physical exertion. The primary effects of heart strain are: chronic hyperthrophy and dilatation, gradual dilatation, or acute dilatation. Symptoms identical with those of strain may be produced by direct violence or nervous shock, as is shown by cases reported. The view that the progression is from physiological to pathological dilatation does not seem borne out. The onset seems to be sudden. Two points observed by the writer in the community of 600 boys at Harrow are that cases of heart strain are of infrequent occurrence, and that their appearance bears no relation to the severity of the strain to which the boys have been exposed. The schoolboy heart breaks down as the result of exertion, not because the strain is too severe for the hearts of boys of that age and physical development, but because the individual possesses some cardiac insufficiency, either primary or inherent, or dependent upon some condition such as anemia or influenza. There is a tendency to recurrence of the dilatation in the subjects, and the prognosis should be guarded and each step of renewed active exercise be watched carefully. The writer believes that pathological dilatation of the heart of the growing boy from strain, however short its duration, and however complete its apparent cure, leaves its indelible mark upon the mechanism of the heart, and that its effects have to be regarded as an existing factor of greater or less degree, sufficient perhaps to determine the failure of the heart under an anesthetic, or to decide whether in some acute illness the resultant of the forces acting in and on the patient shall take the direction of recovery or of death. Where cardiac disability is due to damage of a valve alone, and the myocardium is sound, the heart is able to accommodate itself, by dilatation, to the larger output necessary to compensate leakage, and by hypertrophy to the increased work entailed; whereas in the case of the strained heart, the seat of incompetence is the myocardium, and this being faulty no factor can compensate for the defect.

Etiology and Pathology of Hepatis Cirrhosis in Infants.-L. M. Spolverini (Revista di Clin. Ped., April) draws attention to the general belief in the rarity of hepatic cirrhosis in infants. He believes that this condition is much more common than is generally thought. Perhaps it is not as generally diagnosed during life as in the adult. The liver of an infant reacts differently to the various poisons that enter the system, and hence the same poisonous effects may not be produced as in the adult. The causes of cirrhosis of the liver in the child are as follows: I. Cases of infective origin, arising from syphilis, tuberculosis, malaria and biliary poisoning. 2. Toxic cases, from alcohol, dyspepsia and splenomegaly. 3. Mechanical, that is, circulatory cases. The most frequent cause is syphilis. Malarial cirrhosis is rare, as is the circulatory form. It has been supposed that alcoholic cirrhosis is rare, on account of the age of the child. The author has had 2 cases, and has reason to believe that among the poorer Italians, especially of the Campagna, it is the habit to give wine to children with their food, as well as to quench thirst at night. The

dyspeptic form is rare, notwithstanding the frequency of digestive disturbances, owing to the resistance of the child's system to poisons that enter through the intestine. The author had 1 case of hypertrophic cirrhosis, of toxo-infective form, resulting from a very extensive eczematous trouble.

Hysterical Vomiting in Children.-G. Carrière and C. Dancourt (Le Nord Méd., Feb. 15) state that hysterical vomiting in young children is quite frequent. The diagnosis is not easy, and must be made by excluding all other forms of stomach trouble. It is characterized by repeated vomiting, occurring soon after feeding, a part of the meal taken being rejected unchanged from the stomach. There are no abnormalities of the gastric juice; pain is unusual, and other symptoms are wanting to show any serious stomach disturbance. The kind of food taken makes no differ ence, and in some cases the most digestible forms of nourishment are rejected and candy and cakes are retained. The infant seems to do it voluntarily and does not seem to suffer from the loss of the food. If the condition is not treated as a hysterical manifestation it goes on to incoercible vomiting, nutrition gradually fails, and fatal complications may ensue.

Syphilitic Coryza.-Paul Gastou (Revue d'Hygiene et de Méd. infant., III, 1904) describes syphilitic coryza as one of the earliest and most frequent symptoms of congenital syphilis. He gives a very vivid picture of the afflicted child. The coryza may appear in two or three days after birth, but usually in the second or third week of life. It is noticed first from the difficulty of nursing and respiration, before the discharge appears, because the affection occurs first in the post nasal space, and the discharge runs down the throat. After a week it advances to the anterior nasal tissues and there is a seropurulent discharge, fetid and mixed with blood, running over the upper lip and excoriating it, as well as the lower one and the chin. Black scabs and red fissures in the skin appear over the scarlet skin. When the child sits up it can breathe, but as soon as it lies down it strangles, becomes purple in the face and nearly suffocates; sleep is impossible and suckling almost so. There is often spasmodic cough and vomiting or disphagia. Diarrhea and asthenia soon are added. The mucous membrane becomes entirely changed in appearance; the epithelium becomes cylindrical and lymphoid tissue appears abundantly under the surface. There are many complications, mechanical, reflex, toxo-infectious, of near and distant organs, ending frequently in the death of the patient. The treatment includes cleansing the nasal spaces, disinfecting them, and preventing complications, as well as antisyphilitic medication of the mother and the child.

