Part 77

Pasteur employs as the media for cultivation--(1st) urine neutralized {489} by a few drops of potash solution; (2d) a liquid prepared by boiling for twenty or thirty minutes the yeast of beer in water, neutralizing, and filtering; and (3d) chicken tea, prepared by boiling equal parts of water and the lean of muscles a quarter of an hour, filtering, and neutralizing. A small drop of infected blood is placed in the liquid of cultivation, and the microbes which it contains multiply so abundantly that the liquid becomes turbid in a short time, and they are found in all parts of it. A drop of this liquid is added to another portion of the medium, and this also soon becomes turbid from the immense development of organisms which have the same microscopic appearance and character as those in the drop of blood. The process is repeated many times, until the microbes are far removed from their original source in the blood and tissues, and a drop of the last cultivation, whether it be the fiftieth or the hundredth, is inserted under the skin of a healthy animal selected for the experiment. If it be true, as stated by the experimenters, that the original disease is thus reproduced with the microbes of at least three or four distinct maladies, this age is distinguished by one of the most important discoveries ever made in pathological studies. It remains to determine whether this great discovery is of general applicability to the infectious diseases with which man is afflicted. If so, it is not improbable that we are on the eve of finding a method by which some at least of these maladies may be prevented or mitigated, as small-pox has been since the time of Jenner. The result of experiments made by Pasteur with the microbes of that fatal malady of the herbivora, known under the various names of splenic fever, anthrax, wool-sorter's disease, and charbon, encourages this belief. Originating among the herbivorous animals, it has in many instances been contracted by individuals who have rapidly perished. Many engaged in assorting alpaca and mohair have lost their lives by it, some with all the symptoms of profound blood-poisoning, without external lesions, and others with redness and swelling at some point of infection where a sore or abrasion existed, but with speedy blood-contamination.

The microbe of this malady, the Bacillus anthracis, occurs in the form of straight filaments with little movement or only with oscillation, and producing bright-shining spores. Now comes a very interesting and important result of experimentation: Pasteur states if several days elapse between the cultivations the virulence of the parasite diminishes, so that he has been able to produce by inoculation with it a mild and never fatal form of charbon, which affords immunity in the animal from any subsequent attack. This opinion was sustained by a trial experiment on sixty sheep. Toussaint and Chauveau claim that they produce a similar attenuation of the virus by defibrinating infected blood, heating it to 55° C. (131° F.) and filtering it. These experiments awaken the hope that the time will come when the acute infectious maladies in man, scarlet fever among others, will be rendered less virulent. That one of them--to wit, small-pox--has for nearly a century been under our control certainly encourages the belief that there is some way to mitigate others of the same class which are equally fatal if not so loathsome.

As yet, observers do not agree in regard to the parasite which is supposed to sustain a causative relation to scarlet fever. Klebs states that it is highly probable that both measles and scarlet fever are produced by {490} micrococci, and he has sketched the design and described the development of a microbe which he designates the Monas scarlatinosum.

The London Medical Times and Gazette for Jan. 28, 1882, contains an account of the supposed discovery of the scarlatinous microbe by Eklund of Stockholm, an authority in the microscopic examination of parasites. He says that scarlet fever is rarely absent from the Swedish capital and from the barracks and dwellings on the isle of Skeppsholm. In the urine of scarlatinous patients he has constantly found a prodigious number of discoid corpuscles, oval or round, their diameter being less than 1/1000 millimetre and from 1/30 to 1/10 that of a red blood-cell. They are colorless or yellowish white, surrounded by a distinct cell-wall, each containing a well-defined nucleus of a deeper hue. Sometimes one or more microbi may be seen. They exhibit rotatory or oscillatory movements, especially observed when a drop of water is added to the fluid. They multiply, as he has frequently seen, by fission--first in the microbes, next in the nucleus, and lastly in the cell-wall. He cannot say whether they develop into a mycelium. At any rate, the development of fine filaments seems to be exceptional. He has never seen them adhere in moniliform chains nor massed as zooglæa. He considers them to be veritable schizomycetes, and proposes the name Plox scindens.

