1441

the midst of all that science and talent and money can do torescue him from his fate, cannot brace himself to calmlymeet the inevitable unless he can read in the sorrowing facesof those around him a continuance of their affection and theevidence of their sympathy. I have found it more potent thanmost drugs for the relief of many sufferings of body andespecially of mind, and I hold it to be for that suffering andusually uncared-for being, the hysterical female, a betterremedy than the usual scolding and cold douche.There is, and always has been, a partly facetious and

partly ill-natured tendency to lampoon and ridicule, not

individually but collectively, the members of all professionalcorporations, and even to the present day I believe there arestill amongst us ignorant and prejudiced men who talk as ifthey believed the majority of the clergy to be hypocrites andall lawyers thieves. But if you have studied the paintings ofHogarth or the more modern caricatures of Gilray, andespecially if you have read the plays of Moliere, you willknow that medical men in days gone by were looked uponas still greater quacks and impastors, and were ratherworse treated in this respect than their neighbours ;and I am afraid I must add deservedly so, for theywere, with few and brilliant exceptions, most of themmore charlatans and mountebanks than physicians andsurgeons. It is impossible to imagine a greater change forthe better than that which has taken place in the socialstatus of their modern successors, since the days when theirtrade mark was a shaving basin and a lancet, with an armfrom which the blood was freely Sowing, painted over thelintel of the door opening into a room which was one day

their surgery and the next their barber’s shop. At that timethey were men of low birth, no education, and ill manners,and were represented on the stage armed with a clyster as anemblem of their calling, ready to administer its contentsthen and there to their patient, an operation only concealedfrom the sight of the audience by the judicious dropping ofthe curtain. In contrast to this the members of the medicalprofession are now recruited from a totally different class,are as a rule well-educated gentlemen, and looked upon withquite as much respect as any other members of society. Theyare no longer, as I myself have known them in the country,relegated to the housekeeper’s room to get their luncheonwith the upper servants, but are the welcome guests oftheir host and often his pleasantest and most intelligentcompanions.

It is amongst this class of men that you will have to passyour lives-the honour of a great profession will be placedwithin your hands ; be very steadfast to uphold it and to passit on untarnished, and if possible enhanced, to those whoin the course of time will be your successors. Keep inremembrance the words which Robert Louis Stevenson hasleft behind him as a testimony to the merits and position ofdoctors. He wrote them as the dedication of a book of

poems to a few out of many physicians who had brought himcomfort and relief. I will read them to you and will thenask you to go forth in the world determined to justify asindividuals your right to a share of the lavish praise heaccorded to the members of your profession. These are hiswords :-" There are men and classes of men that stand above the

common herd; the soldier, the sailor, and the shepherd notunfrequently ; the artist rarely ; rarelier still the clergy-man ; the physician almost as a rule. He is the flower (suchas it is) of our civilisation, and when that stage of man isdone with and only remembered to be marvelled at in historyhe will be thought to have shared as little as any in thedefects of the period and most notably exhibited the virtuesof the race. Generosity he has, such as is possible to thosewho practise an art, never to those who drive a trade ; dis-cretion, tested by a hundred secrets; tact, tried by a thousandembarrassments; and, what are more important, Heracleancheerfulness and courage. So it is that he brings air andcheer into the sick room, and often enough, though not sooften as he wishes, brings healing."

UNIVERSITY OF CAMBRIDGE.—On Nov. 12th thedegree of Doctor of Medicine was conferred on CharlesRolfe, B.A., of Clare, and the degree of Master of Surgeryon Henry Hugh Clutton, M.A., of Clare. The degreesof M.B. and B.C. were conferred on H. Holmes, B.A.,St. John’s; J. M. Troup, B A., Pembroke; E. J. Maxwell,B.A., Corpus; and W. L. Garner, B A., Emmanuel.

HYPOTHESES AS TO THE LIFE-HISTORYOF THE MALARIAL PARASITE OUT-

SIDE THE HUMAN BODY.

(Apropos of an article by Dr. Patrick Manson.)BY DR. AMICO BIGNAMI.

Translated from the Italian by G. SANDISON BROCK,M.D. Edin., of Rome.

(Concluded from page 1367.)