Partial Diphtheritic Paraplegia.-C. Aubertin and L. Babonneix (La Presse Méd., Feb. 8) says that the patellar tendon reflexes are always abolished in diphtheritic paraplegia, even in those slight forms in which there is only a slight weakness of the extremities and uncertainty in the gait, not confining the child to bed. The abolition of the reflexes is the earliest symptom of the

paraplegia, preceding the others by about one week, and continuing for some time after the paralysis has passed away. It may be the only symptom, combined with a paralysis of the palate. In the absence of lesions of the nervous system in infectious diseases, the reflexes are always normal. Hence the symptom is of great importance as indicating a lesion of the nervous system, evidences of which may be expected in the form of paralysis. In 15 cases of paralysis of the palate the authors found absence of reflexes in 5. It occurs only in late forms of diphtheritic paralysis. The writers believe that this symptom is the expression of a very mild poliomyelitis.

Dilatation of the Heart in Diphtheria.-Hans Dietlen (Münch. Med. Woch., April 11) draws attention to the numerous autopsies in cases of death from diphtheria in which dilatation, especially of the left ventricle, is found. The condition is also frequently diagnosticated during life. Diphtheritic myocarditis sets in during the first half of the second week of the illness, and goes on to marked dilatation of the heart. This dilatation increases gradual. ly, from the beginning of the myocarditis, without much change in the pulse, and reaches its highest degree in the third week of the disease. It is accompanied by diffuse apex beat, visible pulsation, lack of clearness of the heart tones, accentuation of the pulmonary second sound, with a blowing systolic murmur. The dilatation passes away in the same gradual manner, in from 8 days to 4 weeks. In some cases it does not entirely disappear. The degree of pulse change is no index of the amount of dilatation, nor does percussion tell perfectly its extent. The author measures the heart's size and records it orthographically, in the form of a chart. The measurements are to be made with the child lying on his back on a table, as the sitting posture prevents correct measurements. Of 47 cases measured in this way, 20 showed myocarditis of a marked degree.

Results of Prophylactic Inoculation with Diphtheria Antitoxin in the Mariahilf Hospital at Aachen.-F. Wesaner (Munch. Med. Woch., March 21) gives the results of his use of diphtheria antitoxin as a preventive of diphtheritic infection from 1895-1904. His observations were made on children in non-infectious wards, in wards devoted to measles, scarlet fever and whooping-cough, in which the diphtheritic infection was brought in by visitors, and on the children of families one member of which had been brought to the hospital for treatment for diphtheria. It is his custom in such cases to urge the parents to permit immunization of all children in the family under 15 years of age. His conclusions are these: 1. Prophylactic injections are of use in preventing the spread of diphtheria in the city. 2. The protection is not absolute; it does not render isolation useless, but it need not be so severe. 3. The time of protection lasts about 3 to 4 weeks. 4. When protected persons suffer from diphtheria, either in spite of the protection, or from its being too late, the disease is of a very light form. 5. For small children 200 units is sufficient, but 300-400

units is better. 6. For cities, from both a hygienic and a pecuniary standpoint, it is worth while to give free preventive inoculation.

Death in Acute Diphtheritic Toxemia.-Chas. Bolton (Lancet, Feb. 4) says that the clinical aspect of the disease shows that death in acute diphtheritic toxemia is due to primary heart failure. To account for this, extensive fatty degeneration is found in the heart and acute degeneration in the motor nucleus of the vagus. It is quite likely, as all signs of degeneration are found at the same time, that both irritative and paralytic effects in the vagus may be felt by different portions of the heart at the same time, and that in some cases an irritative effect may preponderate whilst in others a paralytic effect may be chiefly evident. The probability is that irregularity of action would be the prominent feature that this irregularity would be subject to great variations in degree, and that in some cases a slowing of the pulse might be expected and in others an increased frequency. The cardiac dilatation is the result of weakness of the heart wall. The irregular pulse and fatal syncope of acute diphtheritic toxemia are therefore due to the disturbed innervation of an acutely degenerated heart. The heart failure exhibited in the acute stage by patients who recover is probably the result of similar though less extensive changes. At a later stage of the disease the results of these changes, together with interstitial cellular infiltration, are sufficient to produce a latent weakness of the heart which can be brought into evidence by some strain, and in this stage, also, degeneration of the vagus nerve probably plays a not unimportant part.