Eklund asserts that he has found these same organisms in vast numbers in the soil- and ground-water of the isle of Skeppsholm, in the mud of the trenches dug for the water-mains, and in the greenish mould upon the walls of the old barracks, where scarlet fever was most rife. He states that scarlet fever has occurred in children after drinking milk mixed with the ground-water of the island, and he observed a case which followed immersion in one of the trenches of the island and the drying of the clothes in a small room. In another instance scarlet fever broke out in a block immediately after exposure of the ground-water by excavations.

It is evident that the discovery of this microbe under such circumstances does not prove that it is the cause of the disease. This can only be determined by inoculation, or by experiments which furnish the conditions of scientific exactness. Although great progress has been made in parasitology during the last decade, it is evident that several years of observation and experimentation must elapse before it is clearly and definitely ascertained whether or to what extent microbes cause scarlet fever and the other exanthematic fevers with which it is classified.

Whether the specific principle of scarlet fever be a micro-organism or a chemical substance, its mode of action and effects have been ascertained by clinical observations. Without doubt it commonly enters the system by the breath, but it may enter in the ingesta, and it infects the blood. That it resides in the blood has been ascertained by inoculation with this liquid, by which scarlet fever has been reproduced in its typical form. From the blood it enters the tissues and secretions. Hence handkerchiefs or linen containing the saliva or mucus of a patient, the epidermic scales shed abundantly in the desquamative period, and probably also the urinary and fecal evacuations, contain the poison, so as to be highly infectious. Even the discharge of a scarlatinous otorrhoea is thought by some to be contagious for a considerable time.

Scarlatina is communicable not only by direct exposure to a patient, {491} but also by exposure to objects which happen to be in his room during his illness, and to which the poison becomes attached, such as clothing, books, and toys; small packages, even letters, it is believed, from cases which have occurred, sometimes convey and disseminate the contagious principle.

In England observations have been made which show that scarlatina has been communicated by infected milk. The disease occurred in the family of a milkman, and the milk, before it was distributed, remained for a time in a kitchen which had been occupied by the patients. This milk was taken by twelve families, and in six of these the disease occurred almost simultaneously at a time when few cases were occurring in the locality. There had been no direct exposure to the carrier of the milk nor to members of the affected family (Taylor). In another instance a woman and her son had scarlet fever while they were serving milk to several families, and the disease appeared in all these families except one, which consisted of old people (Bell). It is known that milk absorbs volatile substances so as to be flavored by them, as is shown in the experiment of placing it in an open vessel in a box with a pineapple; and it may in a similar manner become infected by the specific principle of scarlet fever, or it may be infected by detached particles of epidermis; which is not improbable when one convalescing from scarlet fever is allowed to milk the cows or prepare the milk for distribution.

