CASE REPORTED BY DR. CLAUDE R. GROSSER, WILKES-BARRE, PA. Mrs. P., age 38. READ SEPTEMBER 16, 1903. Family history good. Personal history: Had given birth to four children, healthy and at term, the last one was born May 1st, 1903. One year after birth of last child, her menses returned and were regular until March 30th, 1903. Her menses did not appear during the next month (April) and re-appeared May 2d and 3d, together with profuse nose bleed which lasted nearly a whole day. May 12th to May 15th (same month) the menses occurred again and in profusion, and for a month she complained of periodical pains in the hypogastrium. I was called on the evening of May 19th and found her suffering with a severe cramp-like pain of the abdomen, which extended to the back and throughout the pelvis. She also had retention of urine and difficult defecation. Only slight symptoms of shock were present. Bi-manual examination revealed an indefinite fullness or a yielding mass in the pelvis behind the uterus. Immediate operation was advised by me, but her people would not consent until morning. The following morning (May 20th) I made another vaginal examination which showed that the mass had increased in size, but still yielding and not firm. She was taken to Mercy Hospital and prepared for operation at once. Dr. A. F. Dougherty operated immediately and we found to our great surprise not a single, but double extra uterine pregnancy with rupture of both tubes (outer third) and the hemorrhage was intra peritoneal. Both tubes and overies were quickly ligated and removed, the patient meanwhile receiving stimulants, including intravenous injection of normal salt solution. The wound healed primarily and the patient was discharged from the hospital cured June 16, 1903. SCARLET FEVER. BY DR. J. A. BURLINGTON, DURYEA, PA. READ OCTOBER 7, 1903. Scarlatina, or what is commonly known as scarlet fever, is an acute infectious, contagious and eruptive disease. This disease is caused, no doubt, by the entrance into the blood of a micro-organism, the streptococcus scarlatinæ, the bacillus scarlatinæ and other germs, perhaps yet to be discovered and isolated. The place of entrance into the human body is probably the throat, and there these micro-organisms are hatched after a certain length of time, varying under certain conditions from two to six days and there at the same time is produced the poison, whatever it may be, that circulates through the blood, thereby causing certain changes from which follows a line of symptoms, the most prominent of which are sore-throat, rapid pulse, fever and a rash, followed in a few days by a peeling off of the epidermis and the epithelium of the kidneys and some other organs. Sore throat, fever, rapid pulse and a punctuate rash are highly characteristic of scarlet fever and these symptoms are never absent, although they are much more pronounced in some cases than in others. This punctuate rash may vary from a deep lobster scarlet to a mere faintest blush. It makes its appearance usually upon the second or third day of the disease on localized parts of the body, namely, the neck, chest, flexures of arms and legs, finally spreading over the whole body, even effecting the mucus membrane of the nose and mouth. This rash usually begins to fade upon the fifth or sixth day, although we have seen it retarded until ten or twelve days, or even later. As said previously the rash at times is so faint that it entirely escapes the attention of the parents or nurse and sometimes, no doubt, of the medical attendant. Perhaps we all have been called to see a child who has been sick for a few days, its parents telling us that the child has never been very sick, how they have greased it, physicked it, and have given it all the usual household remedies, without any good results. We examine the child carefully, and find a slight punctuate rash in the arm pits, a slight punctuate rash in the groins; we find the strawberry tongue of scarlatina and a slight redness of the tonsils and fauces. We tell them the child has scarlet fever and we know that we are right in our diagnosis; why, because a punctuate rash in the arm pits, a punctuate rash in the groins, the strawberry tongue of scarlet fever and the angina are pathognomonic of scarlet fever. On the other hand, other cases are so pronounced that he who runs, though blind, may read. As already stated, the rash usually lasts about one week, beginning to fade on the fifth or sixth day, fading first upon parts first effected. The temperature is variable, ranging from a state of hyperpyrexia to only a slight increase of heat, say 100.5 degrees to 101 degrees Fahrenheit. In some cases the temperature may be subnormal, the febrile movements ordinarily fluctuate but little from day to day until the fourth or fifth day, when, if the case be favorable and no complications occur, they begin to decline. The temperature is as high at the beginning of the attack as at any other time, although the febrile movements fluctuate but little. We sometimes have cases of the remittent and intermittent type. The pulse is usually more rapid than the rise in temperature. Desquamation of the superficial layers of the cuticle begins on or about the eighth or ninth day of