which are usually to be seen at this period; or we may imagine that both these factors play a part.

It may be that the destruction of a large number of red corpuscles exerts a toxic influence upon the organism. In other conditions, however, in which this occurs, it is difficult to separate the effect of the blood-destruction from that of the exciting cause, while extensive blood-destruction is by no means always associated with a sharp febrile paroxysm. Thus in poisoning by chlorate of potassium or carbon monoxid, when great numbers of red blood-corpuscles are destroyed, with consequent hemoglobinuria, fever may be practically absent.

There are, then, many reasons which might induce us to believe that Baccelli's supposition is true; that the toxic substance or substances responsible for the paroxysm are liberated by the sporulating parasites. The remains of the disintegrated red corpuscles may exert a toxic effect, but it is scarcely probable that they play the primary part in exciting the paroxysm.

The Anemia. The discovery of the malarial parasite has enabled us easily to account for the anemia which is so characteristic of malarial infections. This depends not only upon the constant destruction of the red blood-corpuscles in the circulating blood, but in more chronic cases upon the extensive changes in the blood-forming organs which are brought about by the infection.

The jaundice also is a direct result of the extensive blooddestruction. It is not, strictly speaking, hematogenous. remains of the destroyed red blood-corpuseles and the hemaglobin set free are disposed of ordinarily by the liver through the bile; the increased blood destruction results in so extensive a polycholia that from the inspissation of the bile and the overcrowding of the bile capillaries, absorption of bile with jaundice occurs.

Pernicious Symptoms.-But among the most interesting results which have followed the recent studies of malarial infections have been the explanations which we have found for some of the pernicious symptoms which are especially common in estivoautumnal infections. These symptoms have been shown to be in many instances directly due to the special localization of the parasites in certain internal organs.

Cerebral Symptoms.-The frequency of cerebral symptoms in pernicious malaria is well known. Often, probably, the delirium and other manifestations are due to circulating poisons, but in many cases with symptoms referable to disturbed brain functions, coma, general or local convulsions or paralyses, postmortem examinations have clearly demonstrated their dependence upon local disturbances produced by the accumulation and development of enormous numbers of parasites in certain parts of the central nervous system. In many cases of fatal comatose malaria the capillaries of the grey cortex throughout may be crowded with parasites free and in red corpuscles. In some instances actual thromboses may occur, resulting in serious local changes. Sometimes definite local symptoms have been shown post-mortem to be due to changes resulting from the special accumulation of parasites in small areas of the brain or cord. Thus, in one instance of pernicious fever, with symptoms of bulbar paralysis, Marchiafava was able to demonstrate post-mortem a special localization of the parasites, with quite extensive secondary changes in the medulla oblongata. In like manner the well-known choleriform type of pernicious parox. ysm has been shown to be due to the special localization of enormous numbers of parasites in the gastro-intestinal mucosa.

It may be that those instances of pernicious fever, which I have never had the opportunity to observe, but which have been well described by Baccelli in particular, those cases associated with marked pulmonary symptoms, are due to a special localization of the parasites in the capillaries of the lungs.

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Manner of Infection.-From what I have said it is easy to ap preciate how deep an insight we have gained into the causes and nature of this important disease, and yet much remains to done. For instance, we have no idea as to the form in which the malarial parasite exists outside the human body, nor of the manner in which infection occurs. Owing to our ignorance of the former condition we are naturally more or less at sea in our attempts to elucidate the manner of infection. Does infection occur through the respired air, or through the gastro-intestinal tract? Or may it possibly be transmitted subcutaneously by means, perhaps, of insect bites?

Indeed, there favor of the view

You well know how general the idea is that malarial infection takes place by means of the inspired air. seems to be almost overwhelming evidence in that infection may take place in this manner. proof we do not possess.

And yet definite

In like manner many observers believe that malaria may be a water-borne disease. It must, however, be said that numerous attempts by Celli, Marino and Zeri to produce infection by the administration of water from the most malarious districts, by the mouth, by rectum and as an inhalation, have failed. Grassi and Feletti have furthermore caused patients to drink dew collected from malarial districts, and, indeed, fresh human blood containing malarial parasites, and in every instance with a wholly negative result.

The malaria may be transmitted by hypodermic or in.ravenous inoculation has been indisputably proved by a large number of carefully carried out experiments. And recently a considerable impetus has been given to the idea that malarial infection may be brought about by the bites of certain insects, especially the mosquito.

Laveran, Bignami and others have called attention to the fact that many of the precautions adopted in severely malarious districts against infection are just such as might be directed against the bites of insects, and especially mosquitoes. The discovery of Theobald Smith that the hemocytozoon (pyrosoma bigeminum) of Texas cattle fever is conveyed from one animal to another by means of the cattle-tick, and that of Bruce, that the cause of the tsetse-disease is an hemocytozoon which is introduced by bite of the insect, are certainly suggestive, relating, as they do, to parasites so closely allied to the malarial organism.

The theory recently put forward by Manson, who suggests that the mosquito may represent an intermediate host of the malarial parasite, playing the same rôle that it does in the case filaria sanguinis hominis, is very interesting but purely hypothetical. Much of this idea Manson bases upon the discovery that flagellate bodies may develop from crescentic forms within. the stomach of the mosquito; but this fact, though very interesting, is not remarkable, when we consider that they develop

outside of the body upon the fresh slides of blood. That malarial infection may take place through the bites of insects is an interesting possibility, but it is by no means proven.

Now, what practical results have we gained from these interesting advances of the last fifteen years? The most important, certainly, is the establishment of a positive diagnostic criterion; but further, as a direct result of this, we have learned much that is important with regard to the methods and effects of treatment.

AETIOLOGY OF GLAUCOMA.-Dr. Dudley S. Reynolds discusses this subject in the Tri-State Medical Journal. He sums up his observations with the statement that glaucoma is always an inflammation of the ciliary muscle, or ciliary body, generally of both. That the iris always participates more or less in the inflammation; and that the peripheral portion of the choroid is early invaded. The only predispositions known are the rheumatic and gouty diatheses. A common exciting cause, independently of the diathetic conditions, is traumatism of the ciliary region.

Astigmatism, hypermetropia, and the prolonged use of the eyes by students and artisans, poorly nourished, may lead to incipient or chronic glaucoma. The prolonged use of the eyes in the presence of glaring light, with loss of sleep, may in some lead to augmented tension and peripheral narrowing of the field of vision. All the well-defined typical cases of glaucoma must, however, be admitted to occur in persons with rheumatic or gouty diatheses, or in those who have been the subject of traumatism of the ciliary region of the eye.

The ocular tension observed in syphilitic irido-cyclitis, extending, in neglected cases, to the choroid, retina, and vitreous, sometimes ignorantly called iritis serosa, presents in no stage of its development any clinical resemblance to true glaucoma.

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Editorial.

PUBLIC HOSPITALS AND DISPENSARIES.

There are two sides to the question of dispensing free medical aid to the poor. The great cities of the north and west are realizing that this kind of charity can be carried to an extreme that is got good, while the greater part of the South is experiencing medical the other extreme. Either of these extremes affects the profession and is a matter in which its members should take a special interest. The trouble in the north is that with the great multiplicity of free hospitals and dispensaries the legitimate fields of the regular practitioner are being invaded and his income thereby reduced.

The number of these institutions seems to de pend not so much upon the real needs of the people as upon the number of schools which need material"for the clinical instruction of their students. This is clearly shown by the fact that the greatest complaint comes from those cities where the schools are most numerous. Ambitious young medical men see that it greatly increases a physician's reputation and brings him more frequently and prom