords entire immunity against malaria in sections of country where no white man dared live using the surface-water. Nor must it be understood that the exclusive use of pure water simply fortifies and strengthens the system against the attack of the germ. The water is the primary cause of infection, which acts as the direct carrier of the germ into the system through the intestinal tract. R. APOSTOLI, together with Dr. Ber Dioz, on the 18th of March, 1895, DR. presented a paper on the above-mentioned subject to the Academy of Sciences of Paris. He now, after longer and riper experience, desires to present a summary statement of his general conclusions :— 1. According to Professor d'Arsonval's discoveries, alternative currents of high frequency and of high tension exert a powerful action upon all living bodies submitted to their inductive influence. 2. The best method of applying these induced currents is to place the patient, free from all contact with electrodes, in the circuit of a large solenoid traversed by these currents. The patient being thus completely insulated, the currents, which circulate in his body by autoconduction, have their origin in his tissues. The body plays the rôle of a closed induced circuit. 3. By this method the physiological discoveries of Professor d'Arsonval are confirmed, and we are able to prove the powerful influence of these currents upon the vasomotor system; although they produce absolutely no sensation and although they have no apparent effect upon the motor or sensory nerves. These currents have, nevertheless, a powerful action upon all the nutritive functions; as has been verified by Dr. d'Arsonval's numerous analyses of the gaseous products of respiration. and by Dr. Berlioz's not less numerous analyses of the urinary excreta. The impression that malaria is caused by purely atmospheric influences has become so fixed in our minds that, unless we come in actual contact in the evidence produced in the meeting in London, 1895. * A paper read before the British Medical Association at the 4. The general therapeutic applications to be deduced from this physiological action are confirmed by clinical observation. Dr. Apostoli has now treated more than a hundred patients by this method, at his clinic and at his private consultation rooms. The greater number of these patients have been greatly benefited by this new treatment, which, be it remarked, has been used to the exclusion of all other forms of medication, dietetic or otherwise. 8. The diseases which have appeared incurable by this treatment are those not associated with well defined organic changes, such as hysteria and certain forms of neurasthenia. Dr. Apostoli has also observed that certain localized neuralgias are refractory to this form of currents; they require its more direct local application. 9. The diseases which have derived most benefit from this therapeutic agent belong to the arthritic class, -rheumatism and gout. 5. These currents exert, in the majority of cases, a most powerful and generally beneficial action upon diseases due to slackening of the nutrition by accelerating organic exchanges and combustion. This is proved by analyses of the urine made by Dr. Berlioz, of whichment in the general condition. the following is a brief résumé :— 10. In certain diabetic subjects the sugar has disappeared altogether from the urine under the influence of these currents, while in others there has been no such change, notwithstanding the manifest and constant improve The quantity becomes more normal; the products of organic waste are better eliminated. The increased combustion is shown by the diminution of uric acid, while the percentage of urea is generally increased. The relative proportion of these two substances changes under treatment so as to reach, in general, the figure of 1 to 40. The elimination of the mineral products is also changed, but in a manner less marked. 6. When daily séances are given, each lasting fifteen minutes, we may generally observe, in patients submitted to the influence of these currents, the following modifications in their general condition. We mention them in the order of their occurrence :— Return of sleep. Increase of strength and vital energy. Increase of gayety, of power for work, and ability to walk. Improvement of appetite, etc. In short, general progressive improvement. This general improvement often manifests itself, after the first séances, before any local Is this difference due to the imperfection of the electrical apparatus, or to the manner of its application? It is hoped that further experience will soon afford an answer to this question; although the fact that diabetes has many different causes may, in itself, explain the difference in the results obtained by this treatment. 11. In conclusion, the currents of high frequency and of high tension, introduced into electro therapeutics by Dr d'Arsonval, greatly increase the field of action of medical electricity. They furnish general medicine with a new and valuable means of treatment, capable of modifying more or less profoundly the processes of nutrition. THE DIAGNOSIS OF ACQUIRED By J. M. KOCH, M.D., influence is apparent and before any change SIN has occurred in the urinary secretions. 7. Local pain and trophic changes are often more slowly affected by these currents, and at times they are entirely refractory for a longer or shorter period. INCE the time of Ricord the manifestations of syphilis have been classified, according to their type, into primary, secondary, tertiary, and, by some writers, into quartenary syphilis. This seemingly arbitrary division of one continuous, chronic, constitutional disease into three periods was determined by his large experience,-firstly, by the manner of possible infection, and, secondly, by the In such cases the same currents must be applied locally, by contact with the electrodes. This subject will be treated later on, in a localization of the symptoms. Thus, the separate communication. primary, or local, stage was that in which in |