on the following points: 1. The eruption did not have the regular course of the eruption of variola, for it appeared first on the trunk and spread irregularly over the whole body; and when the first lesions were drying on the eleventh day, new vesicles appeared, as has been noted before in generalized vaccinia. 2. The general symptoms of variola-vomiting, pains, and general malaise-were absent, and the fever never reached 39° C. 3. The history excluded all possibility of direct or indirect exposure to smallpox. 4. No subsequent case of smallpox developed in those in contact with the child, although several had not been vaccinated since

FIG. 1.-D'Espine and Jeandin's case of generalized vaccinia (Arch. f. Kinderh., 1899).

childhood. 5. Inoculation of the contents of some of the vesicles into a calf produced vaccinia, these lesions in turn furnishing good vaccinelymph, the calf also being protected against vaccine virus known to be strong.

Scarlet Fever.-W. J. Class describes a germ found by him in cultures from the epidermic scales and from the throats of scarlet-fever patients, which he feels almost convinced is the specific germ of the disIt is a diplococcus resembling the gonococcus somewhat, but being larger and having almost the appearance of a tetrad, owing to a pale 1 Phila. Med. Jour., May 13, 1899.

ease.

streak running transversely through each half of the organism; it takes the anilin dyes well and is decolorized by Gram's method, but not completely; the culture-medium is the ordinary glycerin-agar, to which 5% of black garden-earth, rendered sterile by interrupted heating, has been added; growth occurs at 35° C. in from 2 to 7 days, in the form of small, whitish-gray, semitransparent colonies; experiments on rabbits and guineapigs gave negative results, the animals being affected in no

way.

C. K. Millard' investigated the frequency with which the discharge of a convalescent scarlet-fever patient from the Birmingham City Hospital was followed by the development of the disease in another member of the family, constituting a "return case"; 4810 cases in 2 years were discharged, and, at varying intervals from a few days up to 6 weeks, 171 return cases were admitted. After consideration of isolation, infectivity with regard to age, sex, and season, and the condition of the infecting cases, the author discusses desquamation, which, he thinks, is not in itself the special source of infection, though it may act as fomites; and he thinks that the period of infectivity may in many cases last beyond the period of desquamation, a point which bacteriology will probably ultimately settle.

A. Woldert reports a case of scarlatinal nephritis with free hemoglobin in the renal epithelium.

R. H. Kennan3 seeks to explain instances of relapses of scarlet fever (3 of which have come under his notice) by exposure to an atmosphere loaded with infection, such as is found in the principal hospitals, where many cases are treated; and he suggests that there should be different wards for the patients in different periods of the disease.

4

J. B. A. M. van den Berg reports, from Baginsky's service at the K. and K. Friedrich Children's Hospital in Berlin, on a study of the blood in 16 cases of scarlet fever. After general considerations of the differences in constitution and behavior of the blood of children from that of adults, and a discussion of leukocytosis in general, a table is given for each of 12 cases, showing at each examination the day of the disease, the body-temperature, the percentage of hemoglobin, the specific gravity, the number of red cells, the number of white cells, the ratio between the two, the amount and specific gravity of the urine, and general remarks. The study of the leukocytes gave the most important results, a leukocytosis being found in every case, the maximum being reached usually from the fourth to the sixth day, the condition generally lasting from 20 to 30 days; there was no distinct relationship between the number of white cells and the severity of the disease, but the lighter cases seemed to have the higher counts; nor could any connection with the extent and severity of the eruption be established; and even the disappearance of the angina was not, as some observers have found, accompanied by a fall in the number of white cells. While the leukocytosis seems to last through the course of the disease, declining toward the end, yet there seems to be no prognostic value in the disappearance of the excess. Because a marked leukocytosis was seen in 1 light case, which 2 Phila. Med. Jour., Oct. 8, 1898.