THE observations of Tomnaasi-Crudeli lead substantially tothe same results as those of Hirsch, but he adds somevaluable observations, dr.1wn in great part from popularexperience, on the way in which malaria diffuses itself in thevertical direction, and how it spreads on slightly inclinedlevels, &c.1 Tommasi-Crudeli calls emphatic attention to

the well-known fact that malaria can rise only a shortdistance in the vertical directicn. Experience has taughtthe inhabitants of the Pontine marshes to sleep at nightduring the fever season on platforms supported on stakesfrdm four to five xnetres high. The same is done in manymalarious districts of Greece. A similar considerationenables us to comprehend why the ancient structures in theCampagna often have no other aperture in the outer wallthan the door and a very tiny window placed just below theroof. In the same way Tommasi-Crudeli explains thedifference between Norma, Sermoneta, and Sezze as regardsmalaria. These three villages are in the same line along theslope of the Lepini Hills, which overlook the Pontinemarshes. All three are exposed in the same way tothe south wind, which passes over the underlying marshesbefore arriving at these towns. Norma is quite healthy ; Sezzenot entirely so ; and Sermoneta (which is situated betweenNorma and Sezze) is rendered almost uninhabitable frommalaria. The reason of the difference lies in this, that atNorma the malaria of the underlying marshes cannot reachexcept by means of vertical aerial currents, because Norma,is joined to the level of the Pontine marshes by means of a,

high precipitous rock. Therefore, although Norma is justabove Ninfa, one of the most pestiferous places of thePontine marshes, malaria does not flourish there. With

regard to the action of the winds as carriers of malaria,Tommasi-Crudeli agrees on the whole with the conclusionsof Hirsch. To explain how it comes about that the malariagerm, although present in the air, is not transported by thewinds, he suggests that the winds may lose it ; consequently,it follows that the atmosphere of places far removed fromthe focus of production of the malaria, cannot be chargedwith any very dangerous load of it. The sea breeze whichblows in Rome in summer does not bring danger with it,although it passes over all the numerous malarial foci ofthe western half of the Campagna and over all the marshesof the adjoining littoral. It is not, writes Tommasi-Crudeli,that this breeze does not carry the malarial germs in thedirection of Rome ; it does carry them, and in greatquantities. But in carrying them it acts at the same timeas a ventilator, dispersing them in every direction, althoughit may be constituted by a current cf air of but very slightvelocity. The explanation is ingenious ; but it is not easy tobelieve that a current of air carrying daily, as Tommasi-Crudeli admits, a great store of malarial germs does notdeliver up in the town any of its malarious freight. And a

suspicion is not unnaturally aroused that the starting-pointof such a line of reasoning is not correct, and that, as amatter of fact, the sea breeze does not transport anymalarial germs. The explanation which Tommasi-Crudeligives of the variations of the quantity of malaria at varioushours of the day is also interesting. As everyone knows, theload of malaria in the air is less during the middlethan at the beginning and at the end of the day-thatis, after the rising, and, more especially, after the setting,of the sun. Now, remarks Tommasi-Crudeli, it is

precisely at these two periods of the day that thedifference between the temperature cf the lower strataof the atmosphere and the tempetature of the surface of thesoil is greatest, so that the currents of air which ascend

vertically from the soil into the atmosphere above are

1 Tommasi-Crudeli : Il Clima di Roma. E Loscher, 1886.

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stronger. Allowing that malaria is formed of solid particlesof light specific gravity (as are the germs of the livingferments), one understands perfectly how it might accumu-late in the inferior strata of the atmosphere, especially atthese two periods of the day.2 It must be admitted thatthese weak ascending currents raise the malarial germs fromthe "ground-air." Now it is difflcult, as has already beensaid above, to imagine how this can take place from dampsoil, and especially after rain, just when the load of malaria, as everyone knows, is greatest.To the supporters of the air-conduction theory belongs the

merit of having called the attention of the studious to certainlaws, which, after all, are in accord with the results of popularexperience, as the action of the winds, the slight diffusionof malaria in a vertical direction, &c. But if I am not

mistaken, this same theory, which was the starting point oftheir observations, did not, and does not, permit of a satis-factory explanation of the facts observed. Notwithstandingthe mot ingenious explanations, how is it conceivable thatthe winds do not transport the malarial germs if these arepresent in the air? ? How explain the fact, noticed manytimes, of the preservation of the crews of ships which arestationed off the most unhealthy coasts, whilst those menwho are obliged by their duties to pass the day on hore areattacked ? ? This fact has been put forward in support of theidea that the germs are of telluric origin ; but granted theadmitted possibility that they can be carried for shortdistances from the place of origin, this is certainly not infavour of the hypothesis that they pass from the soil into theair. Why have we malaria breaking out after rain, thetime of all others when the passage of the germs from thesoil into the air becomes most difficult ? Why are the even-ing and night hours the most dangerous ? 2 Whence the greatdanger of sleeping in a malarious place whatever the hoar ofday in which one sleeps? ? And why the great difference ofdanger between waking and sleeping in unhealthy localities ?