Infectivity of Scarlet Fever.-W. T. G. Pugh (Lancet, Feb. 4) says that the evidence that infectivity lies not in the desquamating cuticle but in the throat and nasal cavities is decidedly strong. In scarlet fever, therefore, as in diphtheria, it must be impossible to ascertain definitely by clinical means when the patient has been freed from infection. It must not be assumed, however, that prolonged infectivity is the rule; it is probable that the majority of patients are free from infection at the end of the minimum periods of isolation usually prescribed-6 weeks for scarlet fever and 4 weeks for diphtheria. It would seem impossible to discover by clinical means the minority who retain infection longer, and difficult even to differentiate those by whom transmission of infection is likely. The impression derived from experience has been that such transmission is especially liable to occur from those who suffer from rhinitis at the time of their discharge or have suffered from this complication during their period of isolation, and this impression has been supported by statistics whenever subjected to that test. A nasal discharge, therefore, while not to be regarded as proof that the patient continues infectious, is a symptom to be viewed with considerable suspicion, for if the contagnium is still resident in the mucous membrane of the nose it will unfailingly act as a vehicle for its distribution.

Experimental Measles.-Ludwig Hektoen (Jour. of Infectious

Diseases, Mar. 1) reviews the literature of inoculation of measles, showing that the recorded cases in which this has been attempted are mostly without significance. In his own experiments especial care was taken to exclude natural infection. Case 1. Blood of a boy of 9 years, who developed mild but typical measles before desquamation from uncomplicated scarlet fever ended, was withdrawn on the fourth day. Of this 4 c. c. were added to 50 c. c. of a mixture consisting of peptone broth, 2 parts, ascitic fluid heated to 55° C. for 54 minutes, I part. This was placed in an incubator at 37° C. for 24 hours. The flasks and subcultures remained sterile as far as demonstrable by ordinary methods; 4 c. c. of the above culture were inoculated under the skin of a healthy medical student just finishing desquamation after uncomplicated scarlet fever, who was in an institution which was then, previously, and subsequently free from measles. Typical measles, but without respiratory symptoms, developed. Case 2. An Irish servant-girl, 21 years old, had just passed through uncomplicated measles. Thirty hours after the appearance of the rash blood was withdrawn and treated as in the former case. The experimental inoculation was almost identical with the one described, and mild measles developed. The writer's conclusion is that the virus of measles is present in the blood of patients with typical measles some time, at least, during the first 30 hours of the eruption; that the virus retains its virulence for at least 24 hours when such blood is inoculated into ascites-broth and kept at 37° C. In this way the virus of measles may be obtained for study unmixed with other microbes.

Cerebrospinal Meningitis. Francis Huber (Arch. of Ped., Feb.) presents a clinical report of 100 cases of this disease observed during the epidemic of 1904 in hospital practice. Among the features noted was the fact that in only three cases was there a prodromal period, a sudden onset being the rule. The pulse was usually slow in adults, but in children it was extremely rapid. No prognostic value can be attached to sudden falls of temperature. Among the curious symptoms was an abnormal growth of hair over the extremities and body during the two and a half months preceding the discharge of a case which lasted six months and resulted in chronic hyprocephalus and persistent opisthotonus. In one case the diplococcus intracellularis was detected in the cerebrospinal fluid within eight hours from the onset; in others, within ten or twelve hours. The patients came from all sections of the city, usually not more than one from the same house or family, though more than a dozen exceptions to this rule came under the writer's observation. In malignant cases death occurs within 24 to 72 hours, and treatment is of little avail. Anomalous and abortive cases may recover rapidly even after a severe onset. Each case must be judged by itself. Maintenance of the strength by nourishment and nursing is most important. Symptoms must be treated as they arise. Lumbar puncture relieves some symptoms temporarily. Lysol injections proved ineffectual in a few experimental cases.