Brit. Med. Jour., Sept. 3, 1898. Dublin Jour. Med. Sci., No. 329, 1898. * Arch. f. Kinderh., Band 25, Hefte 5 u. 6.

showed neither angina nor gland-swelling, the author believes that the leukocytosis of scarlatina is the result of a chemotactic influence exerted by the toxin of the disease, especially as the degree of temperature stood in no constant relation with the count; an infant, 3 months old, showed in the course of the disease no greater number than 10,200 leukocytes, and the inference is drawn, to be verified by further studies, that the leukocytosis of scarlet fever is absent in infants. The number of the red cells seems to be affected to a marked degree only when a nephritis sets in; the counts at the start of the scarlatina were often over 5,000,000, a slight reduction occurring later. The author attributes the increase not to a concentration of the blood, but to a stimulation of the blood-making organs. Gower's apparatus was used for estimating hemoglobin, which, the author thinks, gives a lower reading than Fleischl's, and may be responsible for the low figures, which ranged, on the average, from 55% to 65%; this seemed to bear no relation to the range of temperature. The specific gravity was found to correspond closely with the normal figures for the corresponding ages, ranging from 1052 to 1056. A differential count of the leukocytes showed the increase to be largely in the polynuclear and transitional forms.

M. Mazaud' examined the urine of scarlet-fever patients with reference to its toxicity, and found that in the febrile period the relative toxicity was increased; and when the urine was normal in amount the absolute toxicity was above normal. Febrile urine is a convulsant, and when it contains albumin violent peristalsis is provoked, sometimes with bloody stools. Febrile urine also sometimes causes lacrimation and salivation, the tendency to produce the latter being more marked with heat. As the temperature of the patient falls, there is a urotoxic crisis of short duration, repeated on 2 or 3 successive days; at the start of the crisis the urine is convulsant, afterward becoming narcotic and causing dyspnea; in convalescence a hypotoxicity occurs, lasting a long time; these variations in toxicity do not coincide with changes in diet.

L. Fischer, after using antistreptococcus-serum in 19 cases of scarlet fever, erysipelas, including 1 case of meningitis and 1 of puerperal septicemia, and having observed no positive beneficial effect in any case, concludes that its use should not be recommended, and that its indiscriminate sale should be prohibited until its true therapeutic value is established by clinical experience.

3

F. Ehrlich claims to be the first to report a case of stenosis of the esophagus following scarlet fever and diphtheria. The patient was a boy, 5 years old, and the attack was of the anginose type, symptoms of obstruction coming on shortly after it.

Measles.-Slawyk speaks of the great diagnostic value of Koplik's sign, which he observed in all of 32 cases of measles.

H. Koplik refers again to the eruption on the buccal mucous membrane, and its diagnostic importance in measles [on which he does not lay too great stress, by any means]. We reproduce his illustrations (Plate 1), which show its appearance better than any description. It comes out a day or two before the eruption on the skin, and in some cases has been

1 Rev. mens. des Mal. de l'Enfance, Sept., 1898.

2 Arch. of Pediatrics, July, 1898.

* Deutsch. med. Woch., No. 17, 1898.

3 Berlin. klin. Woch., Oct. 17, 1898.

5 Med. News, June 3, 1899.

The pathognomonic sign of measles (Koplik's spots).

FIG. 1.-The discrete measles-spots on the buccal or labial mucous membrane, showing the isolated rose-red spot, with the minute bluish-white center, on the normally colored mucous membrane.

FIG. 2. The partially diffuse eruption on the mucous membrane of the cheeks and lips: patches of pale pink interspersed among rose-red patches, the latter showing numerous pale bluish-white spots.

FIG. 3.-The appearance of the buccal or labial mucous membrane when the measles-spots completely coalesce and give a diffuse redness, with the myriads of bluish-white specks. The exanthem is at this time generally fully developed.

FIG. 4.-Aphthous stomatitis, likely to be mistaken for measles-spots. Mucous membrane normal in hue. Minute yellow points are surrounded by a red area. Always discrete.