Scarlatina is the most fatal of the eruptive fevers, and is one of the most contagious. Every effort should be made to prevent its spread from any existing case. This is, however, impossible without the intelligent and painstaking cooperation of those in charge of the patient. It is more malignant under six years of age than after this time, except in the case of adults, in whom the existence of the disease is pretty fair evidence of unusual susceptibility. The best preventive against the spread of the infection, is strict isolation of the patient and its care-takers, together with disinfection of the discharges from the patient, his clothing, and bed linen, and the washing of the surface of the entire body with a non-irritating antiseptic. Whether scarlet fever is contagious before the appearance of a rash or not, is a moot question in medicine, though we are inclined to believe infection highly improbable before the appearance of the rash. People should not alone be cautioned to remain away from scarlet fever on their own account, but more particularly to safeguard the many others with whom they come. in contact, and who may be infected by them though they themselves escape.

This disease is more particularly dangerous to life because of its complications, the most prominent and most dangerous of all being acute nephritis. Then there is the acute sore throat peculiar to this disease, inflammation from which readily extends up the Eustachian tnbes into the middle ear, thus giving rise to deafness, earache, and otitis media, which last may also cause intra-cranial abscess by extension through the roof of the tympanic cavity. It is, therefore, very important to give strict attention to the sore throat of scarlet fever to prevent this extra train of inflammatory conditions. Even if the otitis media does not finally destroy life by involvement of the brain, it may lead to permanent deafness, or an offensive aural discharge. The throat should be looked after, whether complained of or not. We have seen pretty well inflamed fauces unaccompanied by pain, or, at least, not enough of this to cause complaint.

For some reason that is not clear to us, scarlatinal sore throat is quite often complicated with diphtheria. When this occurs, it is necessary to institute the most active anti-diphtheric treatment immediately. 1,500 or 2,000 units of antitoxin

serum should be injected without delay, and the patient put upon one-tenth grain doses of calomel every hour until there is a decided recession of diphtheric symptoms, or there are frequent bowel discharges.

The joints are often inflamed in this disease, and when so, are supposed to be due to streptococci infection. Up to the present time, there is no better treatment for the alleviation of the incidental suffering than anodyne and counter-irritant local applications, and heat. In very severe cases, or even in the less severe ones that do not respond to treatment, it is probably wise to apply anti-streptococcic serum. These joint affections, usually designated rheumatic, are generally caused by infection, as stated, and are rarely, if ever, of rheumatic origin. But of all the complications of this disease, nephritis is, by far, the worst. It may destroy the patient within a few days; may become sub-acute, and have this effect after some months; or it may become chronic, and destroy life after some years. There are different varieties of this complication, which it is not, however, necessary to go into. It may arise without warning, and run so rapid a course that treatment is without avail. It is probably due to the infection of the disease, though quite often apparently caused by chilling of the surface following premature exposure to too low a temperature.

The heart is also liable to damage in this condition, in many cases appearing to be directly affected by the action of the scarlatinal poison upon the nerve-centers governing this organ. Sometimes the

heart muscle becomes affected. At other times it may be pericarditis, which is not at all strange when we consider that the pericardial sac is merely a joint between the heart and adjacent structures. The pleuræ may become similarly affected, and

probably from like causes, while the lungs may show a bronchitis or a broncho-pneumonia. These symptoms require such treatment as the peculiarities of the case would indicate at the time. There are no specifics. Of course, a true, acute croupous pneumonia occasionally occurs, particularly when the kidneys are affected; and there is danger, in most cases, of edema of the lungs.

The nervous system is, of course, more or less involved in nearly every case, although it is not so often a complication as some authorities claim. When, however, there are cerebo-spinal complications, they are apt to be very severe. They may arise at any time.

Concerning the time at which scarlet fever is most contagious, there is every possible variance of opinion, from those who hold it to be contagious from the developments of the first symptoms preceding the appearance of the rash, at which time it is believed to be at its height, to those who maintain that it is not at all contagious until the rash appears, and most so toward the end of the disease, during desquamation. There are exceptions reported that disprove all of these contentions, which only goes to show that exceptions prove nothing, but that Nature does not follow an invariable rule.

The cause of scarlatina being unknown, it is, of course, largely speculative to attempt any specific mode of prevention.

The character of onset is no criterion

upon which to base a prognosis. The mildest onset may be followed by a fatal issue; a severe onset, by an uncomplicated course, and an uneventful recovery. Nothing should be taken for granted in the handling of this disease other than one evident fact that serious complications may arise at any time with little fore-warning. These cases require careful watching and constant attention on this account alone.

should be stimulated to unusually free action. If hot air is used to promote sweating, the patient's head should not be included, but should be left free to breathe the normal air of the bedroom.

A Simple Operation for Hemorrhoids.