The scarlatinous virus surpasses that of any other eruptive fever except small-pox in its tenacious attachment to objects and its portability to distant localities. Hence in the literature of the disease are the records of many cases in which the poison was conveyed long distances, retaining its virulence to the full extent and causing an outbreak of the malady in the localities to which it was carried. In New York, so frequently has scarlet fever as well as measles and diphtheria been contracted from the persons or clothing of well children who come from infected houses, that the Health Board now excludes from the public schools all children who come from such houses, even though they live on separate floors from those occupied by the sick. In one instance that came under my notice a washerwoman whose child had scarlet fever communicated the disease to an infant in the household where she was employed, by placing her shawl over the cradle in which it was lying. A physician of my acquaintance went from a scarlet-fever patient to a family several streets distant, and took one of their children upon his lap. After the usual incubative period this child sickened with a fatal form of the malady, and the remaining children of the household were in time affected. In New York scarlet fever has seemed to me to be not infrequently communicated through school-books, which, profusely illustrated by pictures and rendered attractive to the young, are often allowed to lie upon the bed of a scarlatinous patient and be handled by him during convalescence, or even during the course of the fever if it be mild. The young librarian of the circulating library of a Sunday-school, whose pupils came largely from the tenement-houses, was occupied a considerable part of a day in covering and arranging the books. After about the usual incubative period of scarlet fever he sickened with the disease. His two sisters were immediately removed to a rural township three hundred miles away, and to an isolated house where scarlatina had never occurred. About one {492} month after his recovery, and after his room had been disinfected by burning sulphur and his bed-clothes and linen had been thoroughly washed, and all articles suspected to hold the poison had been either disinfected or destroyed, the brother visited his sisters in the country. Three weeks subsequently to his arrival one of these sisters sickened with scarlet fever, and a week later the other also. It seems that the exposure must have occurred several days after his arrival in the country from some book or other infected article in his possession. About two months elapsed after the last case; the family had returned to the city, the infected room in the country-house had been thoroughly fumigated by burning sulphur from morning till evening, when a little girl from an inland city remained a few days in this house, and probably often entered the room where the young ladies had been sick. In a few days she also sickened with a fatal form of scarlatina. Such histories and experiences are not infrequent. They are common during epidemics of scarlet fever. They indicate an extraordinary attachment of the scarlatinous poison to objects, and show that it is not gaseous nor readily volatilized.

A striking example of this fixity of the poison occurred in the practice of the late Kearney Rogers, formerly a prominent and much esteemed surgeon of New York City. Six children in a family had scarlet fever. Three and a half months subsequently another child, living at a distance, was allowed to return home and occupy the apartment in which the sickness had occurred. One week subsequently to the date of the return this child sickened with the same malady. Elliotson states that a patient with scarlet fever was admitted into one of the wards of St. Thomas's Hospital, and for two years subsequently young persons who were admitted into the ward were apt to take the disease. Richardson of London relates the following experiences of a family whom he attended in a rural district: "At a short distance from one of our villages there was situated on a slight eminence a small clump of laborers' cottages, with the thatch peering down on the beds of the sleepers. A man and his wife lived in one of these cottages with four lovely children. The poison of scarlet fever entered the poor man's door, and at once struck down one of the flock." The remaining children were now removed some miles away, and after several weeks one of them was allowed to return. Within twenty-four hours it also took the disease, and quickly died. The walls of the cottage were now thoroughly cleaned and whitewashed, the floors scoured, and all the wearing apparel either destroyed or washed. Four months elapsed after the last sickness when one of the remaining children returned. "He reached his father's cottage early in the morning; he seemed dull the next day, and at midnight I was sent for, to find him also the subject of scarlet fever. The disease again assumed the malignant type, and this child died." Richardson believes that the contagium was attached to the thatch, which could not be thoroughly disinfected. The fact of this remarkable long-continued attachment of the poison to objects, indicating by this fixity that it is a solid, is consonant with the theory that it is an organism.

INCUBATIVE PERIOD.--The duration of the incubative period varies in different cases. It is sometimes less than twenty-four hours, as in {493} the above case reported by Richardson; in the following well-known case, observed by Trousseau, it was one day. A girl arrived in Paris from Pau, where there was no scarlet fever, and occupied the same apartment with her sister, who was sick with this disease. Twenty-four hours after her arrival she also was attacked with the same malady.

Russeberger attended a child who was exposed at noon to scarlet fever, and took the disease on the following night. B. W. Richardson (Clinical Essays, 1861, vol. i. p. 94) gives his own experience: He had applied his ear to the chest of a patient suffering from scarlet fever, and was conscious of a peculiar odor emitted from the patient. He was immediately nauseated and chilly, and from that moment he dated the beginning of an attack of scarlet fever. In the Transactions of the Clinical Society of London, vol. xi. 1878, the late Charles Murchison gives the statistics of 75 cases, showing the incubative period, as follows:

In 4 cases it was not more than 24 hours. " 2 " " " " 30 " " 3 " " " " 36 " " 4 " " " " 40 " " 1 " " " " 41 " " 4 " " " " 58 " " 1 " " " " 54 " " 1 " " " " 2-1/2 days. " 31 " " within (time not accurately ascertained) 4 days. " 2 " the incubation did not exceed 4-1/2 days. " 17 " " " " " 5 " " 2 " " " " " 6 "

In three cases Murchison believes that the incubation was precisely fixed at thirty-six hours, three days, and four and a half days.

