of a bronzed hue, the temperature was 102.6 deg., and the pulse

II2.

Menstruation, which was exactly on time, had begun on the second day, and was not abnormally profuse. There was also some blood in the stools.

During the next seven days the eruption steadily faded, the swelling of the face and legs entirely disappeared, the temperature and pulse became normal, the soreness of the teeth and gums left her, menstruation ceased, and, save for a dusky appearance of the skin, she looked quite like herself. This duskiness lasted about seven days longer, gradually fading out. Her accustomed strength and color returned rapidly, and she was apparently well.

The patient's family history is negative. She had had one child, now a boy of four, and three miscarriages, all due, her former New York physicians have said, to a prolapsed left Ovary. She had never had any illness or ailment except her miscarriages, and a peritonsillar abscess in August, 1902. There was no history of any venereal trouble. She is well developed and well nourished, with rosy lips and cheeks. She is five feet one inch in height, and weighs 128 pounds.

Her husband is a German, and with her son lived with her. They also were in perfect health. Their food was always fresh. Her husband was very fond of a soup or stew made invariably from fresh meat and fresh vegetables, insisting that it should be on his table every day. Salt and canned foods were almost unknown in the house.

Mrs. D. could not remember having taken any medicine of any kind, except for her tonsillar trouble five months before. Her treatment for the first four days was calomel and saline cathartics, cream of tartar water, and chlorodyne to control the pain. On the fifth day, which was after decided improvement had begun, at the suggestion of Dr. Kimball, who saw the case with me, six oranges daily and all the lemonade she could drink were added.

This very striking and unusual group of symptoms suggests, of course, but two things for differential diagnosis, i.e., scurvy and purpura hemorrhagica.

All authorities agree that scurvy is a disorder peculiar to those who, for one reason or another, are obliged to subsist for lengthened periods of time on improper food, more particularly that from which fruit and fresh vegetables have been excluded; to respire vitiated air, and to endure such confinement as precludes the possibility of daily exercising the body. The disorder is, therefore, common in men, particularly those who fol

low the sea on long voyages, Arctic explorers and others similarly situated. The disease is insidious in its onset. There is a progressive loss of weight and a developing weakness and pallor. The gums first become spongy, later bleed easily on presThe teeth usually become loose and occasionally drop out. The skin later becomes rough and dry, and the hemorrhages occur at first about the hair follicles.

sure.

Dr. Charles E. Banks, of the U.S. Marine Hospital Service, says: "A progressive upward and downward curve marks the course of a case of scurvy from its onset to its finish. It has no definite attack, no crisis; while there are no marked symptoms involving the nervous system, the depression is always noticeable, and the patient seems to be indifferent to his condition and surroundings."

Purpura hemorrhagica, or the morbus maculosus of Werlhof, Osler says, is more often met with in young women, especially delicate individuals, but cases are described in which the disease has attacked persons in full vigor.

H. C. Wood says: "The progress of this affection is that of an acute infectious disease." Its onset is almost always sudden.

Musser says: "It is distinguished from scurvy by the absence of antecedent debility and anemia, of spongy gums, of brawny induration of the limbs, and by the fact that the hemorrhages do not usually occur around a hair follicle. In scurvy there is a history of long deprivation of vegetable food, whereas purpura may occur in robust health.”

Pain in the limbs, rise of temperature, and the purpuric spots, at first usually individual, finally coalescing into ecchymotic areas, are common to both diseases.

To return again to our case, Mrs. D. was apparently perfectly well in every particular, saving only a possible prolapsed ovary, up to the time she was seized with pain in the legs. She occupied rooms in a poor quarter of the city, but they were on the second story, and they were large, dry and airy. Her husband, her son, and two boarders were not affected. Her food was varied, fresh, and with a liberal amount of fruit and vegetables. She was active and out of doors every day, walking some distance. There were no gingival symptoms until the third day, and then although the gums bled they were not spongy and the teeth did not become loose or drop out. The skin of the legs was neither dry nor brawny. There were general hemorrhages from the mucous membranes of the mouth, tongue, trachea, scleræ, bowels, and a profuse menstruation. There was

no mental inactivity nor depression, but rather a hopeful attitude to a speedy recovery, and an active interest in her domestic affairs even when she was sickest. The hemorrhages did not begin around hair follicles, but anywhere and everywhere, rapidly coalescing into larger ecchymotic areas.

If this had been a case of scurvy, it must, ipso facto, have been due to food and general surroundings. Neither was in any way changed, yet her recovery was complete in three weeks. It therefore seems to me to be a perfectly logical and honest conclusion that we are fully justified in making an unqualified diagnosis of purpura hemorrhagica.

Some one may say, What difference does it make? Who cares whether it was scurvy or purpura? It is only a splitting of hairs.

Maybe it is. But, aside from the fact that one always likes to be as nearly diagnostically correct as possible, it does have a practical side to the attending physician.

All authorities agree that, if the proper hygienic conditions. ›can be provided, cases of scurvy almost invariably recover. They are equally unanimous that cases of purpura often result fatally, and that it is a much more serious disease, as the etiology is unknown, and the cause cannot be so readily removed. And although this particular case fortunately recovered, nevertheless with a diagnosis of purpura hemorrhagica, and with the disease progressing so rapidly that on the third day there was a hemorrhagic edema of the trachea, I confess I did not feel so comfortable as I should have felt had it been a case of scurvy.

