NOTES: AND ITEMS

these than in other forms. The employment of leeches the bacteria found in human milk. Various observers and blisters may be of some use, but the principal med- had reported having found the streptococcus, both in icine to employ is potassium bromide. It may be used healthy milk and in that from mothers suffering from in all the milder forms of the affection, but when it is a puerperal fever. Escherich examined 25 women. Of question of true mania it must not be forgotten that, in these, 24 specimens were sterile and 1 contained bacilli. addition to opium, morphine, and atropine, tartar eme. He again examined 13 with puerperal fever, and found tic in weak doses constitutes a very efficacious sedative, staphylococcus in 12; 4 being of the white and yellow which is extensively used in England, especially in cases variety intermixed; 8 the white only, and 1 of an uncer. of this kind.-N. Y. Med. Jour. tain form. Cohn and Neumann experimented on 43 cases of milk from healthy women, and found 36 containing staphylococcus albus, 1 staphylococcus aureus and pyogenes, 3 staphylococcus pyogenes albus and streptococcus pyogenes; in 2 all the above forms were united. The writer made a series of investigations, drawing and using milk from the deeper parts of the breast only, the experiments being made under the strictest antiseptic precautions. The milk was taken from 12 healthy and 13 unhealthy patients. The results mens contained staphylococcus pyogenes albus; 2 speci were as follows: 3 specimens were sterile; 17 speci mens contained staphylococcus pyogenes aureus; 1 specimen contained staphylococcus pyogenes albus and Hygiene of the Teeth. In a communication to aureus; 2 specimens contained staphylococcus pyogenes the Berlin Medical Society, Dr. Ritter reported that albus and streptococcus pyogenes. An examination of after having examined the teeth of 637 persons, more the months of nursing infants revealed corresponding than half of whom were under 15 years of age, he found only 4 with sound teeth. On this basis the number of individuals with their teeth in good condition is only about 6.2 per 1000, which shows how necessary is a scrupulous hygiene of the mouth and teeth.-Jour. d. Hygiene; Jour. Amer. Med. Ass'n.

American Orthopedic Society will hold their Ninth Annual Session at the Columbia Memorial build ing, 103 State street, Chicago, Sept. 17 to 19, 1895. A large number of papers by leading orthopedic surgeons, both of this country and from abroad will be presented and discussed.

Epidemic Spread of Cholera in Japan.Much anxiety is felt in Japan lest the cholera scourge extend throughout that country, notwithstanding the efforts made by the sanitary officials. The Japan Ga. zette, August 1, published in Yokohama, has the follow. ing paragraph compiled from facts given by native au

thorities:

"Fears are entertained in some quarters that this year may prove one of the most calamitous Japan has wit nessed for many years past. To begin with, cholora broke out in the country early in the year, slowly but steadily working its way even to the remote corners of the Empire. Though stringent precautionary measures are taken by the authorities, and the exceptionally cool weather has been prevailing, and the malady has so far been prevented from general spread in a city like Tokyo, we are still in the middle of summer, and the worst may yet be brought about. In Osaka, Hiroshima, and other western cities, the disease shows uo signs of abatement. The official report to hand puts the total fatalities from cholera up to the 28th, noon, at 6,592. This is by no means a small figure, though it is small compared with that in 1883 and the year following."-Jour. Amer. Med. Ass'n.

Bacteria in Human Milk.-Dr. Ringel contributes the report of a series of investigations upon

bacteria in their secretions.-Amer. Jour. Med. Sci.

The Weber-Parkes Prize.-This prize was founded by Dr. Hermann Weber in memory of the late Dr. E. A. Parkes. It is of the value of about $750, and will be awarded triennially to the author of the best essay upon some branch of the subject of tuberculosis, especially with reference to pulmonary consumption in man. The first award will be made in 1897, and the adjudicators have selected as the subject for the essay "The Means, Proplylactic, or Curative, deemed by the Author to have Value in the Control of Tuberculosis, especial Regard being had to their Application to Human Tuberculosis." This subject was selected by Dr. J. E. Pollock, Dr. Thorne Thorne, and Professor W. S. Greenfield, who were nominated by the President of the Royal College of Physicians of London, and the merits of the competing essays will be determined by the same men. The essay must be based on original work and observations (experimental or other) of the author, and must include a detailed exposition of the methods employed and their mode of application. The competition is open to members of the medical profession in all countries. The essays must be type-written and in English; or if written in a foreign language must be accompanied by a translation into English. The essays must be delivered to the Registrar of the Royal College of Physicians on or before July 1, 1897. In addition to the money prize a bronze medal will be given to the holder of the prize, and a second medal to the essayist who comes next in order of merit. Further information for the guidance of competitors may be ob tained by addressing the Registrar of the College, Dr. Edward Liveing, London, England.

