at the time of the sporulation of the parasites.

The parasites of tertian fever, for example, have a cycle of existence lasting about 48 hours; toward the end of the period the organisms, having reached their complete development, undergo sporulation; and in direct association with this segmentation of a group of parasites occurs the malarial paroxysm. It might thus be easily conjectured that infection with a single group of tertian parasites would result in a paroxysm every third day- which is the case. But in many infections with the tertian parasite we see daily paroxysms. In these instances we have to do with infections with more than one group of parasites, usually with two groups reaching maturity on alternate days and producing, thus, daily paroxysms"double tertian" infections.

The parasite of quartan fever passes through a cycle of development lasting about 72 hours and when present as a single group produces fever every fourth day. It is easy to understand how infections with both of these groups of the quartan organism produce double or triple quartan fever; in the one case consisting of chills on two successive. days with an intermission on the third day, and in the other, daily chills.

The third variety of parasite, the estivo-autumnal parasite, does not possess to the same degree the characteristic of being present in sharply defined groups at the same stages of develop

ment.

There are often multiple groups of parasites, or parasites in different stages of development present at the same time. Sporulation thus occurs frequently and at irregular intervals, resulting in a more irregular and often continuous fever.

The Roman observers have noted that while the earlier cases of malarial fever, those occurring in the winter and spring consist, almost entirely, of the regularly intermittent varieties, the tertian and quartan fevers, those occurring in the summer and fall are, however, much more severe in nature, more irregular in their manifestations and are associated

with the third variety of parasites parasite of estivo-autumnal fever.

Some Italian observers have gone yet further, dividing the estivo-autumnal parasites into two or even three distinct varieties and associating these with dif ferent types of fever. ferent types of fever. This, however, the majority of observers have not succeeded in doing. During the last two years Dr. Hewetson and the writer have been engaged in analyzing all the cases of malarial fever occurring at the Johns Hopkins Hospital. The results have confirmed almost entirely the Italian observations.

A few of our results which will appear shortly in a volume of the hospital reports I will briefly mention. Our cases numbered 614, not including relapses of cases once included in the list.

The following tables show the relation of the cases to the time of year : There occurred in

From this table it appears that while in the winter months, December, January, February and March, malarial fever is at a minimum, the number of cases begins to increase, as a general thing, with the month of April, showing a gradual steady rise until the climax, which occurs in the months of September and October. In November and December a well marked fall begins. This table, while it gives a good general idea of the distribution of the malarial infection throughout the year, is, however, a trifle misleading if taken too strictly. The cases during the latter half of the year 1889 were few, as the hospital was new and the clinics had not yet developed, while the cases from January to August of 1894 represent a much larger clinic. The proportion of cases occurring in the first seven months is thus over-represented, while the second half-year suffers, the under-representation of the cases in August being especially marked. The following table dealing with the cases during the four

It may thus be seen that more than five-sixths of the cases of malaria observed by us occur in the second halfyear, while nearly one-half occur in the months of September and October.

We have distinguished three varieties of the malarial parasites: (1) The tertian parasite. (2) The quartan parasite. (3) The estivo-autumnal parasite.

1. The tertian parasite requires about forty-eight hours to accomplish its complete development, and is associated with relatively regular tertian paroxysms, lasting, on an average, between ten and twelve hours, associated almost always with the three classical stages— chill, fever and sweating. Frequently, infection with two groups of tertian organisms gives rise to quotidian paroxysms; rarely, infection by multiple groups of organisms gives rise to more irregular, sub-continuous fevers.

2. The quartan parasite is an organism requiring about seventy-two hours for its complete development. It is rare in this climate and is associated with a fever showing regular quartan paroxysms, similar in nature to those associated with the tertian organism. Infection by two groups of the parasite causes a double quartan fever (paroxysms on two days, intermission on the third). Infection, with three groups of the parasite, is associated with daily paroxysms.

3. The estivo-autumnal parasite passes through a cycle of development the exact length of which has not, as yet, been determined; it probably varies greatly from twenty-four hours or under, to forty-eight hours or more. But few stages of development of the parasite

are found, ordinarily, in the peripheral circulation, the main seat of infection being, apparently, in the spleen, bonemarrow and other internal organs. Infection with this organism is associated with fevers varying, greatly, in their manifestations. There may be quotidian or tertian intermittent fever, or, more commonly, more or less continuous fever with irregular remissions. The individual paroxysms last, on an average, about twenty hours, the irregularities in temperature depend, probably, upon variations in the length of the cycle of development of the parasite, or upon infection with multiple groups of organisms. We have not been able to separate varieties of the estivo-autumnal parasite, though we feel that more investigation is needed upon the subject.

