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to be above normal and gradually rising. Urine is abundant; this stage usually lasts from one-half to two hours.

The hot stage follows immediately upon the cold stage, beginning with a feeling of warmth gradually diffusing over the entire body. The skin surface which was previously cold becomes intensely hot, the face which was cyanotic is now flushed, the urine scanty and febrile in its characteristics, the temperature may rise as high as 105 to 106 degrees Fahrenheit, remains high about one to two hours, then gradually falls to normal or below.

The sweating stage is characterized by a profuse perspiration of the entire body, beginning first with the face, the temperature is gradually reduced, and when the normal is reached the sweating ceases and the patient returns to the preceding state of health.

These paroxysms are not always so distinct and complete; one or more of the stages may be absent or very slight, e. g., there may be only a slight chill, a hot stage of two or three hours and no sweating; or there may be chill and sweating and no hot stage, or cold and hot stages may be absent and merely sweating with a slight rise of temperature. After the paroxysm the patient feels well until after a variable time another paroxysm appears.

In the Aestivo-Autumnal form the fever is remittent in character and the paroxysms last much longer and the gastrointestinal symptoms are well marked. In the Tertian and Quartan the fever is intermittent. In the chronic types organic changes take place, such as a secondary anaemia, enlargement of the liver and spleen. This enlargement is due partly to a fibrosis, partly to a melanin deposit.

Haematuria is also a common accompaniment. One attack does not produce immunity but on the contrary an individual once attacked is very prone to a second attack unless removed from a malarial district.

DIAGNOSIS.

This may be summed up under three points:

First. Clinical periodicity.

Second. Therapeutic test.

Third. Microscopic test.

1. The most important clinical diagnostic point in malarial fevers is the remarkable periodicity of the paroxysms; a fever occurring every third or fourth day with more or less of a paroxysm is strongly presumptive of malaria. The Quotidian fever may be mistaken for typhoid, tuberculosis or sepsis, but in the latter diseases there is usually an evening rise of temperature with morning remissions, whereas in malaria the paroxysms invariably occur before noon and in the intervals the patient feels well.

2. A second diagnostic point is the therapeutic test of quinine and in this connection Manson states that if quinine does not favorably affect a suspected malarial fever, we must be prepared to revise our diagnosis.

3. The third and most important diagnostic point is the microscopic test for finding the malarial parasite in the blood. The microscopic test should, if possible, be carried out before quinine is administered, as it has been observed that where quinine has been given even in small doses which were insufficient to check the paroxysms, it nevertheless caused the parasites to disappear from the peripheral circulation.

The difficulty in the diagnosis of malarial affections does not usually lie in the mistaking of malaria for some other affection, but rather in appending the diagnosis of malaria to other affections. To illustrate this fact I will quote from a paper by Dr. Douglass Vanderhoof which appears in the Journal of the American Medical Association for the current week (April 20) under the caption of "Pseudo-Malarial Types of Pyelitis." In this paper Dr. Vanderhoof states that during the past five years he had seen in consultation forty-seven cases of pyelitis (non calculous and non tubercular); of these twenty-one had been previously treated for malaria, a percentage of approximately 45 per cent. The history of one of his cases is as follows: Case 1. Patient-a professional man, aged 53, who had always enjoyed excellent health, with the significant exception of an attack of acute prostatitis one year previously, developed chills and fever in September, 1906, while on a vacation at Hot Springs, Va.

Clinical history: After having two shaking chills at an interval of forty-eight hours, he was told that he had malaria and returned to his home in Richmond. For over three weeks he continued to have hard chills, followed by high fever and profuse sweating. The chills occurred every day, although on a few occasions he went two days without a rigor. After the chill his temperature often reached 104 degrees F. Except for the chills, fever and sweat, he was free from symptoms, complained of no pain in any part of the bladder or kidneys.

Quinine was administered in full doses from the beginning of the illness and at the time this note was made he had been taking forty grains of quinine daily for a week.

Dr. Vanderhoof saw this case in consultation about four weeks after the onset and by a microscopic examination of the blood and urine he negatived the presence of malaria and finally diagnosed the condition as acute pyelitis, which made a rapid recovery under suitable treatment.

