ON THE TREATMENT OF CHRONIC MALARIAL DISORDERS.-S. S. Cohen, M. D., recently read before the Philadelphia County Medical Society a paper on the management of obstinate intermittents, from which we copy (Polyclinic) the following:

In my own experience, the most effective salt of quinine is the so-called bimuriate of quinia and urea used hypodermically in doses of fifteen grains. It is perfectly soluble in its own weight of water, and hence adapted for use hypodermically. The objection to it is, that unless extreme care is taken not to allow a drop of the liquid to touch the skin, and, sometimes, in spite of every precaution, an abscess may result. I paint the arm around the point of puncture with tincture of iodine in order to prevent this.

1. That quinine salts are of greatest value in those cases of chronic malaria showing a distinct periodicity, and especially if there be a febrile paroxysm; and that in such cases their chief value is prophylactic, rather than curative. That the administration of quinine until relief is manifested, and then the withdrawal of the drug, will sometimes bring out a periodicity otherwise masked. The bimuriate of quinia and urea, hypodermically, is the preferable salt in acute or subacute exacerbations occurring in the subjects of malarial cachexia.

2. That in cases where the patient is much run down and exposed to unsanitary conditions, iron should be a part of the medicinal treatment.

3. That where the most prominent symptoms are connected with the nervous system, including apparent pulmonary, cardiac, intestinal or gastric troubles, arsenic is indicated.

4. That where the most prominent symptoms are rheumatoid or myalgic in character, salicin, or some of its derivatives or compounds, is of advantage; cinchonidine salicylate, by preference, in order to obtain the anti-malarial virtues of the cinchona alkaloid. Cinchonidine salicylate is also of use in maintaining an effect produced by quinine, after the withdrawal of that drug, and is superior to quinine where the paroxysmal manifestations are vague and irregular.

5. That iodine is of some benefit when administered alone, and of decided benefit when combined with other remedies.

In the discussion to which Dr. Cohen's paper gave rise, Dr. J. C. Wilson said: "With the bimuriate of quinia and urea hypodermically, I have had no experience except in one unfortunate case, in which a serious sore resulted."

Dr. Collins said that he began using the bimuriate of quinia and urea two years ago, and found it a desirable remedy.

Dr. Watson had observed that in cases of a rheumatic type salicin has seemed to act more promptly than the salicylic acid compounds. Salicin and arsenious acid have seemed more efficient than quinine. In chronic intermittent. fever he thought the best treatment iodine and arsenic. The combination of iodide of iron and arsenious acid is often sufficient, without resorting to any thing else. In chronic remittents, strychnia, quinine, and piperine answer well.

Dr. Wm. T. Taylor said: "My treatment has generally been large doses of quinia, and, as a rule, I have not failed. I give from fifteen to twenty grains, producing buzzing in the head. I believe that one large dose will do more good than small doses from time to time. Although afterward I may continue the remedy in moderate doses, yet on each septenary I give a full dose. Where they are indicated, I also use arsenic and iron."

Dr. James Tyson remarked that in regard to the hypodermic use of quinine in obstinate malarial affections, he formerly feared to use the salt in this manner, because of a horror of abscesses, and he never did use it freely until a year ago. He found by experiment that one dram of water would dissolve seven and one half grains of the bisulphate of quinia. The Pharmacopeia says it is soluble in the proportion of one to ten, the sulphate one to seven hundred and forty, the hydrochlorate being soluble in the proportions of one to thirty-four. He began the treatment by injecting this quantity (seven and one half grains) night and morning. In one case treated in this way, the paroxysms of chill and fever disappeared in two days and did not return. There is no more irritation than follows an ordinary hypodermic injection. He says he has never had an abscess from it.

Dr. Carl Seiler said that he had found that the taste of quinine can be almost entirely disguised by mixing it with an equal quantity of extract of glycyrrhiza and powdered chocolate. This is placed, dry, on the tongue, and washed down with a mouthful of water. About the only taste noticed is that of chocolate.

Dr. Cohen concluded by saying: "I do not use the bimuriate of quinia and urea as a routine measure, or where the patient can be readily brought under the influence of quinine by the mouth."

PELVIC ABSCESS IN WOMEN; ITS TEATMENT. Dr. Munde concludes an able paper on the treatment of pelvic abscess in women with the following summary:

1. Pelvic abscess in the female is not very common, in proportion to the great frequency of pelvic exudations, and probably does not

occur in more than ten per cent of all cases, the majority of exudations terminating in spontaneous absorption.