Dr. J. Rawson Pennington, of Chicago, in the Journal of the American Medical Association of December 21, 1901, describes a simple and efficient method of removing piles. He uses, first of all, a specially made forceps with broad, margined ends, which he calls T-forceps. After the patient is placed in proper position and under an anesthetic, either local or general, the muco-cutaneous edge

of the anus is seized with four of these

forceps at equidistant points, and the anus is everted by traction in opposite directions. This causes the pile or piles to be brought into view with the mucous covering tightly stretched over their bulging surface. With scissors curved on the flat, he snips from the topmost portion of the pile an elliptic piece of this mucous covering. This is followed by enough free bleeding to empty the vascular mass constituting the pile of nearly all the blood, after which, the entire varicose mass is removed with scis

sors.

field is dusted with some antiseptic powder, and a rubber-covered tampon is in troduced through a bivalve speculum. The tampon protrudes about one and one-half inches beyond the anal orifice, and is carefully wrapped up with gauze packed close to the anus. The anchoring string of the tampon is wrapped around a piece of gauze held close to one side of the tube, and woven into the other dressings, so as to prevent the tampon's slipping into or out of the rectum. Over this is placed gauze, cotton, and a T-bandage which is made quite taut.

At the end of forty-eight hours the patient is given a cathartic, and the tampon is removed, the latter procedure being easy and painless, as is also the stool which follows; and there is little or no bleeding. Following this, the parts should be washed or irrigated twice daily with an

antiseptic solution, and dusted with some antiseptic powder. The stools should be kept soft for two or three weeks, for which the author recommends Apenta water. Pain or aching is best relieved with hot sitz baths of twenty minutes' duration.

He prefers the rubber dressing to the gauze or other porous materials, because: 1. It is neater.

2. Its removal

is painless. 3. As the tender granulationsprouts cannot penetrate it, as they do the gauze and other porous dressings, they are not broken off during its removal; neither is the fibrinous exudate disturbed. Hence, the healing process is 4. Another advangreatly enhanced. tage, and one of no little moment, is that there is but little or no pain during the first and subsequent movements of the

bowels.

The author's experience embraces 138 cases, in 29 of which local anesthesia was used.

The Medical Aspect of Appendicitis.

Dr. W. E. Ford, of Utica, N. Y., last fall read a paper upon the above subject at the semi-annual meeting of the Medical Society of the State of New York, in which he maintained that appendicitis was a disease requiring only medical treatment in a large proportion of cases. This was demurred to by Dr. Herman Mynter, of Buffalo, who maintained that appendicitis was essentially a surgical disease, and that no serious case could ever get well without an operation. In fact, he held that appendicitis had no medical aspect, but that all cases of this disease should be turned over to the surgeon. In a communication from Dr. Beverly Robinson, of New York, which subsequently appeared in the New York Medical Journal, it was insisted that the surgical aspect of appendicitis had been much overdone, and its medical side almost entirely neglected. Dr. Robinson is almost as extreme upon the medical side as Dr. Mynter is upon the surgical. Both must be considered extreme in their views, though Dr. Robinson is perfectly correct when he insists that no should ever go to the surgeon for operation without careful consideration by a thoroughly competent general practitioner. Unquestionably, very many cases of appendicitis, and severe ones, too, at that, recover without operation. We have seen unquestioned cases, with wellmarked tumefaction in the iliac region, that fully recovered without surgical in terference, and which did not recur up to several years afterwards. The necessary thing, however, about this disease, is to determine when the case requires operation and when it does not. Undoubtedly, it is giving the patient the best of the doubt to have him operated upon if he can be placed under favorable circum

case

ence.

stances for such a step, and in the hands of an experienced operator. At other times, when the proper mode of procedure is doubtful, his chances would be better subserved by non-surgical interferFor instance, in distant places, being far removed from a hospital or from an experienced operator, and where the environments are unfavorable to operation. It is, also, an indisputable fact that many cases of "appendicitis," cured without operation, are really diseases of some other kind; but so, also, are there cases operated upon which prove to be typhoid fever, and ovarian disease, pus-tube, etc.; and that this statement may not be doubted, we simply refer to the fact that the appendix has been found perfectly normal in individuals whose abdomens have been opened, after a diagnosis of appendicitis, with the intention of removing this organ of unknown function. It is time, with the surgical experience now in our possession, to turn more to the medical side of this question, with a view to determining the best medicinal treatment for this condition, and learning all we can about the border line that separates the medical from the surgical case, so that we may be able to tell, with tolerable accuracy, by what to be governed in deciding to call in the surgeon for the removal of the condition that it is probably impossible to

cure.

We invite especial attention to the excellent and practical series of articles upon certain diseases of the respiratory tract-Tonsillitis, Hypertrophied Tonsils, Diphtheria and Capillary Bronchitis-in this issue. These articles come at a time of greatest prevalence of these diseases, and hence should physician's work this season. be the means of doing much good in the family We hope others

may be led to add some useful points from their own practical experience in these and kindred diseases. The family physician, with his magnificent clinical opportunities, can add much to enrich medical science.