MEDICAL REVIEW.

A WEEKLY JOURNAL OF MEDICINE AND SURGERY.

The formerly so called scrofulous glands were simply methods in vogue. It is a well-known fact that large cases of tuberculosis.

better results than an active operative therapy. These of the left tibia, one of the sternum and has had two ab. facts find a ready explanation in the circumstances under scesses of the lower jaw. He also has a tubercular nodwhich most early exsections of the hip-joint are carried ule in the skin of the scrotum and an abscess near the out. The depth of the diseased joint; the difficulty of liberating the head of the femur, still held down firmly by undestroyed ligaments; the desire of operating sub periastially, that is with the employment of a good deal of blunt force; the forcible manipulations in distending the edges of the deep wound by retractors, all serve to propel any freed caseous matter into the cut orifices of veins and lymphatics. The result is that by the time the local tuberculosis combated by the surgeon is healed, the patient succumbs to meningeal or pulmo nary tuberculosis, probably chargable to operative inter ference."

apex of the left scapula. He has undergone nine oper ations on different parts of his body during the last eight years. Four of these abscesses were still discharging a characteristic tubercular pus when he was sent to me by Dr. Broome four weeks ago. He had had daily injections of serum in doses of 20 to 30 drops. One abscess has closed and the discharge from the others is now about one-fifth as much as before the beginning of the treatment.

The progress of these cases should convince the most sceptical of the efficacy of the serum. I have made numerous microscopical examinations of tubercular pro ducts during the treatment with the serum and have in variably found the bacilli decreasing in numbers. I have also found disintegrated tubercle bacilli which undoubt edly resulted from the specific action of the serum. The specific action of the serum is due to the nuclein which it containe, but this will form the title of a paper to be

Iodoform emulsion in olive oil has been extensively used especially by Dr. Senn. It is only useful in one class of cases, that is where no secondary infection with pus microbes has taken place. To be efficacious it should be used in the absence of oxygen, in the joints, abdomen, or tendon shreaths by means of a trocar. If it is to be used after extensive operation on tubercular published shortly. parts we must be certain of the sterility of the parts and the wound should be tightly closed by means of sutures, making it practically subcutaneous. A large proportion of such cases, however, can not be success fully treated with iodoform.

From my experience with the use of the anti-tubercle serum of Paquin during the last seven months I am confident that a great advance has been made in this department of surgery. The report of cases of pulmonary tuberculosis treated with Paquin's serum have been published elsewhere and I wish to mention a couple of surgical cases which are quite interesting.

Mrs. M. age 25 years, the mother of two children, youngest six weeks old; has been troubled with tuber culosis of the right knee-joint for more than a year. She also has beginning pulmonary tuberculosis.

4403 Washington av.

Remittent Miasmatic Fever.

BY JAMES MACREADY, M D., MONROE, OHIO.

Read before the Ohio State Medical Society, May 17, 1895.

It is my purpose in this paper, to discuss a type of fever, with which the pioneer practitioners, and their immediate successors in southern Ohio, especially in the Miami Valley, were familiar, from frequent observation of its phenomena; but which, during the past three decades has almost wholy disappeared, viz. "Remittent Fever of Miasmatic or Paludal Origin."

The history of the febrile diseases prevalent in the Miami Valley during the first six decades of the present century discloses the existence of two types of paludal fever, endemic in many circumscribed areas of greater or less extent, which the early settlers and their immedi ate descendants expected to recur, yearly, with the ad vent of warm weather, and continue until arrested by the frosts of autumn; one being intermittent and the other continued, with a marked tendency to daily remissions. The latter from its protracted and often irregular course, with manifest debility and close re semblance to typhus, with frequent fatal results was often denomenated typhus fever by the early practi tioners.

Two months ago I made an exsection of the joint. I found a cheesy tubercular focus in each condyle of the femur and two foci in the head of the tibia. The cap sule of the joint was gelatinous and the cavity contained large numbers of the so-called rice bodies. The case in fact looked so unpromising that a thigh amputation would have been the proper treatment had I not intended to use the serum. A large rubber drainage tube was inserted, the wound closed and the usual dressings ap plied. One week later the first dressing, tube and sut ures were removed? Since that time the wound has been perfectly dry and has not required re dressing. The patient has been entirely free from pain ever since the operation and has slept well every night; her appetite is good and she has improved greatly in general An extensive tract of low alluvial land through which health. Patient has been given 30 drops of serum daily the boundary line beteen Butler and Warren Counties since the operation. passes, laying north, east and west of the village of MonAnother case is that of a young man, aged 18 years, roe, in the first named county, was the habitat of all who had coxitis of the right hip eight years ago. He types of miasmatic fevers, intermittent, remittent and has ankylosis of the joint and several fistulous tracts occasionaly the pernicious. Drainage of wet parts and running through the thigh. He has a tubercular abcess the subjection of almost the entire area to cultivation Hə

wrought a change, which for a series of years almost banished or rendered milder the endemic fevers. Dur ing the year that closed with the frosts of November, 1894, the areas that were subjected to thorough drainage and put under cultivation within the five years immediately preceding, have been exempt from malarial disease. Those tracts formerly furnished most of my malaríal patients.