The relation of the occurrence of these different types of fever to the time of the year is shown by the following tables.

Thus in the first half-year there were :

year we have more single tertian than double infections; while in the second half-year, when malarial fever assumes a more severe type, we have nearly twice as many cases of double tertian as of single tertian infection. The increasing severity of the type of malarial fever becomes more marked when we observe the course of the estivo-autumnal cases. While in the first half-year only five cases were noted, a little less than one-twentyfourth of the total number of cases observed, in the second half-year we see one hundred and eighty-three cases, or nearly an half of all the cases which occurred.

Thus it may be seen that with the earliest cases of malarial fever in the year, the mildest types of infection are met with, the single tertian type predominating. As the season advances and the months approach which are richest in malarial fever, the single tertian cases become less frequent and the double tertian infections more common; while at the height of the malarial season a majority of the cases are of the estivo-autumnal, the most severe type in this climate.

It has seemed to us, however, a matter of interest to make another table, which appears below, showing the time at which the patient observed the first symptoms of the affection; this shows several interesting variations from the other table :

We see thus that the smallest number of cases occurred in the months of December, January and February, only two cases beginning during the month of February. From this time on there is a fairly, steady increase until the month of May, which shows the spring maximum; in July again an increase begins, reaching the climax in September, when 156, or more than one-fourth of all the cases, appear to have shown their first symptoms; 103 cases origi nated apparently in August, while only 69 appear to have originated in October; in 50 cases the date of onset could not be obtained. Thus nearly one-half of all the cases originated in the months of August and September, and whereas 137 cases were first admitted to treatment in October, only 68 dated their symptoms from that time.

Another interesting point brought out by our tables is the fact that while of all the cases observed, 21 per cent. date their apparent origin to the first 3 months of the year; of the first attacks, only 15 per cent. originated during this period.

Whether this means that a number of cases which were considered fresh infections were really relapses of old attacks or that the individual who has once suffered from dual fever is more subject to future infection is not yet clear.

concludes that the massage of sprained joints will :

1. Prevent swelling, or rapidly disperse it if present.

2. Prevent pain, or quickly remove it when due, as it must be, to tension.

3. Prevent stiffness, or overcome it when already present from disuse.

4. Prevent the sense of weakness and restore the part to its original vigor and strength.

5. Reduce the time of treatment from weeks to a corresponding number of days. 6. Permit the immediate use of the injured member.

SO LONG as the function of the external or orbital and the internal or nasal method of operating for the cure of this affection is a debatable one, even the recital of the history of a single case may not be amiss. Permit me to recall to your attention the classical symptoms of frontal empyema, the most constant of which is pain in the forehead of a boring, bulgy and throbbing character, which increases as the secretions form and distend the cavity; at times the pain is intermittent and neuralgic, and occasionally is altogether absent; the patient complaining only of a sense of pressure at the inner angle of the orbit; still again, the story is of a sharp supraorbital neuralgia, lasting three or four days, relieved by a flow of pus running from ten to twelve hours; after ceasing, not to recur, or only returning after a longer or shorter interval to become chronic.

In the latter case, other cells becoming involved from infection cause the growth of granulation tissue from necrosing bone. The bony dissepiments become absorbed in the process, granulation tissue and accompanying suppuration extend in various directions, more especially through thin party walls, often membranous-in which one frequently finds natural openings between ethmoidal attics and the roof of the large chamber in the superior maxilla. Thus is explained the frequent occurrence of antrum implication as a compli cation of ethmoidal necrosis.

Empyema of the frontal sinus results through absorption of the inner wall of the infundibulum blocking the entrance to this cavity from the nose. One may compare this trouble with a similar disease in the tympanum, with the subsequent involvement of the mastoid. Pain. is usually increased by mental and bodily activity; pressure over the parts, cough,

etc. If one examine the sinus membrane in an acute case one finds it swollen, edematous and ecchymosed.

