The Home Medical Library Volume I Part 18

=Treatment.=--The patient should remain in bed while the fever lasts.

A liquid diet is advisable during this time. Fever may be allayed by frequent sponging of the naked body with tepid water. High fever and delirium demand the constant use, on the head, of the ice cap (a rubber bag, made to fit the head, containing ice). The relief of pain in the swollen gland is secured by the frequent application of a thick layer of sheet cotton, large enough to cover the whole side of the neck, wrung out of hot water and covered with oil-silk or rubber sheeting, with a bandage to retain it in place.

Paregoric may be given for the same purpose--a tablespoonful for adults; a teaspoonful for a child of eight to ten, well diluted with water, and not repeated inside of two hours, and not then unless the pain continues unabated. Inflammation of the t.e.s.t.i.c.l.es demands rest in bed, elevation of the t.e.s.t.i.c.l.e on a pillow after wrapping it in a thick layer of absorbent cotton, or applying hot compresses, as recommended for the neck. After the first few days of this treatment, adjust a suspensory bandage, which can be procured at any apothecary shop, and apply daily the following ointment: guiacol, sixty grains; lard, one-half ounce, over the swollen t.e.s.t.i.c.l.e.

=WHOOPING COUGH.=--A contagious disease characterized by fits of coughing, during which a whooping or crowing sound is made following a long-drawn breath. Whooping cough is generally taken through direct contact with the sick, rarely through exposure to the sick room, or to persons or clothing used by the sick. The germ which causes the disease is probably in the mucus of the nose and throat. Whooping cough is usually more or less prevalent in all thickly settled civilized communities, at times is epidemic, and often follows epidemics of measles. It occurs chiefly in children from six months to six years of age. Girls and all weak and delicate subjects are slightly more susceptible to the disease. Some children are naturally immune to whooping cough. One attack usually protects against another.

=Development.=--A variable period elapses between the time of exposure to whooping cough and the appearance of the first symptoms. This may be from two days to two weeks; usually seven to ten days.

=Symptoms.=--Whooping cough begins like an ordinary cold in the head, with cough, worse at night, which persists. The coughing fits increase and the child gets red in the face, has difficulty in getting its breath during them, and sometimes vomits when the attack is over.

After a variable period, from a few days to two weeks from the beginning of the cough, the peculiar feature of the disease appears.

The child gives fifteen or twenty short coughs without drawing breath, the face swells and grows blue, the eyeb.a.l.l.s protrude, the veins stand out, and the patient appears to be suffocating, when at last he draws in a long breath with a crowing or whooping sound, which gives rise to the name of the disease. Several such fits of coughing may follow one another and are often succeeded by vomiting and the expulsion of a large amount of phlegm or mucus, which is sometimes streaked with blood. In mild cases there may be six to twelve attacks in twenty-four hours; in severe cases from forty to eighty. The attacks last from a few seconds to one or two minutes. Occasionally the whoop comes before the coughing fit, and sometimes there may be no whooping at all, only fits of coughing with vomiting. Between the attacks, puffiness of the face and eyes and blueness of the tongue persist. The coughing fits and whooping last usually from three to six weeks, but the duration of the disease is very variable. Occasionally it lasts many months, especially when it occurs in winter. The contagiousness of whooping cough continues about two months, or ceases before that time with the cessation of the cough. Oftentimes there may be occasional whooping for months; or, after ceasing altogether for some days, it may begin again. In neither of these conditions is the disease considered still contagious after two months. When an attack of whooping is coming on, the child often seems to have some warning, as he seems terrified and suddenly sits up in bed, or, if playing, grasps hold of something, or runs to his mother or nurse. Coughing fits are favored by emotion or excitement, by crying, singing, eating, drinking, sudden change of temperature, and by bad air.