2. Pelvic abscess may be either extra-peritoneal, the result of cellulitis (by far the most common variety), or intra-peritoneal, the consequence of pelvic peritonitis. If intra-peritoneal, the adhesive inflammation between pelvic viscera and intestines may so seal the abscesscavity as to render it practically extra-peritoneal.

Abscess of the ovary and pyo-salpinx do not belong in the category of "pelvic abscess" proper, and do not fall under the same therapeutic rules, unless when, by agglutination to the abdominal wall or to Douglas's pouch, they become virtually extra-peritoneal.

3. Small, deep-seated pelvic abscess, not exceeding a capacity of two ounces, and minute multiple abscesses in the cellular tissue, can often be permanently cured by evacuating the pus thoroughly with the aspirator. The surrounding exudation is then rapidly absorbed.

4. About one half the abscesses 'open spontaneously into the vagina, rectum, bladder, or through the abdominal wall and ischiatic fossa. These cases may gradually recover without treatment, or the sinuses may persist until closed by surgical interference.

5. Abscesses containing more than two ounces of pus should be opened by free incision along an exploring needle or grooved director, cleared of debris by finger or blunt curette, and drained and irrigated, if necessary, through a drainage tube."

6. This incision should be made at the spot where the pus points most distinctly, which is usually the vaginal vault.

7. In a certain number of cases the pus points through the abdominal wall, generally in the iliac fossa, and the incision should then be ample, and free drainage should be secured.

8. When the pus has burrowed deep into the pelvic cavity, and a probe can be passed from the abdominal incision down to the vaginal roof, mere abdomino-cutaneous drainage will not suffice, and a counter-opening must be made into the vagina, and a drainage tube carried through from the abdominal wound into the vagina. This drainage tube may have to be worn for months. In making this incision care should be taken not to wound the bladder.

9. The opening of a pelvic abscess which points through the abdominal wall does not differ from, and is no more dangerous than the same operation elsewhere on the cutaneous surface of the body. It is not an "abdominal section" or a "laparotomy," in the sense that these terms are now used to indicate the surgical opening of the peritoneal cavity.

10. Chronic pelvic abscesses, which have burst spontaneously, and have discharged through the vagina, rectum, or elsewhere for months or years, are exceedingly difficult to cure. This is particularly the case when the opening is high up in the rectum. A counteropening in the vagina, or enlarging the opening if there situated, the curette, stimulant irrigation, etc., may occasionally succeed, but usually fail.

11. A perityphlitic abscess may point through the abdominal wall, and simulate a pelvic abscess proper. Aspiration will settle the diagnosis; the treatment is the same.

12. The majority of cases of pelvic abscess recover, at least the mortality is small.--American Journal of Obstetrics.

ACETONEMIA AND ALBUMINURIA IN DIABETES. At the conclusion of a recent discussion of the clinical aspect of glycosuria, Dr. F. W. Pavy (Lancet) remarked:

fact

I may say at once that I do not believe in the theory involved in the term "acetonemia." Of course the coma is not a matter for belief; we all know that patients are very apt to die in a comatose state -a I mentioned in my work on diabetes, the second edition of which was published in 1869; and the same observation had been previously recorded by our countryman, Dr. Prout. Why, therefore, it should now be called Küssmaul's coma I can not conceive, seeing that he only described it in 1874. So far as I am enabled to judge, this comatose state arises from a deprivation of power in certain nerve centers, and thus fatigue, or any thing which tends to throw the patient off his balance, will tend to produce it. I have often met with it in patients who have undertaken a long journey to see me. They were buoyed up by hope on their way to London, but, when they presented themselves in my consulting-room, I have been enabled even then to recognize the first indications of the advent of coma, and the patient has died in the course of a day or two. I am inclined to consider that the coma depends, as I have said, rather on the exhaustion of certain nerve centers than on the action of any direct poison in the blood. A simple attack of vomiting may lead to it in a diabetic patient who has not been able to eat any thing for a day or two. It is usually ushered in by a rapid pulse and a peculiarity in the breathing. There is a breathlessness or out-of-breath condition, not dependent on any impediment to the entrance of air into the chest, but simply as though the patient were unable to get sufficient for his requirements in the peripheral parts of the system. He becomes drowsy, and this deepens into a comatose