the disease, sometimes continues for four or five weeks and occasionally even a longer period and is a marked characteristic of scarlet fever. This desquamation occurs in the form of bran-like scales or in larger flakes or casts of certain portions of the body. At the same time we have also a peeling of the superficial layers of the gastro-intestinal tract and also of the kidneys. In the past many theories have ben advanced as the cause of this desquamation, but, no doubt, the simplest explanation is, that the rash, the skin and mucus membrane being in a state of hyperemia or congestion, causes certain trophic changes by reason of the amount of poison contained in the blood or by simple pressure by the congested blood vessels upon the sensitive fine nerve fibrils causing the superficial layers of the epidermis to die and to be cast off as waste products. Although many bacteriological examinations have been made from these casts or shreds of the epidermis no specific germs, I believe, have ever been found. I have seen in my own practice children convalescing from scarlet fever and in the stage of desquamation mixing with healthy children with no bad results; and from these facts I am led to believe that the stage of desquamation, or at least, the latter part of desquamation is not infectious; or at least not so infectious as was formerly supposed. The inflamed condition of the throat shows where the microorganisms lodge and breed and from there are taken into the blood, causing scarlet fever; the adjacent glands, the submaxillary and sometimes the cervical become involved, being enlarged and tender to the touch. Undoubtedly this is caused by their effort to prevent the poison from entering into the general circulation through the lymphatic system. The bacteriology of scarlatina has been studied by Klein, Frankel, Freidenburg and many others. No specific germ has ever been found. We have in this disease, the streptococcus, the bacillus scarlatinæ and often the bacillus diphtheria, besides others. No doubt the pseudo-membrane is caused by these germs and also the otitis, the adenitis, the nephritis, the pneumonia and the joint disease that we frequently get in this disease are caused by these germs. These germs These germs are poisonous and when. animals become infected with them, they produce lesions similar to those found in man. This micro-organism is found in the mucus of the throat in its early stages and occasionally as late as the eighth or ninth week. It has been found in the nasal discharges and also in the discharges from the ear, but it has never been found in the desquamated cuticle of scarlet fever. As said, the bacillus scarlatina has been found and the bacillus of diphtheria is sometimes seen beside the germs of other observers. Although it has never been proven, no doubt the disease is caused by some germ, and the passage of that germ from person to person causes the disease to spread and to take root in suitable soil. Children over one year of age are especially susceptible to this disease. Infants between three and twelve months are not very susceptible. Infants under three months are almost immune. The most susceptible period in life appears to be between one and five years of age. Every year after five, appears to afford some immunity from the disease and we can see from this how important it is that parents should take special care, to prevent, as much as possible, their children from coming in contact with it during this period of life. The disease is most infectious during its earlier stages, during its period of febrile movements. It is infectious from the very moment that sore throat and vomiting appear and may continue as long as sore throat, rash and fever continue. Its virulence diminishing after this period and perhaps entirely disappearing during the latter stages of desquamation, if no complications occur. The most frequent complications in my experience are nephritis, otitis, pneumonia, adenitis and rheumatism, and in the order named.. The infection of scarlet fever is given off in the breath from the throat, from the skin and from mucus membranes. Scarlet fever poison passes from person to person very readily. The infection may be carried either directly or indirectly. The infection may cling for long periods of time, under suitable conditions, to wall paper, bedding, clothes and other articles of furniture. In this respect it is more tenacious than any other of the eruptive fevers except, perhaps, small-pox. The mortality of scarlet fever is variable. In some years the mortality is greater than in others; greater in some sections of country than in others. Thus the mortality in the Northern States is higher than in some of the Southern States. Forty years ago the mortality was from eight to ten per cent. of all cases affected, and to-day, under our present mode of treatment and better sanitary conditions, it is less than eighttenths of one per cent., although the disease is just as prevalent to-day as it was in 1860, and it also seems to be a fact that the virulence of scarlet fever is much less than formerly, and it seems to be growing less each year. This is, no doubt, due in greater part to more modern methods of treatment, better sani |