=Complications and Sequels.=--These are many and make whooping cough a critical disease for very young children. Bronchitis and pneumonia often complicate whooping cough in winter, and diarrhea frequently occurs with it in summer. Convulsions not infrequently follow the coughing fits in infants, and, owing to the amount of blood forced to the head during the attacks, nosebleed and dark spots on the forehead and surface of the eyes appear from breaking of small blood vessels in these places. Severe vomiting and diarrhea occasionally aggravate the case, and pleurisy and consumption may occur. The violent coughing may permanently damage the heart. Rupture of the lung tissue happens from the same cause, and paralysis sometimes follows breaking of a blood vessel in the brain. But in the vast majority of cases in children over two years old no dangerous sequel need be feared.

=Outlook.=--Owing to the numerous complications, whooping cough must be looked upon as a very serious disease, especially in infants under two years, and in weak, delicate children. It causes one-fourth of all deaths among children, the death rate varying from three to fifteen per cent in different times and under different circ.u.mstances. For this reason a physician's services should always be secured when possible.

=Treatment.=--A host of remedies is used for whooping cough, but no single one is always the best. It is often necessary to try different medicines till we find one which excels. Fresh air is of greatest importance. Patients should be strictly isolated in rooms by themselves, and it is wise to send away children who have not been exposed. Morally, parents are criminally negligent who allow their children with whooping cough to a.s.sociate with healthy children. If the coughing fits are severe or there is fever, children should be kept in bed. Usually there is not much fever; perhaps an elevation of a degree or two at first, and at times during the disease. Otherwise, children may be outdoors in warm weather, and in winter on warm, quiet days. Sea air is especially good for them. It is best that the sick should have two rooms, going from one to the other, so that the windows in the room last occupied may be opened and well ventilated.

Fresh air at night is especially needful, and the patient should sleep in a room which has been freshly aired. The temperature should be kept at an even 70 F., and the child should not be exposed to draughts.

Vaporizing antiseptics in the sick room has proved beneficial. A two per cent solution of carbolic acid in water is useful for this purpose, or a substance called vapo-cresoline, with which is sold a vaporizing lamp and directions for use. A one per cent solution of resorcin, or of hydrogen dioxide, diluted with four parts of water, used in an atomizer for spraying the throat, every two hours, has given good results. In the beginning of the disease, before the whooping has begun, a mixture of paregoric and syrup of ipecac will relieve the cough, ten drops of the former with five of the latter, for a child of two years, given together in water every three hours.

The bromide of sodium, five grains in water, every three hours during the day, for a child of two, is serviceable in relieving the fits of coughing in the day; while at night, two grains of chloral, not repeated, may be given in water at bedtime to secure sleep, in a child of two. The tincture of belladonna, in doses of two drops in water, three times daily, for a child of two, is also often efficacious.

Quinine, given in the dose of one-sixth grain for each month of the child's age under a year; or in one and one-half grain doses for each year of age under five, is one of the older and more valuable remedies. It should be given three times daily in pill with jelly, or solution in water. Brom.o.f.orm in doses of two drops for a child of two, and increasing to five drops for a child of six, may be given in syrup three times daily with benefit. Most of these drugs should be employed only with a doctor's advice, when this is possible. To sum up, use the vapo-cresoline every day. When no physician is available, begin with belladonna during the day, using bromide of sodium at night. If this fails to modify the whooping after five days' trial, use bromide and chloral. In severe cases use brom.o.f.orm. During a fit of coughing and whooping, it is well to support the child's head, and if he ceases to breathe, he should be slapped over the face and chest with a towel wet with cold water. Interference with sleep caused by coughing, and loss of proper nourishment through vomiting, lead to wasting and debility.

Teaspoonful doses of emulsion of cod-liver oil three times daily, after eating, are often useful in convalescence, and great care must be taken at this time to prevent exposure and pneumonia. Change of air and place will frequently hasten recovery remarkably in the later stages of the disease.