During the summer and autumn of 1894, I found them in localities that had been long free from malarial or miasmatic poisoning, and that were noted of late years because of freedom from febrile diseases.

which some form of hepatitis was developed. A few cases vomited yellow and brownish colored bile. The duration of the febrile exacerbation varied greatly in different cases, and often at different periods of the same case. The first exacerbation invariably appeared either in the afternoon or evening, and continued with unabated severity until the forenoon of the following day, when, in most cases, a remission occurred. In some of the cases the remission did not appear until the afternoon, when the temperature would decline two, three or four degrees. The duration of the remission varied greatly in different cases, lasting two, three or four The first week of July last, marks the beginning of an hours to be followed by an exacerbation often of equal endemic manifestation of malarial disease, which ended severity to that of the previous day. In the mild cases, with the frosts and light freezing weather of November, the exacerbations gradualy decreased in duration and that rivals in intensity of poisoning any period of pioneer severity, terminating by lysis in from six to fourteen days, It began with a series of diarrheas, which were protracted in duration and complicated with an inter mittent type of fever of the quotidian variety, the paroxysms of which continued to recur until cinchonism was induced.

In the last week of the month named, cases presenting entirely different phenomena began to appear in the village of Monroe, its immediate vicinity and along the line of a sluggish stream, which passes through and drains the lowlands west of the village. The hot, dry weather of the past summer, caused this stream to be come dry where it passes through the bottom lands, which, I am informed, never occurred during any previ

ous summer or autumn.

days. Some of the severe cases showed no remission for four days, which was then induced by the cold sponge bath, and cold compress applied to the abdomen and the anterior and lateral parts of thr thorax.

Perspiration seldom appeared during the remission, unless the normal was reached. The severe cases were frequently protracted in duration.

One case was characterized by two well-marked exacerbations and remissions each twenty-four hours, for four successive days; one exacerbation beginning about noon, and the other soon after midnight. Each day, forty grains of quinine were exhibited with two drams fluid extract ergot to prevent congestion of the auditory apparatus. During twelve hours of the fourth day, forty drops of Fowler's Sol. were given.

The exacerbation did not recur again until after the expiration of thirty-six hours when another period of thirty six hours passed without fever, followed by a slight elevation of temperature, with no subsequent recurrence.

Notwithstanding the administration of large doses of quinine between each exacerbation, cinchonism was not manifested by the usual subjective symptoms, which I believe I am justified in attributing to the antagonism of the ergot.

Fifty-one cases of well marked remittent fever came under my observation from July to November.

The inception of the attack in these latter cases was marked by a short and usualy slight prodromal period, with headache, tongue furred, broad and flabby, slight nausea and epigastric tenderness, stiffness and soreness of the lateral and post-cervical muscles; aching and sore ness across the shoulders and lumbar region while a sense of weariness was complained of. These symp. toms, which invariably manifested themselves prior to the advent of the febrile movement, were accompanied by a marked paleness of the countenance and exposed mucus surfaces, denoting a diminution of the number of the red corpuscles. The prodromal stage rarely lasted longer than forty-eight hours, and was succeeded by an ill-defined cold stage-not a rigor-but a feeling of chilli ness, languor, debility, some cerebral oppression, and slight gastric derangement, followed by the development of a febrile movement which quickly reached its acme of 104° or 105°. The skin became hot and harshly dry to the touch; the pulse increased in force and frequency; the face became flushed, headache throbbing and severe, and the lumbar pains increased in severity. The bowels were constipated, in some cases obstinately so. When opened by mercurial or saline cathartics, the dejecta were of a brownish color, showing the presence of bile Some of the cases lapsed into a diarrhea, with dejecta having a color and an odor denoting a redundancy of bile. The prutrescent odor which denotes a suspension of billiary and pancreatic secretion was never present, In this case the liver became enormously enlarged, except in the latter stages of the protracted cases, in the free margin descending to the umbilicus.

Four deaths resulted. One during the fourth week of the attack from hepatitis, with jaundice inducing a secondary toxemia. One in the fifth week from pyemia following crural phebitis and suppurative inflammation in the left iliac region. The third death occurred dur. ing the fourth week, and was caused by meningitis. The fourth death was that of a child, four years of age, who became free from fever by the end of the second week, and maintained a normal temperature for seven days when she became the subject of a pneumonia, which, at the end of ten days terminated by resolution. Five days after the pneumonic action had ceased, she was attacked by a chill and soon passed into a condition of collapse, followed by death.