If I am not mistaken, whoever accepts the view that themalarial germs pass from the soil into the air can give nogrounds for his belief beyond what popular experienceteaches us, unless artificial and inadequate explanations. Iteems to me if one considers the difficulties which have to

be encountered in accepting either of the two hypothesesabove discussed, that of water- and that of air-conduction,one is perforce brought to think of another mechanism bywhich the germs might penetrate into man-I mean themechanism of inoculation. One arrives at this idea partly byexclusion (it is this which has rendered necessary the exa-mination which precedes) of the theories now dominant, andin part by the knowledge that inoculation is, up to the present,the only means by which malaria has been successfully intro-duced into man experimentally. Extremely small quantitiesof infected blood are sufficient for this, as Bastianelli and Ihave demonstrated,3 and intravenous inoculation is not neces-sary, a subcutaneous injection being sufficient.Does the idea that malaria is a disease of inoculation

accord with well-known facts regarding the diffusion of thefever and the conditions which favour the contraction of themalady ? I shall endeavour in what follows briefly to examinethis question. But, first, I wish to recall a very instructiveexample of a disease of the blood due to an intra-corpuscularparasite, and inoculated into cattle by a suctorial insect,which is furnished by the so-called Texas fever ofcattle. Upon the pathogenesis of this infection Smith andKilborne4 have made important researches, of which I thinkit will be useful to give a short account. The Texas fever isa blood disease characterised by destruction of the red blood-corpuscles. The symptoms are partly due to the secondaryaummia and in part to the great quantity of refuse material inthe blood, which is eliminated with difficulty and producesdisorders in the organs occupied in its removal. The destruc-tion of the red blood-corpuscles is due to a micro-organism(Pyrosorna bigeminum) which lives in them. It belongs tothe protozoa and passes through various distinct phases inthe blood. The cattle coming from territories permanentlyinfected, although apparently healthy, carry the parasite ofthe Texas fever in their blood. The Texas fever can be

reproduced in susceptible cattle by direct inoculation ofblood containing the parasite. The authors made a series

2 Loc cit., p. 63.3 Studi sulla Infezione Malarica. Bollettino della R. Accademia

Medica di R Roma, 1893-94, anno xx.4 Investigations into the Nature, Causation, and Prevention of Texas

or Southern Cattle Fever, by T. Smith and F. L. Kilborne, Washington,1893.

of experiments to show the importance of a tick (Boophilusbovis, Riley) in this infection: 1. Experiments with cattlefrom the south, from which the ticks had been removed,showed that the tick is necessary for the transmission of theinfection to the cattle of the north. 2. Direct experimentsto show that the fields can be infected by even the ticks alonewhich come from infected cattle were completely successful.3. Direct experiments to find out if young ticks artificiallyreared produce Texas fever when placed on susceptiblecattle were also entirely successful. The experiments ofthe authors have thus demonstrated that this tick is thenatural carrier of the malady ; they have demonstrated ina definite way that not only tee pastures can be infected bythe simple dispersion over them of the adult ticks, butthat the same cattle in the stalls, far from every cause ofinfection, can be infected by placing upon them young ticksartificially reared.Now, what is the relation, according to the authors,

between the tick of the cattle and the micro-organismof Texas fever ’? The hypothesis which seemed most