state, terminating in profound coma and death. It has long been known that a fatty condition of the blood is frequently observable in diabetes, and this has been suggested as a possible explanation of the coma, through the production of fatty emboli. But I maintain that this fatty condition of the blood is a purely physiological state. Fat shows itself normally in the blood after the ingestion of a meal containing much fatty matter. When formerly lecturing on physiology, I used to demonstrate this in the blood collected from an animal shortly after the free ingestion of fatty substances, and which, after standing for a little time, presented a well-marked cream-like layer on its surface from the aggregation of the fatty particles. It is, I repeat, only a physiological condition, and its presence in the blood of diabetic patients may be accounted for by the great amount of food they take, and especially from the fatty nature of a large proportion of it.

Albumen is sometimes present in the urine in diabetes, and may continue for years with out being accompanied with any serious results. Not unfrequently a decided quantity of albumen at the commencement of treatment may decrease and disappear as the patient improves. When present in small amount, I do not attach any significance to it.

Other cases however exist which pass on to well-marked Bright's disease; and it is to be noticed that generally, as this condition becomes established, the diabetes shows a tendency to subside. I remember a lady with diabetes who became the subject of Bright's disease, and the sugar entirely disappeared from her urine in a manner that permitted her taking any kind of food without passing sugar.

THE PREVENTION OF CHOLERA.-The Lancet draws the following important lesson from a survey of the five visitations of cholera at Gibraltar :

While the cause of cholera is still unknown, and its mode of propagation a disputed question, it is very satisfactory to find that the efficacy of sanitary measures in preventing the development of the disease has been well established. Of this there can be no stronger evidence than that afforded by the history of the late epidemic at Gibraltar. Since the disease first appeared in the Mediterranean, it has broken out five times in Gibraltar. These epidemics occurred in 1834, 1854, 1860, 1865, and in the past summer. In the first, the cases among the total population, civil and military, amounted to 81 per 1000, and the deaths to 19.78; of the epidemic of 1854 we have no details; in 1860 the cases only amounted to 7.7, and the deaths to 3.57

per 1000; the epidemic of 1865 was very severe, the ratio of cases having been 43.8, and of deaths 23.96, while in the present year it was only 1.36 and 0.99 per 1000. This marked exemption, compared with previous outbreaks, and with the prevalence and mortality in the adjoining Spanish town of La Linea, may, we think, be fairly attributed to the great sanitary improvements introduced into the garrison after the severe epidemic of 1865. On that occasion a new system of drainage was begun and has been carried out; since then a well has been sunk on the north front which affords an abundant supply of water, and although it is not of a quality suitable for drinking, it furnishes ample means of cleanliness and for the purposes of conservancy. The drinking-water in Gibraltar is almost entirely rain-water, collected and stored in large tanks. In addition to this, during the late epidemic, the governor, Sir John Adye, brought into operation some condensing machines by which an additional supply of fifty-two thousand gallons per week of pure water was obtained, and distributed at a very moderate price. Before the outbreak of the disease all the usual sanitary precautions connected with flushing the sewers, emptying dust-bins, cleansing and disinfecting dwellings, etc., where necessary, were brought into operation, and, on its appearance, house-to-house visitation was adopted. Arrangements were also made for the distribution of food to the people who, by the want of employment arising from the imposition of quarantine, had been deprived of their ordinary means of subsistence. The result of these measures in checking the progress of the disease in the garrison has been too well marked to require further comment, and can not fail to prove a useful stimulus to their adoption elsewhere under similar circum

stances.

THE REFINED TESTS FOR ALBUMINURIA.In the last few years there has been a considerable revival of interest in the subject of albumen tests. The old method of boiling the urine and adding a drop or two of nitric acid has fallen more and more into disuse by those skilled in detecting albuminuria. Many have been the substitutes proposed, and imposing is the roll of names of the proposers. Among them are Dr. Pavy, Dr. George Johnson. Dr. Roberts, Dr. Oliver, and others. Indeed, the tests have been named after these gentlemen, and we hear of Dr. Pavy's ferro-cyanide pellets, Dr. George Johnson's picric-acid test, Dr. Roberts' brine test, and Dr. Oliver's testing papers. Besides the above-named reagents, we have sodium tungstate, potassio-mercuric iodide, and mercuric-iodo-cyanide. With all

