cyanosis cccurred on the evening of the second day, with a temperature of 100°. Twice on the following morning the infant became blue, with a rectal temperature of 100.2°. In the morning of the third day the rectal temperature rose to 102.8°, and frequent attacks of cyanosis ended fatally.

Many additional cases could be cited from the First Series, but this will illustrate the statement that fatal cyanosis occurs on account of an infection.

The treatment of cyanosis is to ascertain the cause and remove it. For the attacks, artificial respiration takes first place. During feeding the nurse must watch the breathing and if the slightest cyanosis appears, must stop the feeding and restore the breathing. Pinching the baby often restores this function. Tapping on the head with the finger will remind the nervous system to act. When these methods are insufficient, artificial respiration, to initiate the respiratory function, must be employed. Before doing this one must be sure that the upper respiratory tube is clear of milk or mucus. The baby is rolled on its face and the head lowered. Milk will then flow out of the larynx or pharynx. It can then be wiped away.

As to the method of artificial respiration, the exigencies of the case must decide. Undoubtedly, Schultze's method is the most effective, but has the great objection that the swinging rapidly cools the infant. If the rectal temperature is high, this method can be used. When the temperature is subnormal other methods should be chosen. Marshall Hall's method is applicable in the incubator. Silvester's method will more generally be found serviceable and can be used in the incubator or bath. The infant should at once be placed in a warm bath (temperature 100°F.) if the rectal temperature is below 36°C.

It is well to have several methods of artificial respiration in mind, as different conditions necessitate the choice of different procedures. The methods of Pacini, Bain or Behm can be used in the incubator. Prochownick's method (suspension by the feet and compression of the chest) can be used advantageously if the cessation of the respiration is caused by milk or mucus in the upper respiratory tube. The method of Harvie does not necessitate exposure so much as Schultze's procedure.

Simple suspension alone will often initiate respiration. The method of Laborde was used in one case unsuccessfully.

One or two attempts at blowing air into the trachea were unsuccessful. It was our custom in many cases to place one drop of a 1/1000 solution of nitroglycerin on the tongue of these babies. Often it seems very helpful. Oxygen inhalations were constantly used. I am not very sure as to its value. Oxygen can not initiate the respiratory function. When the breathing has started, oxygen hastens the oxygenation of the blood and dispels cyanosis.

Altogether the problem of cyanosis is one of the principal tasks awaiting solution. With skill and great care its dangers may be obviated, but in infants weighing less than 1200 grams, it is only rarely that cyanosis will not appear. (To be Continued.)

The Ruediger Blood Test for Typhoid.

BY GEORGE C. CRANDALL, B.S., M.D.,

ST. LOUIS, MO.

Professor of Internal Medicine, Medical Department, St. Louis University.

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URING the past few years the Widal agglutination test for typhoid fever has proved itself a most valuable aid in differentiating continued fevers, and recently there has appeared a modification of this test which must certainly add greatly to its usefulness.

The new test consists of a macroscopic agglutinative reaction occurring in a bouillon culture of typhoid bacilli and blood serum. This test obviates the necessity of a living typhoid culture, and a microscopic examination, making it as easy of application by any physician as a test for albumin, which in appearance it resembles very much.

Ficher,' of Berlin, reports very favorably upon its use and considers it thoroughly reliable, being applicable to dried as well as fresh blood.

Radzikowski,' of Vienna, reports seventeen cases in which he had tested this method, using fresh and dry blood of typical typhoid cases which gave the Widal reaction and found it positive in all. He concludes that it is simpler than the Widal,

Read before the Medical Society of City Hospital Alumni,

December 15, 1904.

is as reliable, requires shorter time and enables every physician to make his own typhoid test.

Ruediger, of Chicago, reports thirty-four cases and as his method of applying the test is one of the simplest, I will give it somewhat in detail:

Inoculate 500 cc. bouillon with B. typhoid, incubate at 36°C. for twenty-four hours, and add to this I per cent formalin. Make a 1/500 formalin' solution. These are the two stock solutions. Put four drops of blood in 2 cc. of the formalin solution which makes approximately a 1/10 per cent solution of the blood, likewise lakes the blood. Add 10 cc. of blood formalin mixture to 4 cc. of the bouillon culture which make approximately 1/50 dilution.

In a few minutes to an hour there appears a coagulum suspended throughout the solution which gradually settles, resembling very closely the albumin test of urine when small amounts of albumin are present. This contrasts closely with the control solution which shows a fine cloudiness charisteristic of the bouillon culture.