likely after the first experiments of the authors in 1882was that the tick, infected by sucking the blood ofthe sick cattle, conveyed into itself the parasite, which,having passed into a resistant state, was disseminated inthe pasture when the body of the mother tick broke up.It was supposed that these spores then penetrated intothe alimentary canal with the food and thus carried theinfection. The last experiments completely demolish thistheory. Administering to cattle adult ticks, or eggs of ticks,or grass from infected pastures gave negative results. Onthe other hand, the direct experiments show plainly that thesame young ticks introduce the infection into the bodies ofthe cattle. This fact implies one of two possibilities-eitherthe tick is a necessary host or it is an accidental host of theparasite. If it is a necessary host we are obliged to supposethat the parasite accomplishes certain migrations, and,perhaps, undergoes certain changes of state in the body ofthe adult tick, and finally localises itself in the eggs. Laterit may invade certain glands of the young tick and thenbe discharged into the blood of the cattle. This hypo-thesis supposes a complete biological union between thetick and the parasite on the one hand and the tick andthe cattle on the other. Or, according to a more simplehypothesis, the tick might only be an accidental hostof the parasite. In this case one may suppose that theparasite, entering into the body of the tick with theblood of the cattle, is already in a state of sporulationor very near that state. The young ticks growing near thedead body of the female may be infected by it. Theinfection being localised in their oral armature would then beintroduced into the blood of the cattle, to which afterwards theyoung ticks attach themselves. The question can evidentlyonly be answered by further investigations. The contents ofthe body of the ticks in various states of development weremicroscopically examined by the authors with great care.On account of the great difficulty of the research they didnot obtain any result.Can the disease, the authors ask, be communicated by

any other agency ? It has been seen that the transmissionof the Texas fever can be prevented altogether by removingthe ticks from the cattle coming from the South, andthus suppressing the new generation, besides which youngsick animals (sick natives) can remain in the same premiseswith the healthy ones for months without transmitting thedisease, provided they have no ticks upon them ; or, in otherwords, provided the malady has been produced by directexperimental inoculation. It may therefore be concludedthat the transmission is effected by the tick. But consideringour ignorance of the ectogenous life of the parasite we cannotdeny other possibilities. One cannot deny, for example,that the disease may be transmitted by insects which per-forate the skin and suck the blood. Parsing rapidly fromthe sick animals to the healthy ones they may carry enoughblood in their oral armature to inoculate these last. Buteven in favourable conditions it appears that this does not

happen. It also seems that the infection cannot comethrough the alimentary tract. Other investigators havestudied this or analogous diseases of cattle in Europe also,but it is not my intention to review the literature of thesubject. I have cited that part of the researches of theAmerican observers which is more especially concerned withthe manner in which contagion occurs. This shows that theparasite certainly is inoculated into cattle by a suctorialinsect by a mechanism reminding one of that which Manson

1443

supposes for malaria ; but the disease is carried by the ’’

agency of the same insect from the sick to the healthy.cattle-a thing, as everyone knows, without analogy inmalarious infection.As regards malarious infection, the idea that insects, and

especially mosquitoes, have an intimate relation with the.mechanism through which man takes the fever has beenstarted by many observers, particularly by some of theAmericans. Laveran, who, as is well known, is the principalsupporter of the water - conduction theory, notes the.abundance of mosquitoes in marshy places, calling attentionto the fact that the drainage of the soil, whilst it suppressesthe fever, also suppresses the mosquitoes. He also callsattention to the possibility (without excluding it) that

mosquitoes have a part in the pathogenesis of malaria as theyhave in that of filariasis, and, as believed by Findlay andothers, also in the dissemination of yellow fever. Grassi.and Feletti exclude this possibility without even con-

sidering it, because places exist infested with mosquitoeswhere one does not take the fever. The fact is knownto all, but it is not sufficient to exclude the hypothesisthat mosquitoes are the carriers of the infection. Itwould further be necessary to demonstrate that in thesoil or in the waters of those places there exist malarial

germs, of which these insects are only the vehiclesand inoculators into man. Besides this they recall a factasserted by Calandruccio, that in the intestine of mosquitoesmalarial parasites die without developing further (a similarfact has also been observed in leeches). But the observationof Calandruccio can be fairly opposed to those of Ross andthe hypothesis of Manson, whilst, if I am not mistaken, ithas no value against the hypothesis that man is inoculatedwith malaria by the mosquito. On the other hand, the know-ledge, if it could be well authenticated, that there existplaces in which malaria can be contracted notwithstandingthe absolute absence of mosquitoes and of insects which couldinoculate it, would suffice to exclude the hypothesis. But one11as no authenticated information of such an occurrence. Onthe contrary, all authors speak of the abundance of these=diptera in malarial districts. Kelsch and Kiener in their:well-known treatise do not even allude to the possibility ofinoculation. They also exclude the water-conduction hypo-thesis. That the infection comes by inhalation through thelungs they have no doubt..