The question may be asked, why should a region so hillsides. The ponds were constructed by the erection

long free from malarial diseases, except the mildest and most tractable forms, become again affected by the severe type?

of dams across these depressions or ravines. They became filled with water by drainage from the village during the rainy season. Filth of various kinds is washed into them from the streets, stables and privies.

I answer that the intense and protracted heat and the long continued absence of rain in the summer Three of them are used to produce ice, which is sold to and autumn were important factors. The agency of butchers, dairymen and others. When filled with water, these dried up the stream refered to as causing the cases they are probably harmless, so far as atmospheric poi. west of the village. Although this stream contained no soning is concerned, and become dangerous, only when water, its sandy, and in many places, alluvial bottom their filth laden bottoms are exposed by evaporation of was constantly moist from water brought to the surface the water during the latter part of summer and the au by capilary attraction, and thus made an excellent cul tumnal months; when they become excellent culure beds ture bed for the microbe of the disease, the "corpuscle for breeding the microbes of miasmatic fever. Soon of Laveran," the plasmodium. These germs dwell in after the beginning of the hot and dry weather of the the soil, and are developed by heat and moisture. Sur- summer of 1894, the water in these ponds began to faces containing them in abundance had been exposed evaporate rapidly. In the month of August, fevers of by the evaporation of the water usualy covering the a mild remittent type began to appear, September bottom of the stream. The region through which it brought a larger number of a severe grade, but all hav· passes and drains, had, part of it, in former years, been ing the same general symptoms. With these cases, wet and swampy and had then been visited annually by there occurred in August one case of enteric fever, one both the intermittent and continued types of malarial in September, two in October and three in November. fever, and though never entirely free from malarial During those months, fifty-one cases of well marked repoisoning, the attacks of late years were mild and easily mittent miasmatic fever came under my observation. controlled by treatment.

When the C. C. C. and I. R. R., which passes through this region was under construction, the laborers engaged on the work in the low grounds, who lived in shanties adjacent to the road, were frequently attacked by malarial disease. South of the low grounds, the land is elevated to a degree that necessitated deep excavations for the road bed. This elevated region had long been free from malarial visitation of any kind. The laborers engaged in the work, and adjacent residents were the subjects of malarial fevers; the latter for two or three years after the work was completed. The germs of the disease, which were brought to the surface by the work of excavation, multiplied by the aid of heat and moist ure, and soon became diffused through the atmosphere of the immediate neighborhood.

Soils that have once been the producers of germs that induce malarial fevers, probably never become free from the cause, except those parts which are repeatedly exposed, in the process of crop cultivation to the actinic rays of the sun. In such regions, deep excavations, ex tensive in area have been contaminators of the atmosphere, with miasmatic manifestations among adjacent residents.

The physician who had the opportunity of observing these cases from the inception of the attack, who studied them closely, and made an accurate record of each case at the bedside, can scarcely be led into error as to the nature of the disease. The only ailment, liable to cause confusion in arriving at a differential diagnosis, is enteric or typhoid fever, and then a doubt could occur only because of the protracted febrile movement and its resistance to quinine. Notwithstanding these, enteric must be excluded, because of the absence of its cyclical course, tendency to diarrhea, and other intestinal lesions; its peculiar eruption, enlargement of the spleen during the first and second weeks; and absence of the mental hebetude that characterizes most cases of enteric, except one case in the fourth week, when meningitis, with tetanic manifestations, was developed, followed by death.

The beginning of the febrile movement was abrupt and the elevation of temperature during the first exacerbation equal to that of any subsequent period of its course, and the remissions irregular as to the time of the daily occurrence.

The febrile movement of enteric or typhoid is developed by a gradual effervescence, which reaches its acme In the lowlands adjacent to this stream, fourteen well by the end of the fifth to the seventh day, when the marked cases of remittent fever occurred.

In the village of Monroe and its immediate vecinity thirty seven cases came under my observation. Here I belive I am justified in attributing the cause to a miasm emenating from ponds close to the village, five in all, which were originaly constructed for carp culture.

The land on which the village is located is much ele vated above the surrounding lowlands. At some time in a prehistoric period, from geological indications, the lowlands were probably covered by water. The village has natural drainage by the aid of depressions in the

fastigium begins, during which there is a marked tendency to a daily fall of the temperature of from one to two degrees, between the hours of 7 and 9 o'clock in the morning, followed by a gradual rise until the acme of the previous day is reached in the evening. This vari ation in the morning and evening heat continues until the seventeenth, twenty first or twenty eighth day is passed, when the period of effervescence begins.

Physicians sometimes conclude that because a fever having a continued course is not arrested in its move. ment by the exhibition of quinia, it is, therefore, not of