=ERYSIPELAS.=--Erysipelas is a disease caused by germs which gain entrance through some wound or abrasion in the skin or mucous membranes. Even where no wound is evident it may be taken for granted that there has been some slight abrasion of the surface, although invisible. Erysipelas cannot be communicated any distance through the air, but it is contagious in that the germs which cause it may be carried from the sick to the well by nurses, furniture, bedding, dressings, clothing, and other objects. Thus, patients with wounds, women in childbirth, and the newborn may become affected, but modern methods of surgical cleanliness have largely eliminated these forms of erysipelas, especially in hospitals, where it used to be common.

Erysipelas attacks people of all ages, some persons being very susceptible and suffering frequent recurrences. The form which arises without any visible wound is seen usually on the face, and occurs most frequently in the spring. The period of development, from the time the germs enter the body until the appearance of the disease, lasts from three to seven days.

Erysipelas begins with usually a severe chill (or convulsion in a baby) and fever. Vomiting, headache, and general la.s.situde are often present. A patch of red appears on the cheeks, bridge of nose, or about the eye or nostril, and spreads over the face. The margins of the eruption are sharply defined. Within twenty-four hours the disease is fully developed; the skin is tense, smooth, and s.h.i.+ny, scarlet and swollen, and feels hot, and is often covered with small blisters. The pain is more or less intense, burning or itching occurs, and there is a sensation of great tightness or tension. On the face the swelling closes the eye and may interfere with breathing through the nose. The lips, ears, and scalp are swollen, and the person may become unrecognizable in a couple of days. Erysipelas tends to spread like a drop of oil, and the borders of the inflammatory patch are well marked. It rarely spreads from the face to the chest and body, and but occasionally attacks the throat. During the height of the inflammation the temperature reaches 104 F, or over. After four or five days, in most cases, erysipelas begins to subside, together with the pain and temperature, and recovery occurs with some scaling of the skin. The death rate is said to average about ten per cent in hospitals, four per cent in private practice. Headache, delirium, and stupor are common when erysipelas attacks the scalp. The appearance of the disease in other locations is similar to that described. Relapses are not uncommon, but are not so severe as the original attack. Spreading may extend over a large area, and the deeper parts may become affected, with the formation of deep abscesses and great destruction of tissue. Certain internal organs, heart, lungs, spleen, and kidneys, are occasionally involved with serious consequences. The old, the diseased, and the alcoholic are more apt to succ.u.mb, also the newborn.

It is a curious fact that cure of malignant growths (sarcoma), chronic skin diseases, and old ulcers sometimes follows attacks of erysipelas.

=Treatment.=--The duration of erysipelas is usually from a few days to about two weeks, according to its extent. It tends to run a definite course and to recovery in most cases without treatment. The patient must be isolated in a room with good ventilation and sunlight.

Dressings and objects coming in contact with him must be burned or boiled. The diet should be liquid, such as milk, beef tea, soups, and gruels. The use of cloths wet constantly with cold water, or with a cold solution of one-half teaspoonful of pure carbolic acid to the pint of hot water, or with a poisonous solution of sugar of lead, four grains to the pint, should be kept over small inflamed areas. Fever is reduced by sponging the whole naked body with cold water at frequent intervals. A tablespoonful of whisky or brandy in water may be given every two hours to adults if the pulse is weak. Painting the borders of the inflamed patch with contractile collodion may prevent its spreading. The patient must be quarantined until all scaling ceases, usually for two weeks.

CHAPTER III

=Malaria and Yellow Fever=

_The Malarial Parasite--Mosquitoes the Means of Infection--Different Forms of Malaria--Symptoms and Treatment--No Specific for Yellow Fever._

=MALARIA; CHILLS AND FEVER; AGUE; FEVER AND AGUE; SWAMP OR MARSH FEVER; INTERMITTENT OR REMITTENT FEVER; BILIOUS FEVER.=--Malaria is a communicable disease characterized by attacks of fever occurring at certain intervals, and due to a minute animal parasite which inhabits the body of the mosquito, and is communicated to the blood of man by the bites of this insect.