Nothwithstanding the authority of the observers cited ithas for a long time appeared, and still appears, to me that-an attentive examination of the question which I havemooted above will not be wholly useless. If one admits theinoculation hypothesis many facts which are difficult to

explain by the theory of air-conduction would find a simpleand satisfactory explanation, and it is easy to demonstratethis. First of all, the fact, which we have already discussedat length, that malaria is not carried by the winds would beeasily understood, knowing as we do how closely thesediptera are bound to the soil on which they are hatched-and how adverse they are to allow themselves to becarried away, hiding when the wind blows, in the ground,amongst the grass, or under the trees. Also when asea breeze blows in the afternoon the mosquitoes ofthe Roman Campagna do not show themselves, and onlywhen the wind has gone down at the setting of the sundo they rise in clouds everywhere and attack animals andmen. That the evening and night hours are the most

dangerous, on account of the facility with which fever isthen taken, would be easily understood by anyone who knowsthe habits of this nocturnal dipter. That malaria only risesto a moderate height would also be equally intelligible,because the inoculating insect always flies near the ground.A satisfactory explanation would also be furnished of thegreat danger of sleeping in malarial districts, a fact of whichthe supporters of the air-conduction theory have never been’able to give more than an artificial explanation. Anyonewho has experience of malarious districts well knows anumber of cases in which the patient attributes the feverthat torments him solely to having slept a few hours in aplace where several times he had perhaps remained while’awake without harm. Three years ago I made with my

5 Corre, Archives de Médecine Navale, xxxix., pp. 67-70, 1883. King,Mosquitoes and Malaria, The Popular Science Monthly, New York,Sept., 1883. Josiah Nott, New Orleans Medical and Surgical Journal,1883, iv., p. 563-901. John Crawford, Mosquito Origin of MalarialDisease, Baltimore Observer, 1867 (cited by Nicholas. Cantier deterrassement en pays paludéennes, Paris, 1887).

6 Yellow Fever, its Transmission by the Culex Mosquito, AmericanJournal of Medical Soc., La Havana, 1886.

colleague, Dionisi, various excursions into malariouslocalities for the purpose of study, and more especiallywith the object of collecting frem the inhabitantsthe results of their experience-an experience whichone finds with difficulty in books. Many precautionswhich they take against the fever are taken, one

would say, to defend them from the sting of insects.

They avoid going out at night ; they are very careful not tosleep in the open air ; they hermetically close the windows-windows with badly fitting shutter, which might impede theingress of insects, but certainly not of air and of the germswhich it might contain. They take great care of their

mosquito curtain, making it of very cloóe net, under whichthey sleep, thoroughly shut in, notwithstanding the greatheat.

It is interesting to remember that Emin Pasha neveromitted to take a mosquito-net with him on his Africanjourneys, and he attributed to this precaution his not havinghad fever, the malarial agent in his idea being a corpuscularsubstance of which he supposed the close net did not permitthe passage. Nicolas, in his book on the Hygiene of Campsin Marshy Places, thus expresses himself on this question." And the mosquito-net, well shut, is indispensable at night.Without attributing to the puncture of mosquitoes anyrelation whatever with the microbes of the fever, one maybe certain that irritation by them produces sleeplessness andpredisposes to the fever." On the estates and farms visitedby us in the Campagna, the overseers, who are less frequentlyattacked by the fever than the workmen, protect themselveswith great care from the bites of insects, especially duringsleep. On the estate of Porto, near Fiumicino, where a badtype of malaria prevails, and which I visited several times incompany with my colleague Dionisi in the height of summer,we obtained the greatest amount of information about the

habits of mosquitoes, and the results of the experience of theinhabitants on the way in which the fever is caught. The

greater number think that the fever ie taken almost alwaysduring sleep. A very brief stay sometimes suffices-evenone night. But ordinarily, even in districts very subject tomalaria, a longer stay is necessary, so that the workmenwho go on to the property at the beginning of Julyfor the threshing commence get ill as a rule eightor ten days after their arrival. On the other hand,those who go in September for the working of the

ground often get ill more quickly-after only two or threedays’ stay. Many have observed that in autumn after therains the mosquitoes increase and likewise the fevers, andas the season advances they disappear together little bylittle. Thus, collecting from the inhabitants (who are reallymuch better informed about malaria than some medical men)the results of their experience, the conviction grows uponone that if malaria were inoculated by mosquitoes into manall the questions which I have put in a preceding paragraphwould receive an adequate answer. Malaria behaves itselfwith regard to man as if the malarial germs were inoculatedby mosquitoes.