Watson says that a man reached Devonshire on mid-day to see his daughter, who had scarlet fever. Two days later he was also attacked. Rehn saw a child who was attacked two days after its grandmother returned from a case of scarlet fever; and Zengerle, a girl of ten years, residing at Wangen, where there was no scarlet fever, who took the disease two days after her mother had returned from visiting a family affected with it. Loochner states that a boy aged four and a half years was attacked one and a half days after admission into the infected wards of a hospital. Armistead, in his annual report on the health of the Newmarket rural district, states that three children, coming from a different part of the district, visited Westley, and stayed next door to a child who had scarlet fever six weeks previously, and who was allowed to play with these children on the evening of Aug. 13th and morning of the 14th. The family then returned home, and on the 18th, four days after the exposure, all three children sickened with scarlet fever (Brit Med. Jour., Sept. 30, 1882).

Ordinarily, therefore, the incubative period, though varying in different cases, is within six days. Many cases, however, occur in which it seems to be longer. Thus in my practice scarlet fever appeared in a family on April 26, 1882. The patient was immediately removed to the third floor and the other children to the basement. All communication between the infected room and the basement was forbidden, but on May 8th, twelve days after the separation, one of these children sickened with the disease. {494} Many observers--among whom may be mentioned Niemeyer and Copland--believe that the incubative period may be longer than one week, but, on account of the subtlety of the poison and the many modes of transmission, it is possible that in the instances of an apparently long incubative period there were other and unsuspected exposures. When scarlet fever has been communicated by inoculation, as in the experiments of Rostan and others, the incubative period has been about seven days, but Gerhardt states that a man was attacked four days after an abscess was opened by a knife used upon a scarlatinous patient. This variation in the incubative period, which also occurs in some other infectious diseases, as diphtheria, is probably due mostly to individual differences, some being more susceptible than others; but it may be due partly to those obscure meteorological conditions which we designate the epidemic influence. Probably, as a rule, when the disease is quickly developed after exposure, the attack is more severe than when several days elapse.

CONTAGIOUSNESS.--The area of the contagiousness of scarlet fever is small. It apparently embraces only a few feet. Therefore, close proximity is the necessary condition of its propagation. Hence many who are exposed, particularly of those who are remotely exposed, do not contract the disease. There is also an idiosyncrasy in some children, so that they resist infection even when repeatedly and closely exposed. In the New York Medical Record for March 23, 1878, C. E. Billington states that of 90 children in 26 families who were exposed to scarlet fever, 43 contracted the disease and 47 escaped; whereas, as is well known, comparatively few unprotected children escape pertussis, variola, varicella, or measles if exposed to either of these diseases. By strict isolation, therefore, the spread of scarlet fever is more easily prevented than that of most other acute infectious maladies. In the New York Foundling Asylum for a number of years children with scarlet fever were isolated in a small room attached to one of the wards. The door between the two rooms was closed, and not opened during the continuance of the sickness. Entrance into the small room was through another door, and a nurse was assigned to the scarlet-fever cases, with strict directions that she should not mingle with the other children. These simple precautions were found sufficient in the various epidemics of scarlet fever which occurred in the city to prevent the spread of the malady through this institution; whereas, similar measures were much less effectual in arresting the spread of measles and pertussis. Consequently, an outbreak of scarlet fever in this institution was usually limited to a few cases, while the extension of measles and pertussis was arrested with difficulty till a more efficient quarantine was established.