The exudation of a mucous or a purulent secretion is, as a rule, to be seen only in old cases. With this, one of several things occurs. When there is still a communication between the nose and the frontal sinus, unilateral flow of pus (rarely bilateral) makes its appearance in the middle meatus and is seen running just over the anterior third of the middle turbinated bone. This flow is increased by bending the head forward and downward almost to the knees. (This is one of the most constant and important signs). This constant flow of pus may lead to hypertrophy and polypoid growth, as will be shown later on. The same occurs in empyema of the antrum.

If the sinus is not freely drained, a soft fluctuating tumor, generally in the vicinity of the root of the nose, somewhat above the lachrymal sac, gradually forms and causes exophthalmos with displacement of the eye forward, outward and downward. This is accompanied by a swelling over the sinus. which gives either a doughy feel or the sensation given by pressing the cover of a tin ointment box. But rarely there is formed without any swelling of the soft parts at the inner angle of the orbit a hard lump which may soften and fluctuate and then open outwards through the nasal cavity.

By increase of pressure due to increasing accumulation of fluids here the sutures between the lachrymal bone and the orbit are sundered, so that the edematous sinus membrane hangs down in the nasal cavity and is there to be seen as a suspended tumor from the nasal roof. Consequently the nose is more or less shut off from respiration, or occasionally the fluids pass through

the thin posterior wall of the sinus into the cranial cavity and cause death from purulent meningitis.

The diagnosis rests on the history and the subjective signs as shown here. In obscure cases (Schech) the diagnosis can only be made after clearing the middle meatus of granulations, polypi and hypertrophies. Where communication between the sinus and nose is impervious in acute cases the malady may be ushered in with fever, boring pains in and over the orbital region, almost unbearable supra-orbital neuralgia, vertigo, even stupor or delirium. The upper lid, the area at the root of the nose and the eyebrows may become edematous. Even when exophthalmos supervenes, the movements of the bulbus are rarely interfered with, though diplopia and strabismus divergens are present. In severe cases though mobility of the bulbus, amaurosis, conjunctivitis, keratitis from ophthalmos may be encountered. Fistulas formed spontaneously do not usually heal without surgical aid. So frequently is antrum trouble associated with frontal disease that one should never treat the latter alone without positively excluding the former.

In points of diagnosis I would insist upon the importance of realizing the fact that where we have suppuration in the nose together with granulation tissue or polypi in the middle meatus, we can seldom at first sight be sure of the full extent of the disease and must therefore be guarded in our prognosis. I have not infrequently seen cases where suppuration of the antrum was supposed to comprise the whole disease and the patient promised a cure upon its termination, whereas the anterior ethmoidal cells and possibly also the frontal sinus were quite as much at fault. On the other hand, cases of so-called necrosing ethmoiditis were treated with an eye to this alone, when the antrum had been overlooked, although the prime source of the suppuration.

Eliza D., aged 65, was sent to me by her physician, Dr. Hall, for a small lump at the inner upper angle of the orbit, the tip of which ended on the upper lid. The growth had made its

appearance some three or four weeks prior to this date and caused considerable annoyance. At first sight and feel it looked like an exostosis or sarcoma. While manipulating, a small head of thin pus was seen exuding from the lump. This it was learned was the usual course. I concluded we had to deal then with a choleastomatous degeneration of the gland, and a simple incision and curettement would end the trouble. But this it did not; she returned in a few days with a free discharge of pus, but less pain; thinking I had not been sufficiently thorough in my curetting I burned the sac with a stick of silver nitrate, and again a second time, but still without ending the trouble.

Although at each visit I reached unsuccessfully for necrosed bone, I determined to make a more thorough search, this time, especially as she had an ozena. Notwithstanding my deep incision and careful search, I could find no tract. She returned in a few days with a discharge as bad as ever. I then elicited the following history:

She had an attack of “neuralgia" in the middle occipital region lasting some two weeks, to be followed by a supraorbital neuralgia, of three or four days' duration, after which she noticed the lump in question! It never occurred to her that there was any connection between the neuralgia and the lump; nor could we elicit any history of exophthalmos, diplopia or other disturbance of vision. Just how much we can depend on this evidence can be gathered from the fact that her family did not notice the odor from the nose; and therefore could give no data as to its origin.

Rhinoscopic examination showed widely dilated left nares and general atrophy of the turbinates. But there was no sign of pus, and probably at that time gave no necrosis; maxillary atrium not involved. Now here was the problem the only positive factors of which were, one-sided ozena and a sinus which could not be said to communicate with the nose, and a supraorbital neuralgia of short duration, apparently the outcome of an occipital neuralgia.