it happened that after three to five days of observation it was possible to determine the type of fever we were dealing with.

Three cases of malarial fever of the intermittent type, generally of the tertian variety, but also of the double tertian and quotidian, were observed and easily recognized by the characteristic temperature-curves.

From these it became no difficult matter to distinguish the typhoid varieties, with their vascillating temperature-curves, irregular through the day but always high at night, and lower in the morning. Among these cases there were a number which were not pronounced enough by their characteristic symptoms, such as exanthema, enteric pains or diarrhoea, delirium, etc., to be called typhoid, but could only be designated as continuous, remittent fevers. They were also pronounced by some as chronic malarial fevers.

Now there is no doubt that true malarial fevers will take a prolonged and tedious course from which the patient finally recovers; but for my part, I think that the term malaria is used too indiscriminately to cover all sorts of morbid conditions, which may or may not have had their origin in true malaria. I prefer to confine that term to those fevers only which show decided intermissions; that is, periods of time in which the patient is quite free from fever, that is, high temperature and pulse.

Upon the detection of this intermission the selection of the remedy is often dependent, but this period of apyrexia is often so short that it escapes detection if the temperature is taken only once in twelve hours. Nurses were, therefore, directed to take the temperature oftener, say once in two or three hours, and in this way it was often possible to discover the period of apyrexia if there were any such period in the case. This malarial character of such cases was also tested by the blood test, which would always disclose the plasmodium malariae if the blood came from a case of malarial fever. Where the plasmodium was absent, I doubt much if we found a single case of intermittence of the fever or a true period of apyrexia.

Many of these cases had had plenty of food, but not of the

kind they needed. Plain porridge, broths, soups, or gruels were at first given freely, and in many cases the unquenchable thirst was allayed by frequent but moderate draughts of water. It seems obvious after a while that this excessive thirst was not so much due to the fever as to the salty food and insufficient or unpleasant water of the journey.

There were also cases of ravenous hunger which could hardly be appeased, and several patients as soon as they could walk would go out and purchase pies and cake in large quantities, which, distributed through the wards, caused quite a number of serious relapses.

But, the diet and hygienic questions being disposed of, a brief allusion must be made to the pharmaco-therapeutics of these cases. In the typhoid, rhus and arsenic were generally indicated, besides belladonna, gelseminum, and others. The cases, once made out and put on proper diet, all did well but two, which were hopelessly low when brought to us.

In the cases of true malaria there were also a limited variety of medicines used, — chiefly china, arsenic, and nux vomica. The indications for arsenic were, especially in those cases of continuous remittent fevers, the indistinct periods of chill and heat with restlessness and great thirst; and where much quinine had probably been used, as shown by the apathetic state of the patient, who, though he had no fever paroxysms, felt quite sick and miserable.

Nux vomica in indistinctly developed fevers showing no particular type, but with evening chills, hot head, red face, rigors without external coldness, headache, nausea.

China, or, as I prefer to use it, the sulphate of quinia, was still the most important remedy, and when the intermittent nature of the case was once established it' was noticed by nurses and assistants how promptly the whole disease vanished, how the paroxysms failed to return, and how the pulsecurve became normal, and how the plasmodia vanished from the blood. But this will never come about, rapidly or at all, unless one condition is faithfully and intelligently followed. This condition is to watch for the period of apyrexia, that is, when the temperature and pulse have reached their lowest

point. It need not be normal, but it is absolutely necessary to ascertain the lowest point the temperature and pulse will reach; and having found that, give your china or quinine, or it may be arsenic or nux vomica. But there is no use in giving these medicines in attenuated doses during a fever paroxysm. They may suppress it then if given in large doses, but the convalescence will be very unsatisfactory.

My whole method can be summed up in a few words: Find the fever-fall point, and give one grain of sulphate of quinine every six hours, and you will find that in a large number of cases the paroxysms will not return.

I have quite a long list of cases outside of the hospital practice in which three grains of sulphate of quinine cured the case completely, without relapse or disagreeable after symptoms. The hard and complicated cases of our soldiers, especially if they had been overdosed with quinine and other medicines, may have required five or six grains, one grain to be given at intervals of six, eight or ten hours. It is always best to wait as long as possible for the return of a paroxysm and to make the intervals between doses as long as possible. If another paroxysm did overtake the patient, our rule was to await its end, and again to watch for the free interval, and then to give another grain or more.

