Formerly Resident Physician Pennsylvania Institution for Feeble-Minded Children; Formerly Assistant Physician Illinois Central Hospital for the Insane; Physician to Oak Lawn Sanitorium and Passavant Memorial Hospital; Neurologist to Our Savior's Hospital; Lecturer

Psycho-Physics, Illinois College.

AND EGBERT W. FELL, B. S..

JACKSONVILLE, ILL.

The Associate Infections of Scarlet Fevers.-The object of Jacques' paper (Journal A. M. A., Dec. 19, 1899) is to show that scarlet fever is seldom a single infection and that its successful treatment requires a knowledge of all the factors. He has found the coccus described by Dr. Closs in all cases examined. One bacterial infection may so lower the resistance of the patient that other infections may take place. Thus it is in diphtheria associated with scarlet fever; the infection with scarlet fever coccus per· mitting infection, which would otherwise not have taken place, by KlebsLoeffler bacillus. The presence of diphtheria may be completely covered up by the symptoms of scarlet fever, aud if death results, the more important factor may not have been recognized. Different authorities vary greatly as to the frequency of this double infection. Most scarlet fever cases develop into streptococcus infections. The glands of the bucal region often become involved and the infection may extend to the middle ear. Influenza, measles, mumps, etc., are apt to accompany or follow scarlet fever. The author emphasizes the necessity of frequent bacteriological examinations. It is only by this means that we can determine the nature of the infections and apply the proper treatment.

A Preliminary Note on Antipneumococcus Serum.-(McFarland and Lincoln, Journal A. M. A., Dec. 16, 1899.)-The pneumococcus is present alone in seventy-five per cent of cases of croupous pneumonia, in combination with other bacteria, about fifteen per cent. It is also present in the complicative and sequelæ, such as meningitis, endocarditis, empyema, etc. Its presence in the blood is usually fatal. Inoculation of animals causes lesions similar to and sometimes identical with those of croupous pneumonia, Immunity was first produced by F. and G. Klemperer by the use of filtered cultures. It is now known that immunity can be produced by live cultures, either virulent or attenuated and by filtered or unfiltered dead culThe most important recent work has been done by Washburn, De Perzi and Pane, who used the serum of a horse to which had been administered first dead, then virulent cultures. One centimetre was necessary to protect a rabbit. The coccus produces very little toxin, the symptoms being due to local rather than systemic infection. An anti-infectious serum like Washburn's or Pane's is therefore indicated rather than an antitoxic. The work of the authors has been along the same lines as Washburn and Paner It is hoped that the serum will act on the pneumococci in the lungs, the immediate effect of its use being reduction of temperature, strengthening of the pulse, production of an early crisis and prevention of metastatic inflammation. The use of serum has so far given very satisfactory results.

Typhoid Fever in the Young.-A Jacobi in Pediatrics of December 15, 1899, advises the study of the older works, such as Taupin's Relliet's and Edmund Fuedrich's. The opportunities for infection are the same in the young as in the adult. Water is usually the medium, and the fact that it is generally boiled explains the relative absence of typhoid in the first years of life. The severity of the illness does not correspond with body temper ature, the worst cases of sepsis sometimes exhibiting the lowest temperature. The rise in temperature is mostly gradual. It is high in the second stage, and frequently irregular, owing to complications, such as otitis media, scarlatina, malaria or suppurating arthritis, or to the nature of the individual infection. The lips, tongue and mouth exhibit the same surface changes of the epithelium as in the adult. Vomiting is noticed in bad cases. Diarrhea of a catarrhal nature, depending on the presence of toxins or of ulcerations, is a frequent symptom. Intestinal ulcerations are not invariably met with, and when present do not necessarily cause diarrhea. Constipation is not uncommon symptom in the first as well as the second week. Gurgling in the ileo secal region is common in intestinal catarrh, and is not characteristic of typhoid fever. Tympanitis is usually moderate, extensive peritonitis being uncommon. The local form is, however, quite frequent. Hemorrhages are very rare, and are mild in children over four years old. The organs of circulation are not affected to the same extent as in adults. If the pulse becomes feeble and frequent owing to toxic and organic myocardial weakness, persistent stimulation should be resorted to. A decrease in the size of the spleen during the third week is a good symptom. Permanence of the swelling is infrequent and abscesses rare.