In accordance with this definition malaria is not a contagious disease in the sense that it is acquired by contact with the sick, which is not the case, but it is derived from contact with certain kinds of mosquitoes, and can be contracted in no other way, despite the many popular notions to the contrary. Mosquitoes, in their turn, acquire the malarial parasite by biting human beings suffering from malaria.

It thus becomes possible for one malarial patient, coming to a region hitherto free from the disease, to infect the whole district with malaria through the medium of mosquitoes.

=Causes.=--While the parasite infesting mosquitoes is the only direct cause of malaria, yet certain circ.u.mstances are requisite for the life and growth of the mosquitoes. These are moisture and proper temperature, which should average not less than 60 F. Damp soil, marshes, or bodies of water have always been recognized as favoring malaria.

Malaria is common in temperate climates--in the summer and autumn months particularly, less often in spring, and very rarely in winter, while it is prevalent in the tropics and subtropics all the year round, but more commonly in the spring and fall of these regions. The older ideas, that malaria was caused by something arising in vapors from wet grounds or water, or by contamination of the drinking water, or by night air, or was due to sleeping outdoors or on the ground floors of dwellings, are only true in so far as these favor the growth of the peculiar kind of mosquitoes infected by the malarial parasites.

Two essentials are requisite for the existence of malaria in a region: the presence of the particular mosquito, and the actual infection of the mosquito with the malarial parasite. The kind of mosquito acting as host to the malarial parasite is the genus _Anopheles_, of which there are several species. The more common house mosquito of the United States is the _Culex_. The _Anopheles_ can usually be distinguished from the latter by its mottled wings, and, when on a wall or ceiling, it sits with the body protruding at an angle of 45 from the surface, with its hind legs hanging down or drawn against the wall. In the case of the _Culex_, the body is held parallel with the wall, the wings are usually not mottled, and the hind legs are carried up over the back.

When a mosquito infected with the malarial parasite bites man, the parasite enters his blood along with the saliva that anoints the lancet of the mosquito. The parasite is one of the simplest forms of animal life, consisting of a microscopical ma.s.s of living, motile matter which enters the red-blood cell of man, and there grows, undergoes changes, and, after a variable time, multiplies by dividing into a number of still smaller bodies which represent a new generation of young parasites. This completes the whole period of their existence. It is at that stage in the development of the parasite in the human body when it multiplies by dividing that the chills and fever in malaria appear. What causes the malarial attack at this point is unknown, unless it be that the parasites give rise to a poison at the time of their division. Between the attacks of chills and fever in malaria there is usually an interval of freedom of a few hours, which corresponds to the period intervening in the life of the parasite in the human body, between the birth of the young parasites and their growth and final division, in turn, into new individuals. This interval varies with the kind of parasite. The common form of malaria is caused by a parasite requiring forty-eight hours for its development. The malarial attacks caused by this parasite then occur every other day, when the parasite undergoes reproduction by division.

However, an attack may occur every day when there are two separate groups of these parasites in the blood, the time of birth of one set of parasites, with an accompanying malarial attack, happening one day; that of the other group coming on the next, so that between the two there is a daily birth of parasites and a daily attack of malaria. In cases of malaria caused by one group of parasites the attacks appear at about the same time of day, but when the attacks are caused by different groups of parasites the times of attack may vary on different days. In the worst types of malaria the parasites do not all go through the same stages of development at the same time, as is commonly the case in the milder forms prevalent in temperate regions, so that the fever--corresponding to the stage of reproduction of the parasites--occurs at irregular intervals.

In a not uncommon type of malaria the attacks occur every third day, with two days of intermission or freedom from fever. Different groups of parasites causing this form of malaria, and having different times of reproduction, may inhabit the same patient and give rise to variation in the times of attack. Thus, an attack may occur on two successive days with a day of intermission.

The reproduction of the parasite in the human blood is not a s.e.xual reproduction; that takes place in the body of the mosquito.