these tests, except perhaps Dr. George Johnson's picric acid, it is recommended to use citric acid; some say that the picric acid test is improved by the use of citric acid. All of these tests can be used cold, and thus a great hindrance in bedside testing is done away with. It is difficult to say which is the most sensitive of these tests. Dr. Pavy's is certainly very sensitive, ready, and easy of application, and its portable form very strongly recommends it. The harmless and permanent nature of the materials, too, are great advantages. The only question that arises out of a precipitate with this test is that of peptones, and it is generally admitted that it does not deposit peptones; so that, as far as we know, we may have absolute confidence in it. The great question now for physicians is, What importance is to be at tached to the quantities of albumen detected by such refined tests? We have been too much in the habit of judging albuminuria by its coarser forms, and even these have been known by physicians to cover almost a lifetime. We shall be grateful now for more investigation into (if we may so speak) the physiology of albuminuria.--The Lancet.

NUTRIENT SUPPOSITORIES.—A case was related by Mr. God lee, for himself and Dr. Barlow, at the last meeting of the Clinical Society, in which the advantage to be derived from nutrient suppositories was well exhibited. The patient, as will be seen from a perusal of our report of the meeting, suffered from typhlitis. Mr. Godlee opened the abscess cavity, and allowed a large quantity of fetid pus to escape. The patient eventually quite recovered, without any palpable evidence of the thick bands of inflammatory material which are so troublesome in many cases treated on expectant methods, and had since had no sign in any way of any trouble whatsoever about the cecum. Dr. Barlow, speaking of the diatetic treatment after the operation, remarked "that in this case it was especially desirable to keep the stomach and intestinal tract at absolute rest. For many days, therefore, the very minimum of food, namely, a little barley-water, was given by the stomach, and the patient was fed by the rectum. The thirst was found to be entirely relieved by enemata of three quarters of a pint of water, which were in all cases absorbed. With regard to rectal alimentation, it is often observed that after two or three days the rectum becomes intolerant of nutrient enemata. To avoid this result, food was given in the form of digestive suppositories. Of these, two very convenient forms were made by Mr. Gerrard, dispenser at University College Hospital. The first was made by diluting a good meat-extract with

water, and peptonizing it with Bullock's pepsin, neutralizing, and then concentrating, to a soft paste. Cocoa-butter was then added in fine shavings, and mixed with one third of its weight of the peptonized meat-extract, and rolled into cones weighing one hundred grains. The second was made by peptonizing milk with pancreatic solution, boiling and concentrating to a paste, mixing and dividing as in the first case. Peptonized milk being now sold in a concentrated form, it may be used instead of ordinary milk, which saves much time and trouble. The suppositories were certainly absorbed, and kept the patient going for several days. One was introduced about every three hours. His tongue became very dry, and after a time he was given some pieces of underdone chop, which he was allowed to chew and swallow the juice derived therefrom, but not the fiber. Besides maintaining his nutrition fairly, the patient, who was rather an irritable, querulous subject, was satisfied and comfortable, and the advantage in keeping his abdomen quite quiescent was very great indeed." If other cases should confirm the favorable impression as to the advantages to be derived from this method of feeding, when contrasted with the failure which in a few days generally results from the attempt to sustain life by nutrient enemata, as the rectum generally soon becomes intolerant of them, there will doubtless be found a wide use for these suppositories in the very large class of cases in which the stomach requires to be kept at rest. requires to be kept at rest. It may be found, too, that the liquid which the system requires daily may be in some cases administered by the stomach; this would tend still less to the disturbance of the lower bowel, and leave it still more at rest to digest and absorb the suppositories.—British Medical Journal.

ESSENTIAL SHRINKING OF THE CONJUNCTIVA. At a recent meeting of the Ophthalmological Society of the United Kingdom, Mr. Anderson Critchett and Mr. Juler showed two patients, the subjects of essential shrinking of the conjunctiva (so-called pemphigus of the conjunctiva). One case-that of a farmer, aged fiftythree-was of special interest, as it had been under observation from its commencement. He came under Dr. Felix Semon's care in September, 1884, on account of an affection of the right nostril, which resembled syphilitic perichondritis and periostitis. In June, 1885, he was transferred to Mr. Nettleship's care, on account of epiphora and conjunctivitis, with partial obliteration of the lower cul-de-sac. The conjunctiva of the upper lid was marked by scars parallel to the free border. The affection went on progressively from bad to worse in the

