action on the mucous membranes of these parts. If vomiting again establishes itself towards the end of the attack or after the patient's recovery from the disease per se, it is in many instances the initial symptom of an uraemia and proper proceedings should be taken to aid the kidneys.

In considering the fever, always remember that this symptom is not to be combated unless it threatens to get beyond control. A temperature of 104 degrees F. occurring for a short time during this disease is not necessarily an indication of trouble or a signal to begin active intervention. But where this temperature is continued for a few days and threatens to climb it warns us that something must be done besides masterful inactivity. Here, again, however, comes our old warning of overtreatment which consists, as a rule, in the use of the coal tar products. Unless the child becomes extremely nervous and irritable and temperature cannot be reduced by natural hydrotherapy, we should never use phenacetin and the like and even then they should be used sparingly and timidly.

In those cases of septicaemia where temperature continues for several days and patient presents a typical case of profound sepsis, no coal tar products should be given. These cases should be supported in every way possible, by rational stimulation, e. g. where pulse is weak and tension is low, digitalis should be used. Where there are present no kidney complications, the diet should be broadened to include more foods according to age and digestive ability of child. So many of these cases are starved and purged to death. In extreme cases of hyperpyrexia where albumin, casts and blood are present in large amounts, urine venesection and hypodermoclysis may be necessary. In long continued cases of this extreme septic type, the child's normal amount of sleep should be preserved as nearly as possible, even if it be necessary to resort to opiates. Sometimes the milder hypnotics will serve the purpose as well but here again comes the old warning, use neither the opiate nor hypnotic unless absolutely sure of their rational therapeutic indication.

The method of applying hydrotherapy for the reduction of temperature, is the same here as in other conditions, keeping in mind that the cold pack or cold tub bath is contraindicated in cases where skin is cold and temperature high, indicating cardiac weakness, in organic disease of the heart, dyspnea due to narrowing of air passages, hemorrhagic tendencies, infections in joints and in cases with kidney complications. However, we think that as a rule, the practitioner is too chary in the use of cold for purposes of reducing a high temperature in infants. They seem to respond more promptly to this method than adults. and the reaction is as a rule excellent, because we have present no active organic lesions, suspected or unsuspected.

In closing our remarks in regard to the febrile treatment of this disease, we wish to emphasize the fact that the lighter cases of scarlet fever should receive no active intervention as to the hyperpyrexia and that when active interference is employed, it should be the form of hydrotherapy suited to the particular case and that medicines for this purpose should rarely be used.

In taking up the treatment of the complications and sequelae, we wish to say that we do not want you to consider that we will attempt to cover this subject in detail but that we will only deal with the broader phases of it.

The tissues most often affected by complications or as sequelae are the ear, and kidneys. The discussion of the case of the ear has been delegated to another, so that we will consider only the kidney. Together with empyema and otitis media we find that pyelitis and nephritis are most often missed in the diagnosis of diseases of children. But surely in scarlet fever, except in those cases where no physician has been called because of mildness of attack, can there be a legitimate excuse for lack of diagnosis of this important complication or sequelae. The patient during all attacks of scarlet fever should be placed upon a milk diet not only during attack but for at least ten days after its subsidence. We find that children below a year of age are less subject to the kidney complications due partly to the fact that milk and water constitute their entire diet or at least the

larger part of it. Water should be given freely. The skin and bowels should be kept as active as possible and the child should, in all cases, have plenty of fresh air, even if that air is cold, as plenty of oxygen aids the child in getting rid of its sepsis. In short, all the emunctories should be made active so as to relieve the kidneys of work. The skin should be kept active by daily warm baths, taking every precaution to prevent the child catching cold. The bowels should be kept in good shape by mild laxatives or better still by copious enemata of warm saline solution given twice daily. We are not advocates of such strong remedial measures as pilocarpin, except in extremis. Complete rest is indicated and by that we mean rest in bed.

Prognosis even in cases where there is an abundance of blood, casts and albumin in the urine, is good under proper care and we think that rarely are strong medicinal measures imperative. The kidney trouble usually follows the milder cases because of neglect of proper management and this should always serve as a warning to insist on the particulars of treatment in the milder cases.

We have many other complications and sequelae that may occur but in this short paper but brief mention of them will be made.

Enlargements of the glands of the neck with or without a surrounding cellulitis indicate that the treatment of the posterior nares and throat is not as thorough as it should be, or is too vigorous, or we have extensive poisoning at this point. The treatment is at all stages the ice bag applied to the part and greater vigilance in the treatment of posterior nares and throat. When pus forms early incision should be instituted and complete drainage established.

This is a complication to be feared if not handled in a vigorous manner as we may have the infection eating into the larger blood vessels of the neck and a fatal hemorrhage taking place.

A synovitis either single or multiple should be treated by rest and immobilization of the affected part or parts as near as

possible, and either the ice bag or ichthyol applied locally. These cases usually subside in three to seven days.

The anaemia present during or as an aftermath of an attack of scarlet fever should be treated by Basham's mixture. Some observers go as far as to say "no leucocytosis, no scarlet fever" and as a consequence we find that our iron and ammonium acetate comes frequently into play.

Empyema, serous effusion in pleura and cardiac lesions ast endocaritis may take place, usually as complications of highly septic forms and the treatment indicated is that usually followed in such cases. We may have concurrent with or following scarlet fever, a Klebs-Loeffler infection; when such is the case or there is the slightest suspicion of such a condition, antitoxin should be resorted to immediately. We have no sympathy with the arbitrary use of diphtheria antitoxin for diseases other than diphtheria, and we know that cases of scarlet fever have been treated by this means and the claim made that the case was benefited by its use. The reason, of course, being that a mixed infection was present.

This leads to a consideration of the treatment with sera, usually a streptococcic or streptolytic serum, because we are not absolutely sure of our micro-organism, we find that our sera are not specific or reliable. A number of continental workers have used various sera prepared from several different varieties of streptococci but with very confusing results. This is due to the fact that various epidemics of scarlet fever vary so in their virulence and the results obtained in one epidemic cannot be compared with those obtained in another. There is a sera recently prepared by Moser (Vienna) that has been used by several Germans. It is not in the market as yet and its clinical value has not been thoroughly tested and the most we can say is that it promises much.

In closing, we wish to emphasize the fact of the variability of the strength of this infection and to put you on your guard in the treatment of what may seem a mild case so that a careful thoroughness of the details of treatment be adhered to and the

physician saved a surprise party. Also, that at all times, your treatment should be rational and not empirical and not to overtreat or over-drug your little sufferer.

To recapitulate—

The symptomatic treatment consists largely of hydrotherapy and the prevention as far as possible of extension of infection by application of mild cleansing antiseptics to throat and nose. Rest in bed and a milk diet are essential rules of successful handling of these cases. The proper amount of fresh air is at all times imperative. Mcdicines are to be used and not to be abused. The serum treatment is as yet in abeyance.