VARIATIONS IN TYPE.--The type of scarlet fever varies greatly in different epidemics, and frequently also in cases which occur in the same epidemic, even in the same family. One child may have scarlatina so mildly that little treatment is required and convalescence soon begins, while another has the malignant form, and soon succumbs, notwithstanding the prompt employment of the most efficient and appropriate measures. Ordinarily, however, if the first case in a family be very severe, subsequent cases will present a similar type; but there are notable exceptions. This variation in type in different years and different epidemics is probably not equalled in any other infectious malady. Consecutive {495} epidemics may present this variation, or the same type may continue for a series of years, and then, from some unknown cause, change to one milder or more severe. In England, during Sydenham's life, scarlet fever was so mild that he regarded it as a trivial affection, requiring little attention, like rötheln of the present time, but after the death of Sydenham, Morton and his contemporaries in London found, to their sorrow, that the type of scarlet fever was very different from that described by Sydenham's pen. The late Graves of Dublin and his contemporaries treated a mild type of scarlet fever with a very small percentage of deaths--much less than that during the preceding generation--and they attributed their success to their greater knowledge and more appropriate use of remedies than their ancestors possessed and employed. By and by the type changed, the mortality of former years was restored, and they discovered that their previous success in saving life had been due not to their skill, but to the mild form of the malady. A distinguished physician of New York treated more than fifty cases of scarlet fever in one of the institutions without a single death. A few months afterward the type of the malady changed, and his own son perished from it.

SURGICAL AND OBSTETRICAL SCARLATINA.--After surgical operations, and sometimes in surgical cases not requiring operative measures, a scarlatinous efflorescence occasionally appears upon the whole or nearly the whole body, and remains for several days. The following were cases of the kind alluded to. They occurred in Guy's Hospital, and were published by H. G. Howse in Guy's Hospital Reports for 1879: On March 15, 1878, Jacobson performed osteotomy upon a child suffering from extreme rachitis. The operation was followed by a moderate febrile movement (100° to 101°), and after three days by the appearance of an efflorescence, with sore throat and the strawberry tongue. The osteotomy had been performed under carbolic acid spray and with all the details of antiseptic surgery. The rash soon faded, the temperature fell, and the child, temporarily separated from the other patients from the suspicion that the disease was scarlet fever, was brought back to the ward. The subsequent history confirmed the diagnosis of scarlet fever, for the skin desquamated, and on April 1st abundant albumen was found in the urine. The case terminated favorably. Three months previously the same operation had been performed on the other leg, with no unfavorable symptoms. On April 5th, three weeks after the osteotomy, a lipoma was removed from another patient aged twenty-one years. The following day the temperature rose to 101°, and remained at that till April 8th, when it suddenly increased to 103°, and a rose-rash occurred over the body, with sore throat. On April 9th, Howse excised the elbow-joint of a girl of sixteen years having pulpy disease. On the 10th her temperature began to increase, and on the 11th reached 105.8°. Toward evening a roseoloid eruption appeared over her body, and she was isolated. On April 12th, Dr. H. excised a fibroid bursa patellaë from a woman of twenty-nine years. On the following day her temperature was 99°, but on the 14th it rose to 100°, and on the evening of the 15th she had rigors and headache. On the morning of the 16th the temperature was 102.5°, and a roseoloid eruption occurred over the face and chest. The surgeons now perceived that an epidemic of the so-called surgical scarlatina was occurring, so as to justify the postponement of other operations.

{496} In the same volume of Guy's Hospital Reports, James F. Goodhart gives the histories of nearly thirty cases of this disease occurring during a series of years in the same hospital. The patients were chiefly children, having the most diverse surgical ailments, among which may be mentioned hip disease and abscess, genu valgum without operation, necrosis of femur, hydrocele with explorative operation, a scald, a sinus over the great trochanter, spinal disease with abscess, tenotomy for club-foot, and vesical calculus with operation. The most common disease was caries or necrosis with abscess. In cases operated on the intervals between the operations and the occurrence of the efflorescence varied from two days to more than two weeks. Goodhart, after a careful examination of these cases, came to the conclusion that they were for the most part examples of true scarlet fever, especially as a considerable proportion of them occurred in groups, and there was a known exposure of some of the patients to children admitted into the hospital with the sequelæ of scarlet fever.