right eye; and in August, 1885, slight conjunctivitis of the left eye was noticed. The right eye had finally become almost blind. Both eyelids were thickened, and partly adherent to the globe. Both culs-de-sac were obliterated; and, though the globe moved pretty freely, the lids moved with it. The lashes were inverted, and the cornea opaque and vascular. Similar shrinking of the conjunctiva had commenced in the left eye; the lashes were turning inward; and the culs-de-sac were so much diminished that the lids could not be everted without difficulty. The conjunctiva was red and velvety, but showed no scars. Vision was still fairly good. The man gave a distinct history of syphilis ten years earlier. No sign of pemphigus could be discovered on the body, though the man stated that he had seen bullæ on his palate. Mr.Critchett expressed the opinion that the condition had no relation to pemphigus, but was an essential shrinking of the conjunctiva, similar to that described by Gräfe and Bäumler. Dr. F. Semon said that the patient came under his care in September, 1884, suffering from a muco-purulent discharge from the nose, which was sometimes streaked with blood. Beyond slight superficial ulceration of the mucous membrane, there was nothing to account for the symptoms. At that time the only part affected was the left nostril. Mercury and iodide of potassium, given separately and in combination, produced no improvement; but, while he was under this treatment, on one occasion, several large bullæ appeared, and the skin of the face was in a brawny condition, resembling erysipelas. This subsided after withdrawing the drug. Conjunctivitis soon afterwards appeared, and some small serpiginous ulcerations of the mouth. He had been impressed by the infective character of the malady, and had suggested that it might be a case of very slowly advancing glanders.-Ibid.

OPIUM-POISONING THROUGH MOTHER'S MILK. On November 17th Dr. William T. Evans writes:

I attended Mrs. T. in her eighth confinement, which was natural, although rather tedious in its first stage. She was delivered of a fine, healthy female child about 1:30 P. M. I left her a dram of liquor opii sedativus, to be taken in four doses, at intervals of four or five hours, if required, for the afterpains. On visiting my patient the next morning, I found she had had no sleep, on account of the severity of the after-pains; I therefore sent her six doses, of twenty minims each, of liquor opii, to be taken as before. say that this patient had, on former occasions, suffered in an unusual degree from these pains.)

(I may

On the 19th, I found, on my visit, that she had had about three hours' sleep, but that the after-pains were still troubling her about every fifteen minutes. I therefore repeated the medicine I had ordered her the day before. On the 20th, I found she had had more sleep than on the previous night, had finished the medicine, but was not at all drowsy, nor under the influence of opium in any way, except the relief it had afforded her from her pains. The milk came into the breasts during the night, and at 4 A. M. the child was put to the breast, and sucked well. It took it again about 7 A. M., but not quite so freely as before. Up to this time the infant had been fed on milk andwater and gruel. At my visit, it appeared to be comfortably asleep, so much so, that the nurse had not washed it. At 2 P. M., I was sent for, with the request that I would go at once. I did so, and found the infant very drowsy. On examination, the pupils were contracted almost to the size of a pin's head. The respiration was slow and tranquil. The countenance wore a placid expression, like a child in a natural sleep, and was rather pale. The skin was moist with perspiration. roused the child with difficulty, but it relapsed at once into its former sleepy state. From these symptoms, I diagnosed the case as one of opium poisoning, and ordered the nurse not to lay the child down, but to constantly rouse it, and give it frequently strong coffee (with milk) as a stimulant. I also cautioned her not to put the child again to the breast. A few hours later, as there was no improvement, I ordered liquor ammoniæ to be dropped on a pockethandkerchief and applied to the nostrils. I was sent for about midnight, and, on arriving, found the child had ceased breathing. I performed artificial respiration for about half an hour, but without avail; the child was dead.

I

At the inquest, the coroner informed me that he had never met with a similar case; therefore I thought it would be interesting, to record it as a case of opium-poisoning communicated to the infant through the medium of the mother's milk, and at the same time to put medical men on their guard against allowing an infant to take the breast where it is necesary to give large and continuous doses of opium to the mother.-Ibid.

DYSPEPSIA-CAUSE OF FUNCTIONAL INDIGESTION. (1) Eating too rapidly. (2) Drinking too much water at meal time. (3) Improper food. (4) Want of exercise. (5) Too much tea and coffee. (6) Too much tobacco. Treatment: Under-done meats and but little bread. No sweets. Saccharated pepsin, five grains at each meal. The mineral acids before