The nasal mucous membrane is dry and irritated. Epistaxis occurs in older children. A catarrhal condition or ulceration of the pharynx and larynx may cause hoarseness and cough, or dyspnoea and strangulation. Bronchial catarrh is frequent; pneumonia, either catarrhal or hypostatic, may occur; pleuritis and diphtheria are rare. The urine is of high color; urea and uric acid are increased, and chlorides decreased. Indican, albumin, renal epithelium and casts frequently are present. The Diazo test is usually positive from the end of the first week to the middle of the third. The skin is usually dry. The characteristic roseola is the same as in the adult. Miliara and erythema, gangrene, abscesses, furuncles and pustules occur. Desquamation may be copious. Periostitis and osteomyelitis are uncommon. The nervous system is not affected as it is in adults. Ambulant cases are common. Headache is frequently complained of; grinding of the teeth, sopor, or delirium, and screams resembling those of meningitis are met with. Aphasia sometimes occurs; polyneuritis is not rare; hemiplegia is rare paraplegia more frequent. Mania and melancholia are the forms of psychical disturbance most frequently seen. Typhoid fever may occur in the foetus; it is rare in earliest infancy; more common in the second and third years, and after that time increases rapidly in frequency. Different authorities differ widely as to the years of greatest frequency and mortality. The diagnosis is sometimes difficult, the Widal and Diazo tests. being important aids. Meningitis may be recognized by Kernig's symptom or examination of the cerebro-spinal fluid. The mortality varies according to season and the children, and ranges from 2 to 9 per cent, the very young and adolescents being more likely to succumb. Complications are dangerous; relapses not rare. The food should be liquid, and water should be given frequently. A purgative dose of calomel at the beginning, and warm water enemata later in the disease, act beneficially. For offensive diarrhea, permanganate of potassium or thymol enemata; internally, bismuth, sulpho-carbolate of zinc, salol and naphthalin. Collapse requires stimulants by mouth and subcutaneously. Chloral hydrate is the best hypnotic. Sopor or coma should be treated with cold affusions, while the body is submerged in water of 90 to 95°. Antipyrin is safer than acetanilid or salicylates. Cold and warm water are the safest antipyretics. As cold water is often contraindicated the author advises the use of warm baths, 90 to 95°, accompanied by friction, every three or four hours throughout the illness.

Hydriatic Measures in the Febrile Disorders of Infancy and Childhood.-(Baruch, Archives of Pediatrics, January, 1900.) - Water may be used advantageously as a substitute for antipyretic drugs. As a rule, the child should be immersed in water at a temperature of 90° for ten minutes, and then wrapped in a blanket. Repeat the bath every three hours, reducing its temperature 5° each time until 70 or 75° is reached; continue at this temperature as long as the patient's rectal temperature is above 103°. Improvement is shown in every way under this treatment; it contracts the cutaneous vessels, increasing the strength and diminishing the frequency of the heart beat. The abdominal compress at 70°, or in pneumonia the chest compress at 60°, is useful. Cold full baths are not well borne in scarlet fever. The sheet bath or wet pack followed by friction may be used when when objection is made to the full bath.

Some of the Causes and Effects of Mouth Breathing. Ingersoll (Buffalo Medical Journal, January, 1900) says that in children the most frequent cause of mouth breathing is adenoid growths in the naso-pharnyx. Hypertrophied tonsils and nasal polypi are also frequent. Deformities of the septum or turbinated bones sometimes occur. The results of the condition are many and widespread. The facial bones are not properly developed, the air-passages are in a state of chronic inflammation, there is a feeling of languor, a lack of endurance, and sometimes a functional heart trouble may be found. Deafness is common, and frequently causes inattention and an appearance of stupidity. The symptoms are relieved by the removal of the obstruction.