When a healthy mosquito bites a malarial patient, the parasite enters the body of the mosquito with the blood of the patient bitten. It enters its stomach, where certain differing forms of the parasite, taking the part of male and female individuals, unite and form a new parasite, which, entering the stomach wall of the mosquito, gives birth in the course of a week to innumerable small bodies as their progeny. These find their way into the salivary glands which secrete the poison of the mosquito bite, and escape, when the mosquito bites a human being, into the blood of the latter and give him malaria.

=Distribution.=--Malaria is very widely distributed, and is much more severe in tropical countries and the warmer parts of temperate regions. In the United States malaria is prevalent in some parts of New England, as in the Connecticut Valley, and in the course of the Charles River, in the country near Boston. It is common in the vicinity of the cities of Philadelphia, New York, and Baltimore, but here is less frequent than formerly, and is of a comparatively mild type. More severe forms prevail along the Gulf of Mexico and the sh.o.r.es of the Mississippi and its branches, especially in Mississippi, Texas, Louisiana, and Arkansas, but even here it is less fatal and widespread than formerly. In Alaska, the Northwest, and on the Pacific Coast of the United States malaria is almost unknown, while it is but slightly prevalent in the region of the Great Lakes, as about Lakes Erie and St. Clair.

=Development.=--Usually a week or two elapses after the entrance of the malarial parasite into the blood before symptoms occur; rarely this period is as short as twenty-four hours, and occasionally may extend to several months. It often happens that the parasite remains quiescent in the system without being completely exterminated after recovery from an attack, only to grow and occasion a fresh attack, a month or two after the first, unless treatment has been thoroughly prosecuted for a sufficient time.

=Symptoms.=--Certain symptoms give warning of an attack, as headache, la.s.situde, yawning, restlessness, discomfort in the region of the stomach, and nausea or vomiting. The attack begins with a chilliness or creeping feeling, and there may be so severe a chill that the patient is violently shaken from head to foot and the teeth chatter.

Chills are not generally seen in children under six, but an attack begins with uneasiness, the face is pinched, the eyes sunken, the lips and tips of the fingers and toes are blue, and there is dullness and often nausea and vomiting. Then, instead of a chill, the eyelids and limbs begin to twitch, and the child goes into a convulsion. While the surface of the skin is cold and blue during a chill, yet the temperature, taken with the thermometer in the mouth or bowel, reaches 102, 105, or 106 F., often. The chill lasts from a few minutes to an hour, and as it pa.s.ses away the face becomes flushed and the skin hot. There is often a throbbing headache, thirst, and sometimes mild delirium. The temperature at this time, when the patient feels intensely feverish, is very little higher than during the chill. The fever lasts during three or four hours, in most cases, and gradually declines, as well as the headache and general distressing symptoms with the onset of sweating, to disappear in an hour or two, when the patient often sinks into a refres.h.i.+ng sleep. Such attacks more commonly occur every day, every other day, or after intermissions of two days. Rarely do attacks come on with intervals of four, five, six, or more days. The attacks are apt to recur at the same time of day as in the first attack. In severe cases the intervals may grow shorter, in mild cases, longer. In the interval between the attacks the patient usually feels well unless the disease is of exceptional severity.

There is also entire freedom from fever in the intervals except in the grave types common to hot climates. Frequently the chill is absent, and after a preliminary stage of dullness there is fever followed by sweating. This variety is known as "dumb ague."

=Irregular and Severe Form--Chronic Malaria.=--This occurs in those who have lived long in malarial regions and have suffered repeated attacks of fever, or in those who have not received proper treatment.

It is characterized by a generally enfeebled state, the patient having a sallow complexion, cold hands and feet, and temperature below normal, except occasionally, when there may be slight fever. When the condition is marked, there are breathlessness on slight exertion, swelling of the feet and ankles, and "ague cake," that is, enlargement of the spleen, shown by a lump felt in the abdomen extending downward from beneath the ribs on the left side.