In the British Med. Jour. for Jan., 1879, George May, Jr., reported a case of efflorescence in surgical practice which appears to have been scarlatinous. A child was operated on for the radical cure of hernia on Dec. 4th. Toward the close of the same day he became restless, vomited, and his pulse on the following day rose to 136. Forty-eight hours after the operation a rash appeared on the chest and arms, the abdomen became tense and painful, and on the following day he died. The poison, however, in this case may have been septic.

Hillier remarks (Diseases of Children): "In the hospital for sick children, of the children who contract scarlatina a very large proportion have been the subjects of a surgical operation within a week before the rash appears." Gee says (Reynolds's System of Medicine): "It has been doubted by some whether the scarlatiniform rash which sometimes follows operations is really scarlatinal. The eruption appears from the second to the sixth day after the operation, and in the cases which have caused the doubt is very fugitive and the first and only symptom. Yet that the disease really is scarlet fever would seem to be proved by the following observations: first, that the disease occurs in epidemics; secondly, that in a given epidemic a severe case occasionally relieves the monotonous recurrence of the very mild form; thirdly, that a precisely similar scarlatinilla attacks in the same epidemic patients who have not been subjected to operation and who have no open sore; and lastly, by way of a veritable experimentum crucis, that, however freely these patients are exposed to ordinary scarlet fever contagion afterward, they do not contract that disease." Paget and other distinguished London surgeons who have observed this complication of surgical cases, believe that the patients have been previously exposed to the scarlatinous poison, and that the surgical diseases or operations furnish favorable conditions for the occurrence of scarlet fever, so that the exposure, which probably would have been without result in ordinary health, causes an outbreak of the malady.

Those who have reported cases of this form of efflorescence have for the most part neglected to state whether the patients had had scarlet fever previously, knowledge of which would have aided in the diagnosis; but from an examination of the histories of cases, especially those {497} published in the London journals in the last four or five years, there can, I think, be little doubt that surgical maladies of a certain kind, especially traumatism, do produce a state of system which predisposes to scarlet fever, so that this class of patients are especially liable to contract it. Therefore, in my opinion, a considerable proportion of reported cases of surgical scarlatina are genuine, but in a considerable number, perhaps an equal number of such cases, the histories and symptoms indicated a septic rather than scarlatinous efflorescence, and in not a few instances, when consultations have been held, opinions differed, some diagnosticating scarlet fever, others septicæmia. In some of the cases I find it stated that the fauces presented the normal appearance. Now, faucial redness is so generally present in scarlet fever, antedating that of the skin and coexisting with it, that its absence is strong evidence that the disease is not scarlatinous. Moreover, when, as was true of certain of the reported cases, the rash appeared irregularly upon the surface, and faded away in two or three days with the abatement of the fever, and the conditions for septic absorption were present, the efflorescence was probably septicæmic.