A Case of Paratyphoid Infection. ALBERT E. TAUSSIG, M.D., of St. Louis, in the Interstate Med. Jour.

The following case, while unfortunately not completely worked out, is suggestive from some points of view, and therefore, perhaps, worth reporting:

D.S., a Hindoo, aged twenty-five years, came for treatment to the medical clinic of the Washington University Hospital on July 26th, 1904. His family history was good in every way. He had never before had any illness of consequence, did not use alcohol, tobacco or drugs, and gave no history of venereal disease.

His present illness began two weeks ago with a feeling of general langor and malaise. This the patient attributed to constipation, and took a purgative. His bowels moved freely, but there was no improvement in his subjective discomfort. He had been

sleeping poorly, suffered from nearly constant headache, and found himself growing constantly weaker. He believed that he had been having fever ever since the beginning of his illness. His appetite had remained fair, and he had had no particular abdominal discomfort. The bowels had been rather costive.

The patient was a small, sallow individual, showing considerable emaciation, face flushed, eyes dull, skin dry and hot, tongue coated, its margin indented by the teeth, the latter covered with sordes. His temperature was 101.4°, his pulse 80 when quiet, but becoming very rapid when the patient exerted himself a little. On physical examination nothing abnormal was found in the thorax. The abdomen was not distended nor tender, no rose spots; the hard, smooth edge of the spleen could be felt on deep inspiration about 2 cm. below the costal margin. The urine was high colored, sp. gr. 1027, no albumen, diazo reaction negative. A Widal reaction done with the blood serum was negative. After two hours in the incubator at 37° C., there was firm clumping with loss of motion in a dilution of 1 to 20; most bacilli clumped but many still in motion in a dilution of 1 to 50, and only slight clumping at I to 100. There were at the time no cultures of paratyphoid at our disposal.

The patient was sent to St. Luke's Hospital and put to bed there. That same afternoon 8 c.c. of blood were sterilely aspirated from his cephalic vein and divided among three flasks containing 200 c.c. of bouillon each. In all these flasks a pure culture of a bacillus developed, the characters of which will be described below. As for the patient, his temperature rose that evening to 103.6', pulse 98, respiration 28. He was given an enema, a cool tub bath, was put on liquid diet, but given no medication. During the night his temperature gradually declined to normal, and remained there. His spleen was palpable for several days, but slowly receded to its normal size. No new pathologic signs or symptoms developed. He was discharged, well, on August 4th.

The bacillus isolated from the blood was short with rounded ends, very slightly motile. It grew profusely on all ordinary. media, the colonies on agar plates being round, bluish-white and elevated in the centre. It coagulated milk in twenty-four hours with the formation of acid, caused the formation of gas in glucose agar, reduced neutral red agar, but did not produce indol in Dunham's peptone solution. Unfortunately press of work at the time prevented further study of the bacillus, and when it was taken up again all the cultures had died out. The same is true of agglutination tests made with the bacillus. Owing to a technical error, the results of agglutination experiments made on the bacillus with the patient's and other blood were negative. Before another blood sample could be obtained the patient had left the hospital.

Nevertheless, the morphological and cultural characteristics of

the bacillus, as well as its source, all point towards its being a paratyphoid. Clinically the case was of the sort that all of us see with considerable frequency-cases that at first sight impress us as typhoids, but in whom the laboratory diagnosis contradicts the chemical one, and in which the rapid recovery, too, makes the diagnosis of typhoid fever untenable. It may be that more of these obscure febrile cases are paratyphoid than we might suspect.

Exencephalus, Report of a Case.

MARY M. S. JOHNSTONE, B.A.,

M.D., Chicago, Ill., in The Woman's Medical Journal.

November 16th, 1904, I was called to see Mrs. O., who was reported in labor. The patient is a strong, and well-developed woman. She has one child, a large, healthy boy of four years.

Date of last menstruation March 18th, 1004; quickening was first noticed July 1st, 1904.

Examination external and internal revealed a small fetus in the first position apparently occipito-anterior; heart beats 152 per minute and feeble. During the examination, movements of the fetus were distinctly felt; cervix uteri undilated.

The patient was having very fair pains when I reached the house. After four hours waiting the pains stopped, pain in the back, of which she complained bitterly, was relieved; cervix remained closed, and the patient fell asleep. I left the patient and was recalled the next evening, about twenty-four hours after my first visit, arriving just in time to deliver the fetus. There was no time for preparation, so a clean towel was used to protect the mother from infection by the hands. The fetus was rapidly expelled, breech first, legs extended parallel with the trunk, and with considerable force, exerted by the maternal expelling powers. The fetus survived birth about five minutes.

The fetus, female. A monstrosity very similar to one described in Zieglar's "General Pathology," on page 505, and called Hydroencepalocele Occipitalis, except that in the present instance there was no fluid in the protruding pouch. This form of deformity is also well described by Lewis in the American Journal of Obstetrics and Diseases of Women and Children, February, 1905.

After about four months' hardening in formalin, the fetus measured 26 cms. in length and weighed two pounds.

The body and limbs were well developed, the fingers seemed long in proportion, 2 cms. The head was flat, no forehead, nose large, broad and flat, eyes large and bulging, cheeks broad, 5 1-2 cms. There was practically no neck, the head resting on the shoulders; on the top of the head (there was a ridge between the juncture of the frontal and parietal bones. The fetus was delivered at the seventh month of gestation.