Among unusual forms of malaria are: periodic attacks of drowsiness without chills, but accompanied by slight fever (100 to 101 F.); periodic attacks of neuralgia, as of the face, chest, or in the form of sciatica; periodic "sick headaches." These may take the place of ordinary malarial attacks in malarial regions, and are cured by ordinary malarial treatment.

=Remittent Form (unfortunately termed "bilious").=--This severe type of malaria occurs sometimes in late summer and autumn, in temperate climates, but is seen much more commonly in the Southern United States and in the tropics. It begins often with la.s.situde, headache, loss of appet.i.te and pains in the limbs and back, a bad taste, and nausea for a day or two, followed by a chill, and fever ranging from 101 to 103 F., or more. The chill is not usually repeated, but the fever is continuous, often suggesting typhoid fever. With the fever, there are flushed face, occasional delirium, and vomiting of bile, but more often a drowsy state. After twelve to forty-eight hours the fever abates, but the temperature does not usually fall below 100 F., and the patient feels better, but not entirely well, as in the ordinary form of malaria, where the fever disappears entirely between the attacks. After an interval varying from three to thirty-six hours the temperature rises again and the more severe symptoms reappear, and so the disease continues, there never being complete freedom from fever, the temperature sometimes rising as high as 105 or 106 F. In some cases there are nosebleed, cracked tongue, and brownish deposit on the teeth, and a delirious or stupid state, as in typhoid fever, but the distention of the belly, diarrhea, and rose spots are absent. The skin and whites of the eyes often take on the yellowish hue of jaundice.

This fever has been called typhomalarial fever, under the supposition that it was a hybrid of the two. This is not the case, although it is possible that the two diseases may occur in the same individual at the same time. This, indeed, frequently happened as stated, in our soldiers coming from the West Indies during the Spanish-American War--but is an extremely uncommon event in the United States.

=Pernicious Malaria.=--This is a very grave form of the disease. It rarely is seen in temperate regions, but often occurs in the tropics and subtropics. It may follow an ordinary attack of chills and fever, or come on very suddenly. After a chill the hot stage appears, and the patient falls into a deep stupor or unconscious state, with flushed face, noisy breathing, and high fever (104 to 105 F.). Wild delirium or convulsions afflict the patient in some cases. The attack may last for six to twenty-four hours, from which the patient may recover, only to suffer another like seizure, or he may die in the first. In another form of this pernicious malaria the symptoms resemble true cholera, and is peculiar to the tropics. In this there are violent vomiting, watery diarrhea, cramps in the legs, cold hands and feet, and collapse. Sometimes the attack begins with a chill, but fever, if any, is slight, although the patient complains of great thirst and inward heat. The pulse is feeble and the breathing shallow, but the intellect remains clear.

Death often occurs in this, as in the former type of pernicious malaria, yet vigorous treatment with quinine, iron, and nitre will frequently prove curative in either form.

=Black Water Fever.=--Rarely in temperate climates, but frequently in the Southern United States and in the tropics, especially Africa; after a few days of fever, or after chilliness and slight fever, the urine becomes very dark, owing to blood escaping in it. This sometimes appears only periodically, and is often relieved by quinine. It is apparently a malarial fever with an added infection from another cause.

=Chagres Fever.=--A severe form of malarial fever acquired on the Isthmus of Panama, apparently a hemorrhagic form of the pernicious variety, and so treated.

=Detection.=--To the well-educated physician is now open an exact method of determining the existence of malaria, and of distinguis.h.i.+ng it from all similar diseases, by the examination of the patient's blood for the malarial parasite--its presence or absence deciding the presence or absence of the disease. For the layman the following points are offered: intermittency of chills and fever, or of fever alone, should suggest malaria, particularly in a patient living in or coming from a malarial region, or in a previous sufferer from the disease. In such a case treatment with quinine will solve the doubt in most cases, and will do no harm even if the disease be not malaria.