Some may think this excessive dosage. I never wish to give more than is necessary, and have always, with regard to the medicines I use, endeavored to find the least dose which will cure oftenest. In order to ascertain this, I proved sulphate of quinia many years ago, taking a grain every night and morning for three weeks. I had no unpleasant effects from it, nothing which I could call a symptom, but I was conscious only of feeling very well, sleeping better and having better appetite than before taking the quinine.

After this experience, I no longer considered it dangerous, or hesitated to give a grain of quinine three or four times in twenty-four hours, and am convinced that cases treated by me in that way were not instances of suppression but fair and honest cases, and that quinine, used in this way, is most likely to effect a cure in typical cases of malaria, characterized by a period of apyrexia.

A METHOD FOR STERILIZING CATGUT.

BY W. F. WESSELHOEFT, M.D., BOSTON, MASS.

It is unnecessary, perhaps, to emphasize the fact of the great value of absorbable animal material for ligatures and sutures. Catgut, which is really made from the intestine of the sheep, is now readily obtained in all useful sizes, and has abundant strength for the purposes to which it is put.

The great objection to catgut has always been the uncertainty of rendering it aseptic by the different methods used. to sterilize it. So great has this feeling of doubt been that many surgeons have tried and abandoned one method after another, and finally the use of catgut itself, preferring a nonabsorbable material, that can be made certainly sterile, to catgut with all its other advantages.

The only method of sterilizing in which the surgical world has a common and entire confidence is that by means of a high degree of moist heat. Our instruments, dressings, and indeed everything except our hands and the field of operation, are now sterilized either by steaming or boiling to render them aseptic beyond suspicion.

By the following method catgut, cut into convenient lengths and sealed in separate paper envelopes, is sterilized in absolute alcohol at a temperature of boiling water, 212 degrees F., and a pressure of twenty-five pounds to the inch. These envelopes with the gut sealed in them are then dried. out, the alcohol evaporating readily. The gut, sterile and dry, is now ready for use, or can be kept indefinitely, and its strength is not impaired.

The method was suggested by observing that alcohol does. not affect the gum used in sealing paper envelopes.

The gut is cut into the desired lengths (from 24 to 30 inches. commonly). Each strand is wound about two fingers and put into a small paper envelope (Fig. 1), which is not sealed. Two of these small envelopes, each containing a strand of gut, are put into one slightly larger (Fig. 2), two inches square, and this outer envelope is sealed.

These envelopes are of strong bond paper, and in their manufacture their angles and seams are accurately closed and gummed. The outer envelope is a little more than two inches long and is folded on itself to two inches square, thus making what is known as a safety lap closure.

The envelopes, filled and sealed, are now put over a radiator, register, or in an oven for two or three hours to be thoroughly dried out. They should not be laid on the metal, but in a towel, or suspended where the heat is not above 200 degrees F., to avoid their being cooked and made brittle.

After being dried they are ready to sterilize. The sterilizer (Fig. 3) is a square brass box, tinned inside and out, with an inside measurement of 2 1-4 inches on a side. The cover, which is separate, is fitted with a rubber gasket, and is fastened on tight by four steel bolts and thumb screws. The sterilizer is cast square, to fit the envelopes, in order to economize alcohol.

The envelopes containing the gut are placed in a wire basket (Fig. 4), made to fit, and so carried into the sterilizer. Absolute alcohol 99 8-10 Squibb is now poured in up to the point (Fig. 5) which is marked by the upper end of the basket. The cover is screwed on and the sterilizer hermetically sealed.

The basket is a little less than nine tenths the length of the sterilizer inside, and the end of the basket marks the point to which the alcohol is poured. This allows a little more than one tenth of the space for the alcohol to expand in when heated. Alcohol boils at 172 degrees F., and when heated to 212 degrees it expands a little less than one tenth. of its volume. In using the sterilizer this point must be observed. The sterilizer has strength for many times the pressure it is subjected to; but, should it be filled full of alcohol, tremendous pressure would be developed, which it is not made to bear.

It

The sterilizer, filled with the envelopes and alcohol, is immersed under boiling water, and left there for one hour. is immaterial whether the boiling water is in a large enough vessel on the kitchen stove, or in an ordinary hospital instru