The Widal Reaction.-(Cowie, Physician and Surgeon, January, 1900.) The phenomenon of agglomeration and agglutination of bacteria in the presence of serum from an immune animal has long been known, but no practical use was made of it till in 1886, when Widal demonstrated its value in diagnosis of typhoid fever. The reaction occurs in all stages of the disease. The method of applying it is as follows: Fresh or dried blood, or the serum may be used. This should be diluted one to twenty or thirty. The culture may be made on peptone bouillon or agar. A macroscopical test may be made by adding a small quantity of culture to the diluted serum and allowing it to remain for twelve or twenty-four hours at a temperature of 37°C., when a white flocculent precipitate should occur if the test is positive. For a microscopical test a small quantity of the culture should be thoroughly mixed with the diluted serum and examined as a hanging drop. Clumping should occur in thirty minutes if the test is positive. This reaction may occasionally be observed in other conditions, but not so readily, or is so great dilution as in typhoid. "It would be an error to depend on the Widal reaction alone, for it is not the one symptom, but the gathering together of the most important symptoms that enables us to make a diagnosis. The Widal reaction is emphatically one of these, and its presence clinches the diagnosis."

Researches on Infection by the Tonsils.-Packard, in the Wesley M. Carpenter lecture, says (Med. Rec., Dec. 16, 1899) that the tonsils are groups of lymphadenoid tissue which act as filters for the substances absorbed from their free surfaces. Micro-organisms may pass through them; acute tonsilitis is an acute toxemia. It is probably one of the functions of the tonsils to weaken the virulence of micro-organisms. The author has previously reported five cases of endocarditis following angina. noticed a number of cardiac cases having a history of severe attacks of sore throat and dry pleurisy in connection with angina. Two cases were reported showing the relation of tonsilitis to chorea, and the infection theory of this disease discussed. Pyemia as a result of tonsilitis has been noticed. The author considers rheumatism to be due to an infection, the symptoms being caused by toxine rather than by the bacteria themselves. The frequency of angina preceding rheumatism has often been noticed. The tonsils are often abnormal in fatal cases of rheumatism.

PHILADELPHIA LETTER.

[SPECIAL CORRESPONDENCE.]

Bureau of Information for the A. M. A.-Reception by the College of Physicians -Medical Preparatory Course.

May 3, 1900.

During the meeting of the American Medical Association next month at Atlantic City, (which is but one and one-half hours away by rail) Philadelphia will be the central point of interest for most of the visitors from the Middle and Western states. To enable the visiting members to get the most out of Philadelphia's hospitals and dispensaries, the Philadelphia County Medical Society is organizing a bureau of information. The work will be directed by a committee of the society, who have provided a medical man to be present all the time at the College of Physicians, (13th and locust street) to answer questions and furnish information as to the work at the different hospitals and how to best reach them. The saving in time and friction to the visitor will be readily seen.

Ever since Dr. Weir Mitchell established an "entertainment" fund for the College of Physicians, there has been an evening of pleasantry for its members once in three or four years. Usually they have taken the form. of dinners at which the attendance (numbering about 400) has been limited to the membership. This year the bars were let down, and 500 extra invi-` tations went out to the trustees and other dignitaries of all allied institutions in the city (such as the various medical colleges and the different hospitals); also to our judges, prominent lawyers and business men. Advantages were taken of this opportunity to show the laymen how we fight off the forces of disease and death. To this end the Mutter Museum was freely called on. Dr. W. W. Keen, president of the college, received the guests, who were then shown up stairs by Dr. DeSchweinitz to the museum, where they were taken in charge by the committee who conducted the visitors about and explained how the numerous instruments of precision and therapeutic appliances were made use of in combatting disease. The interest shown by the laymen was more than ample return for the great trouble taken by the college authorities in arranging the evening. Retrospectively, the evening showed how, by such methods, the lay people may be brought to a much and more wholesome appreciation of the medical profession-and its hopes and its aims.

The recent ruling by the Medical council of Pennsylvania, absolutely requiring each of the four years of medical study to be carried out in a school of medicine, lends no little interest to the meeting of the Philadelphia County Medical Society just held. On invitation of the Society, there were present at the meeting the following presidents of literary colleges: Stahr, of Franklin and Marshall; Sharpless, of Haverford; Warfield, of Lafayette; Birdsall, of Swarthmore College-all of whom took part in the discussion. The law requires four years of medical study for candidates for the degree of M. D., the last three of which must be spent in a school of