In his summary of cases Dr. Vanderhoof calls attention to the fact that pyelitis and malaria may simulate each other in their symptoms and he averred that these conditions will continue to be confused until physicians realize that quinine is a specific in malaria.

TREATMENT.

Among our armamentarium of drugs in the treatment of disease we have but few specifics, but we can safely say that in quinine we have a specific against malaria. Before Laveran discovered the plasmodium the beneficial effect of quinine was known and made use of, but the discovery of the causal organism and the study of its life cycle placed the treatment of malaria by this drug on a more scientific basis.

It was Golgi who demonstrated the fact that the paroxysm of malarial fevers was co-incident with the period of sporulation of the parasites in the blood stream, he further demonstrated that quinine could only kill the parasites while they were free in the blood stream, and it had very little or no effect on the organisms in the red blood cells.

Therefore, to produce its best result quinine should be administered at least five to six hours before the expected chill

and repeated at regular intervals until all symptoms of the paroxysms have disappeared; the quinine should be given in fairly large doses of twenty, thirty or forty grains per day, best in solution, but it may also be administered in capsules by rectum or hypodermically.

Some individuals exhibit an unusual idiosyncrasy to this drug, some becoming rapidly cinchonized even with small doses, others presenting severe gastro-intestinal disturbances. The former cases, as a rule, are benefited by selecting the hydrobromide of quinine for administration or by dissolving the sulphate in a weak hydrobromic acid solution. The gastro-intestinal disturbances may be overcome by combining the quinine with opium or morphia hypodermically or by giving the drug either rectally or hypodermically. The salt most suitable for hypodermic use is the acid hydrochloride of quinine, the injection should be made in the muscular tissue.

There is some discussion as to whether quinine causes haematuria in some individuals. I, personally, have observed one case of haemoglobinuria occurring in a patient as a result of quinine administration even in small doses. On looking up the literature on this subject I found that Manson reported a case in the Lancet of 1903 occurring at the Branch Seaman's Hospital, London, of haemoglobinuria following quinine administration. Manson considered that this peculiar idiosyncracy to quinine was due to a neglect of its use in the early stages of malarial infection.

As adjuvants to quinine in the treatment of malaria we have such drugs as arsenic, iron and strychnia. Ricchi has observed that arsenic although having no influence on acute malaria, gives excellent results in the chronic forms and under its influence the crescentic bodies of remittent fever which do not readily respond to quinine, disappear rapidly from the blood. The splenic enlargement also quickly resolves under its administration.

The rapid destruction of the red blood cells and the resultant secondary anaemia calls for the administration of iron.

In all forms of malaria after the paroxysms have ceased excellent results will be obtained by administering quinine in

doses of one-half to two grains, combined with aresnic and iron for several months.

PROPHYLAXIS.

The prophylaxis consists in the extermination of the mosquito by the proper drainage of swamps and marshes or where this is impossible by the covering of their surfaces with crude petroleum, screening of the home in malarious districts. Recently the introduction into swamps of a species of fish known as "millions" has proved very effective in the destruction of the larvae of mosquitoes.

Individuals in tropical malarial regions usually secure protection from the daily use of quinine in doses of from two to five grains. In temperate climates, in admittedly malarious districts, quinine administration should be begun in the spring and continued until late in the autumn or early winter.

BLOOD PRESSURE MEASUREMENTS AND THEIR
PRACTICAL VALUE.

BY DR. CHARLES H. MINER, WILKES-BARRE, PA.
READ MAY 8, 1912.

Dr. Theodore C. Janeway, one of the pioneers in the use of the blood pressure apparatus in this country, has recently written in a paper, "When Should the General Practitioner Measure the Blood Pressure," as follows:

"First, in every careful examination of the cardio-vascular system. This, in my opinion, should mean for every practitioner: (a) The first examination of every new patient; (b) the occasional examination for purposes of watching progress in cases of hypertensive cardio-vascular disease and nephritis; and (c) every examination made for the purpose of certifying to the existence of a state of health.

(a) First examination of a new patient. The examination of a new patient should always be for the purpose of making a complete diagnosis. Even patients suffering from apparently trivial ailment may have serious and unsuspected anatomical lesions. Every careful physician knows how fre

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