Ruediger has found that the reaction will appear in 1/1000 or 1/2000 solutions after three to ten hours. He considers it fully as reliable as the Widal test, also found it applicable to dried as well as fresh blood, obtaining a characteristic reaction with dried blood one year old. His thirty-four cases which showed the reaction were thirty typical typhoid, one doubtful, two paratyphoid and one tuberculosis.

I have used the test on about fifty cases of typhoid which gave the Widal reaction, and find it equally accurate.

All observations, so far as I have gathered from the literature, agree that it is fully as reliable as the Widal test and it has the great advantage of placing in the hands of every physician a very simple means of testing the blood of his own typhoid cases and it must make more accurate the diagnosis of the great number of continued fevers.

Further than this, there is the possibility of the application of this principle giving similar macroscopic evidences of other infectious diseases. Investigators are already experimenting along this line and we may hope for fruitful results.

REFERENCES.

Ficker. Berliner Klin. Woch., No. 45, 1903. 2Radzikowski -Weiner Klin. Woch., No. 10, 1904. Ruedigen. Jour. of Infec. Dis., Vol. 1, page 262, 1904.

Epithelioma of the Face in a Young Child.

By M. J. LIPPE, M. D.,

ST. LOUIS, MO.

HE history of this case is as follows: Beatrice B., a girl,

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aged 4 years, has never been ill, excepting the affection for which she was operated on, which constitutes the basis of this report, and is a normal child in every way.

Father and mother living and healthy; has a brother and sister, both healthy; no history of malignant trouble in the family.

About six months ago she doveloped three small flat warts, two below the inner canthus of the right eye and the third along the side of the nose, above the nasolabial fold. After they had been noticed for three months, the lower one (the one on the side of the nose) began to grow; the father of the child tried to pinch it off a number of times, but it grew in spite of his efforts.

I saw the child on January 16, 1905, and at this time observed the following: Two small warts, as before described, below the lower canthus of the eye; above the nasolabial fold was a warty-looking growth about one third of an inch in diameter, raised above the surrounding skin. The color of the base of this growth was slightly red-dark-red, but not inflammatory looking; the top of the growth was grayish looking, like verrucous tissue, with a tendency to breaking down in the center. A lymph node at the angle of the jaw was enlarged somewhat.

A similar condition in an old person would have impelled one to make a positive clinical diagnosis of epithelioma, growing on a wart, but occurring in a child of such tender years one would hesitate to make such a diagnosis unsupported by a microscopical examination.

I told the parents that it was a nasty looking thing and that it was possibly malignant. They consented to an excision which I advised.

The tumor was removed three days later, and sent to Dr.

Read before the Bethesda Pediatric Society, February 10, 1905.

Carl Fisch, who reported a typical epithelioma. This is the report in detail.

Dear Doctor.-The small tumor (about 2.5 mm. in diameter in its alcohol hardened condition) removed by you from the right nasolabial fold of a child, and submitted to me, was found to be a typical epithelioma or a cancroid. Its center had through cornification led to a defect in which granular detritus and inflammatory exudate formed a plug. The periph eral zone of the tumor had grown under the adjoining epidermis, compressing and obliterating it; it was preceded by an area of inflammatory changes in the corium, leading to an elevation above the normal of the epithelium. The interpapillary processes of the epithelium in this zone were seen to be wedged out in a direction away from the tumor mass. In its central portion the tumor had penetrated beyond the elastic layer of the subcutaneous tissue, sending into the corium smaller and larger processes. The tumor is, therefore, an epithelioma, that had its origin from the cutaneous epithelium. It was not in direct continuity with the latter, but everywhere well-defined from it. Yours truly,

CARL FISCH, M.D.

Keen has called attention to the liability of warts, taking malignant changes, in a report of twenty-five cases in the Journal of the American Medical Association, July, 1904. The same thing has been observed by many before this.

Epithelioma occurring at such a tender age is apt to be overlooked, although its early recognition and extirpation is the only hope of preventing a disastrous outcome.

Whether or not the other two warts are small carcinomata, I am at present unable to say; the theory that all epithelial growths are congenital and merely call for the conditions (irritations, etc.) favorable for their activity in order to become malignant is attractive, and this case rather pleads for this theory.

On the strength of the microscopic findings in the tumor removed, I have offered to remove the other two warts and the lymph-node at the angle of the jaw, both for the safety of the child and for a scientific microscopic investigation, and hope to be able to report the result of this study to you later on.

That malignant growths occur at a very early age can be