I could easily add to the preceding other facts that lead tothe same conclusion, but it would be useless. Those whichI have mentioned suffice to prove the probability of thehypothesis ; those which I could add would not do anymore. But they are more than sufficient to justify a furtherstudy of the hypothesis itself. One might imagine the courseof events to be somewhat as follows. The mosquito, as is wellknown, deposits its eggs in water or in damp places ; fromthe eggs are hatched larvæ, which, very voracious, devoureverything they encounter, amongst other things the bodiesof the dead mosquitoes and the envelopes from which theyhave emerged. Then they pass into the state of nymphse,from which emerge the young mosquitoes. During this longperiod of life in damp soil or in water, and especially in thestate of larvæ, one may imagine that they load themselveswith malarial germs, which everything leads us to believeare found most abundantly in the soil and which afterwardsin the last period of life, when the female mosquitoes live assuctorial insects, might inoculate man. This hypothesiswould naturally give rise to other problems. The malariatgerms having entered into the young larvae might live inthem as parasites, going through a necessary stage of theirlife in this host before arriving at man. On the other hand,one might suppose these diptera to be simply carriers of thegerms into man. It will be understood that it is useless nowto insist upon this ; it suffices to mention it. In favour ofthe first hypothesis that the malarial germs pass through anintermediary host (whatever it may be), which afterwards

1444

transmits them to man, one might cite the experiments ofSilVeStrini7 if they were not easily open to criticism.Silvestrini made subcutaneous injections into many subjectswith dew collected from malarious districts and with thewater which had washed the earth or mud from places cele-brated for unhealthiness. Sometimes abscesses appeared atthe point of injection, but he never obtained, out of a totalof fifty-three experiments, one single case of malarial fever.Various criticisms might have been made on the way in whichthe author experimented ; for example, the observation ofinoculated persons was always continued for a shorter timethan what was perhaps necessary. But certainly no onewould wish, for obvious reasons, to repeat similar experi-ments on man to control the results of Silvestrini. If theresults of this observer are tenable we should have to con-clude that the germs of the infection contained in the

ground and the water of malarious places are not directlyinoculable into man, and perhaps the researches of Zeri

point to a similar conclusion. Zeri, as I have relatedabove, caused sixteen persons to inhale nebulised waterfrom marshy places without any result. But, abandon-

ing indirect arguments, in what way might one attemptan experimental study of the question’? ? Three years ago, in

company with Dionisi, I attempted what seemed to methe most direct method for arriving at a solution. Wecollected a great quantity of mosquitoes from the estate ofPorto. We brought them to Rome and set them at libertyin the Hospital of Santo Spirito in a room occupied by a manin robust health who had consented to become the subjectof experiment. Another similar experiment was made in theHospital of San Giovanni. In the subjects experimented onno fever developed. One can only, however, assign verysmall value to this negative result. To begin with, themosquitoes set at liberty in a room rapidly disperse, whateverprecautions one may take, so that only for the first night isthe individual who sleeps there bitten. Now I have alreadystated that in most cases it is necessary to spend several daysin a malarious place in order to contract the fever. We havenot succeeded in reproducing, therefore, in experimental con-ditions, even approximately, the natural ones. Also the directstudy of the mosquito to discover whether elements whichmight be looked upon as malarial germs were to be found inits body has yielded me no result, although made with greatpatience. I think, however, that the want of success was tobe expected, considering the difficulty of the research. TheTexas fever is, as I have already said, a blood disease ofcattle produced by an intra-corpuscular parasite which isinoculated into the animal by a special tick (Boophilus bovis,Riley). Smith and Kilborne, who have furnished a certainexperimental proof of this fact, did not succeed in findingthe parasite in the bodies of the inoculating ticks studied inall the various phases of their life.Attempts to obtain a direct demonstration should again be

made for malaria, but search should at the same time bemade indirectly for a solution of the problem. This mightbe done, for example, by ascertaining whether a number ofindividuals under identical conditions of life as to quantityand quality of work, food, &c., took the fever in the sameproportion when divided into two groups, one of them pro-tected as far as possible from the bites of insects and theother not. It is certainly difficult to protect from suctorialinsects, and only experience can teach the most effectiveway. One might experiment with various substances fordriving the insects away, with the use of very thick mosquitonets and with perhaps other devices. It is known that thosedo not easily catch fever who inhabit the shepherds’ huts,which are made in the form of a cone, with the hearthexcavated in the ground in the middle and with an aperturenear the apex of the cone, so that on account of the smokethe inmates are free from insects. One ought to ascertainwhether these who cover their skins with chalk, as do thecharcoal burners of Fiumicino to defend themselves from thecoal dust, take the fever in the same proportion as others.It is known that carefully covering the skin keeps off thefever to a certain point ; the inhabitants of malarious placesrever omit this precaution. I have heard it related byProfessor Marchiafava that a Russian medical man heknew of considered it sufficient to cover the body completely,even to the face and hands, with woollen stuffs in orderto escape the fever, and was so convinced of this thathe himself always went to sleep in places subject to theseverer forms of malaria protected by gloves and with a,