The following were apparently cases of septicæmia efflorescence: A child aged five years (Brit. Med. Jour., Feb. 15, 1879) had inflammation of the lymphatic glands in the groin, which suppurated. At the time when the abscess was fully formed a rash appeared over the entire body. It consisted of numerous red points, but was paler than that of ordinary scarlet fever; temperature never above 99°; no sore throat nor desquamation of cuticle. No child exposed to her took scarlet fever, and her sickness could not be traced to infection. In the British Med. Jour., Jan. 4, 1879, L. Braxton Hicks states that his son, attending school at Reading, was seized with a severe attack of pyrexia, accompanied on the second day by delirium and the occurrence of a rash like scarlet fever over the entire surface. He had no decided redness of the fauces, though it was perhaps slightly flushed. The right buttock was swollen from inflammation, and a large, deep-seated abscess formed near the tuberosity of the ischium. When the delirium abated the boy said that he was standing the day before the fever began with his legs far apart, when a schoolfellow stretched them farther by suddenly pulling on one of them. The rash, which was nearly universal, lasted three days, and was not followed by desquamation. No case of scarlet fever occurred in the school before or afterward. In the same volume of the British Medical Journal, Surgeon Frolliott of the East India Service relates the case of a private, aged twenty-three years, and three years in India, who, when on duty in the Punjab, was injured by the explosion of an Afghan powder-magazine. The accident occurred Dec. 21, 1878. On Dec. 25th a bright scarlet rash appeared upon the abdomen and spread over the entire body. The following day the eruption was very vivid, like a boiled lobster, and it lasted five days. The temperature, which in the beginning had been 101°, abated to the normal after the rash appeared. No soreness of throat nor redness of the buccal surface occurred, but the epidermis desquamated even from the palms of the hands and soles of the feet. Now, the febrile movement of scarlet fever does not cease while the efflorescence is distinct. It does not even diminish when the eruption appears, while in the above case it fell to the normal--a common {498} occurrence in septicæmia, even when the blood-poisoning is profound. Moreover, scarlet fever is so rare in India that Frolliott, after twelve years' service, had only heard of one case among Europeans and natives. The surgeons who consulted over the case of this private disagreed in opinion, some regarding the disease as septicæmic, others as scarlatinous. But a better knowledge of the clinical history of scarlet fever on the part of these army surgeons would, I think, have removed all doubt as to the diagnosis.

It is the opinion of some reputable surgeons that the exposure of traumatic patients to the scarlatinous poison sometimes aggravates the inflammation of wounds, causing them to assume an unhealthy appearance even though no scarlatina be produced. The late Solly made the remark, "Whenever a case of surgery in private practice takes on a highly phlegmonous appearance I am always sure to find break out, in the inmates of the house, either erysipelas or scarlet fever" (British Med. Jour., Feb. 15, 1879). We will see that the scarlatinous poison sometimes causes pharyngitis or nephritis without producing the general disease. In a similar manner it seems that it may aggravate open wounds, intensifying the inflammation in them, while there is no efflorescence or other symptom to show that scarlatina itself is present. The poison appears to act entirely locally in such cases.

Paget, in his Clinical Lectures, says: "I think it not improbable that in some cases results occurring with obscure symptoms within two or three days after operations have been due to the scarlet-fever poison, hindered in some way from its usual progress." Playfair, in his remarks on the puerperal state, adds: "Mr. Spencer Wells informs me that he has seen cases of surgical pyæmia which he had reason to believe originated in the scarlatinal poison; and his well-known success as an ovariotomist is no doubt, in a great measure, to be attributed to his extreme care in seeing that no one likely to come in contact with his patients has been exposed to any such source of infection." Opinions like these, held by such prominent members of the profession and sustained by many observations, should certainly induce physicians to prevent, so far as possible, any exposure of their surgical patients, especially if they have any sores or wounds, whether by traumatism or the scalpel, to the scarlatinal poison.

OBSTETRICAL SCARLATINA.--Women during convalescence after childbirth are very liable to contract scarlet fever. In the New York Infant Asylum, which has maternity wards, a woman was admitted from a house in which scarlet fever was prevailing, and assigned to a cot next that occupied by one of the waiting women, who was confined soon afterward. Her labor was favorable, but three days afterward she took scarlet fever, and another lying-in-patient contracted it from her. The sore throat and desquamation were characteristic. It has come to my knowledge that a physician of New York, in whose family scarlet fever was occurring, attended three women in succession in their confinement, and all contracted scarlet fever, which presented the characteristic symptoms, and two of them died. Experienced and cautious physicians of New York, aware of the danger, do not go directly from a scarlatinous patient to an obstetrical case, but avoid the risk by intermediate visits to other patients or by remaining for a time in the open air.