Malaria is one of the few diseases which can be cured with certainty by a drug; failure to stop the symptoms by proper amounts of quinine means, in the vast majority of cases, that they are not due to malaria. There are many other diseases in which chills, fever, and sweating occur at intervals, as in poisoning from the presence of suppuration or formation of pus anywhere in the body, but the layman's ignorance will not permit him to recognize these in many instances.

The quinine test is the best for him.

=Prevention.=--Since the French surgeon, Laveran, discovered the parasite of malaria in 1880, and Manson, in 1896, emphasized the fact that the mosquito is the medium of its communication to man, the way for the extermination of the disease has been plain. "Mosquito engineering" has attained a recognized place. This consists in destroying the abodes of mosquitoes (marshes, ponds, and pools) by drainage and filling, also in the application of petroleum on their surface to destroy the immature mosquitoes. Such work has already led to wonderful results.[11] Open water barrels and water tanks prove a fruitful breeding place for these insects, and should be abolished.

The protection of the person from mosquito bites is obtained by proper screening of habitations and the avoidance of unscreened open air, at or after nightfall, when the pests are most in evidence. Dwellings on high grounds are less liable to mosquitoes. Persons entering a malarial region should take from two to three grains of quinine three times a day to kill any malarial parasites which may invade their blood, and should screen doors and windows. Patients after recovery from malaria must prolong the treatment as advised, and renew it each spring and fall for several years thereafter. A malarial patient is a direct menace to his entire neighborhood, if mosquitoes enter.

=Treatment.=--The treatment of malaria practically means the use of quinine given in the proper way and in the proper form and dose.

Despite popular prejudices against it, quinine is capable of little harm, unless used in large doses for months, and no other remedy has yet succeeded in rivaling it in any way. Quinine is frequently useless from adulteration; this may be avoided by getting it of a reliable drug house and paying a fair price for the best to be had. Neither pills nor tablets of quinine are suitable, as they sometimes pa.s.s through the bowels undissolved. The drug should be taken dissolved in water, or, more pleasantly, in starch wafers or gelatin capsules. When the drug is vomited it may be given (in double the dose) dissolved in half a pint of water, as an injection into the bowels, three times daily. Infants of a few months may be treated by rubbing an ointment (containing thirty grains of quinine sulphate mixed with an ounce and a half of lard) well into the skin of the armpits and groins, night and morning. Children under the age of two can be best treated by quinine made into suppositories--little conical bodies of cocoa b.u.t.ter containing two grains each--one being introduced into the bowel, night and morning.

During an attack of malaria the discomfort of the chill and fever may be relieved to considerable extent by thirty grains of sodium bromide (adult dose) in water. Hot drinks and hot-water bottles with warm covering may be used during the chill, while cold sponging of the whole naked body will afford comfort during the hot stage. In the pernicious form, attended with unconsciousness, sponging with very cold water, or the use of the cold bath with vigorous friction of the whole body and cold to the head are valuable. The effect of quinine is greatest during the time of birth of a new generation of young parasites in the blood, which corresponds with the time of the malarial attack. But in order that the quinine shall have time to permeate the blood, it must be given two to four hours before the expected chill, and then will probably prevent the next attack but one. A dose of ten grains of quinine sulphate taken three times daily for the first three days of treatment; then a dose of three grains, three times daily for two weeks; and finally two grains, three times daily for the rest of the month of treatment will, in many cases, complete a cure. If the quinine cause much ringing in the ears and deafness, it will be found that sodium bromide taken with the quinine (in twice the dose) dissolved in water, will correct this trouble. If the patient is constipated and the bowel discharges are light colored, a few one-quarter grain doses of calomel may be taken every two hours, and followed in twelve hours by a dose of Epsom salts, on the first day of treatment, with quinine. It is no use to take quinine by the mouth later than two hours before an attack, and if the patient cannot secure treatment before this time, he should take a single dose of twenty grains of quinine.