7 La Malaria. Lezioni. Parma, 1885.

kind of mask over his face ; and he never took the fever.Everyone knows that the chilling of the body, and in generalany disturbance of balance in the temperature, are amongstthe most frequent and manifest occasional causes of thefebrile paroxysm, but we cannot believe that theseinfluences are sufficient to explain the above-mentioned facts.Numerous observations and experiments made on manypersons systematically and with sufficient means of attainingone’s object would be necessary for the solution of the

problem. The task which I proposed to myself has onlybeen to collect a series of facts which would demonstrate theprobability of the hypothesis that fever may be contractedthrough inoculation. I consider that my work has not beenin vain if the only result of it should be to enable some otherobserver whose attention has been called to these facts toclear the ground of this hypothesis by showing it to be false.To solve the question of how the fever is contracted is thestep which I believe to be the most important that yetremains to be taken, because it would be the starting pointfor a rational prophylaxis of malaria. And to put us on theway to this result, which is the ultimate aspiration of all oilus, even an error may prove useful. I wish, therefore, thatthose who have at their disposal the necessary means maytake the study of the problem out of the field of theoreticaldiscussion into that of observation and experiment.

TWO CASES OF PERFORATED GASTRICULCER SUCCESSFULLY TREATED BY

ABDOMINAL SECTION.1BY H. LITTLEWOOD, F.R.C.S. ENG.,

SURGEON TO THE GENERAL INFIRMARY, LEEDS.

CASE 1.-The patient, a girl aged eighteen years, was

suddenly taken ill on May 2nd, 1896. at about 10 A.M.,whilst at business. She complained of intense pain in theupper part of the abdomen and a feeling of faintness. Shewent to bed and had some hot flannels applied. Feelingbetter the next day, Sunday, she went twice to chapel, andon the following day went to business. At 10 A.M. she was

again suddenly seized with very severe pain in the epigastriumand became greatly collapsed. She was at once put to bedand soon after seen by Mr. Byrd of Pudsey. The patientwas then in great pain. Her temperature was 96° F., andshe was cold and sweating. A small dose of opium wasgiven, and a hot fomentation ordered to be applied to theepigastrium. About 12 o’clock Dr. Hunter saw the case withMr. Byrd, and after a consultation it was thought thatan operation should be performed as soon as possible. I sawthe patient about 4 P.M. and, agreeing with this opinion,made arrangements for opening the abdomen. At this timethe patient had recovered to some extent from the collapse,the temperature had risen to normal, and the pulse was 120.The opium had relieved the pain. The abdomen was greatlydistended -and resonant ; there was resonance over the

hepatic region in front. The breathing was thoracic. The

diagnosis made was that some peritoneal catastrophe hadoccurred, probably the perforation of a gastric ulcer. The

operation was commenced about 5 P.M. Mr. Byrd gave theanxsthetic (ether) and Mr. Walter Thompson and Mr. F.Squire kindly assisted me. As the hot fomentations appliedto the epigastrium had produced a huge blister in this

region, and one was not absolutely certain of the diagnosis,an incision was made in the middle line just below theumbilicus. On opening the peritoneum some odourless gasat once escaped and the omentum presented ; this was in-flamed and in it in parts there were ‘patches of purulentlymph. The free edge of the omentum was turned up andrevealed some coils of small intestine ; some of these werefound distended and on them were small flakes of purulentlymph, but the greater part of the small intestines werecollapsed ; the large intestine was contracted and containeda great many scybalous masses. The pelvis and cascal regionwere exploied and nothing abnormal was found ; a sponge wasthen packed into the lower part of the abdomen and the in-eision prolonged upwards for about four inches in the middle

1 A paper read before the Leeds and West Riding Medico-ChirurgicalSociety on Oct. 16th, 1896. The patients and specimens were shown atthe meeting.