seen 3 to 5 days earlier: The diagnosis of measles in 32 cases, based on this sign, was confirmed in all by the subsequent eruption. Strong daylight is necessary to see the bluish-white center to the red spots. Ordinary manipulation does not remove them; but hard rubbing or forceps will detach them, and on examination they are found to consist of bacteria and epithelial scales. At the height of the exanthem the blue spots are exceedingly numerous; they are not to be confounded with the yellowishwhite pearls often seen in healthy children.

H. Meunier calls attention to his observations on the weight in children during the stage of incubation of measles. He found that, although in apparent health, such children on the fourth day before the invasion began to lose in weight about 50 gm. daily until, on an average, 300 gm. were lost. The author is of the opinion that this phenomenon is not peculiar to measles, but occurs in the incubation of other infectious diseases; and that its constant presence in measles will be a valuable help in isolating before the invasion children that have been exposed to measles, and so preventing them from infecting other children.

Lemoine reports 2 cases of measles contracted from convalescents, in whom the onset had been 20 days previously. He thinks that the measles-virus retains its vitality longer than is usually believed, and urges the use of disinfection.

A. Koeppen discusses the value of the sign described by Bolognini in measles, consisting of a friction sensation on palpating the abdomen, due, according to Bolognini, to an eruption on the peritoneum. Koeppen has observed it in less than 50% of the cases in a large epidemic; and he has also found it in children with diarrhea, but no measles.

W. L. Carr gives tabulated statistics of an epidemic of measles affecting 115 children in hospitals; 62 of the cases were complicated, and 20 died.

K. Fischer reports 3 attacks of measles in children of 1 family, the ages being 4, 8, and 1 year. At intervals of 17, 8, and 13 days there was in each patient a second rise of temperature, with a recurrence of the measles-rash. In the child 1 year old diphtheria developed shortly and terminated fatally.

6

P. Vergely reports a case of measles in a girl, 10 years old, a second attack beginning 17 days after the onset of the first. The literature is reviewed.

Rötheln.-F. Forchheimer describes the enanthem, or eruption on the mucous membranes, seen in rötheln, as an eruption seen only on the uvula and soft palate, consisting of rose-red macules, arranged irregu larly and not crescentically, the size of large pin-heads, very slightly elevated, and appearing contemporaneously with the exanthem, disappearing usually at the same time with it, but sometimes undergoing an involution, which may lead to pigmentation.

Pneumonia.-F. M. Crandall reports 2 cases of prolonged pneumonia, the first terminating fatally on the forty-third day; the second

1 Gaz. hebdom. de Méd. et de Chir., Nov. 6, 1898.

Rev. mens, des Mal de l'Enfance, July, 1898. 3 Centralbl. f. innere Med., No. 26, 1898. Arch. of Pediatrics, Jan., 1899. 5 Correspondenz-Bl. f. schw. Aerzte, Sept. 15, 1898. Rev. mens. des Mal, de l'Enfance, Aug., 1898. 7 Arch. of Pediatrics, Oct., 1898.

8 Ibid., Dec., 1898.

recovering on the sixtieth day, after coughing up a piece of popcorn, which had been inspired 2 days before the illness began.

M. S. Marcy discusses bronchopneumonia in children, urging in the treatment the use of cold, including icebags to the head and chest and cool sponging or bathing; and decrying the use of poultices.

Lemaire reports on Ausset's use of saline solution injected subcutaneously in the treatment of bronchopneumonia; 11 cases were so treated, all successfully. In patients over 3 years old, 200 cc. of 0.6% salt solution were injected at one time; under 3 years, 60 cc. were injected 3 times. The good effects of the injections were seen in the rise of bloodpressure, the increased flow of urine, increased oxidation with a general stimulation of the whole organism, especially the nervous system, and a lessening of all the symptoms. Contraindications to the hypodermoclysis are great weakness of the heart, excessive obesity, renal sclerosis, and pulmonary tuberculosis, the injection tending to light up old foci of tuberculosis. To get the best results the injections should be begun early and combined with baths, stimulants, and counterirritants (except blisters).

H. D. Chapin,3 with reference to the management of the fever in pneumonia, thinks that it is not necessarily an accurate index of the degree of toxemia, and that its reduction is not always of vital importance. The coal-tar antipyretics should not be given; but when the fever must be brought down, the local use of cold, by means of rubber bags containing cracked ice, or compresses of cold water (70° F.), is recommended, coupled with stimulation and the application of hot bottles to the feet. The use of the tub-bath is deprecated.

L. E. Holt outlines the treatment of pneumonia in very young children, and states that the cause of death is exhaustion, some complication, or acute toxemia; the first is to be avoided by fresh air, careful nursing, and diet, with stimulation, as needed, the best stimulant being alcohol. All the complications of pneumonia in infants are fatal, except pleurisy. The toxemia is to be overcome by vigorous stimulation, the best drugs being strychnin, nitroglycerin, ammonia, alcohol, and caffein. The best means for reducing temperature is the cold pack. H. Koplik, on the same subject of treatment, advocates the use of strychnin and digitalis, considering nitroglycerin, caffein, and ammonia to be too transient in action; in sthenic cases baths are useful, but should not be used if they weaken the pulse. With Holt, he recommends the vaporization in the room of creosote or some other respiratory antiseptic. W. L. Carr recommends in the bronchopneumonia in measles cleansing of the nasal passages with a solution of boric acid, counterirritation to the chest, hydrotherapy for the reduction of fever, and irrigation of the colon with normal salt solution, if there is intestinal fermentation. S. Baruch mentions the benefits of hydrotherapy, when properly applied, to be due to the dilatation of the cutaneous blood vessels, following an initial stage of contraction, this dilatation relieving the heart and increasing excretory activity, thus favoring elimination of the toxins and reducing the fever; in addition, the ventricular contraction is strengthened by a reflex stimulation. The water of the bath should be at 95° F. when the child is first placed in 1 Arch. of Pediatrics, Feb., 1899.

2 Sem. méd., Rev. mens. des Mal. de l'Enfance. Feb., 1899. 3 Med. News, Nov. 19, 1898.

Ibid. 5 Ibid. 6 Loc. cit. 'Ibid. @Ibid.

it, and then ice-water added until the temperature of the bath has fallen to 85° F., the face being bathed meanwhile with water at 75° F., and friction maintained over the whole body all the time it is immersed; this may be repeated in from 4 to 6 hours if the temperature rises above 101° F., cold packs being used in the interval if necessary.

J. Carmichael gives a description of the pathology of croupous and catarrhal pneumonias as seen in children, the relative infrequency of croupous pneumonia in them as compared with adults, although the infection remains the same in the majority of cases, being ascribed to the difference in the anatomy of the lung in infancy from that found in maturity, the infantile lung having smaller alveoli, with thicker walls, more blood vessels, and a connective tissue prone to proliferate. The author recognizes 4 distinct clinical types, as follows: a. Complete consolidation, with lobar distribution and absence of signs of bronchial catarrh; sudden onset, ending by crisis from the seventh to the tenth day, the symptoms not depending on the extent of consolidation, but on the toxemia. b. No sign of consolidation; bronchial catarrh of general distribution over one or both lungs, involving the smaller bronchioles (the so-called capillary bronchitis), with a fever; like the other forms of bronchopneumonia. c. Bronchial catarrh, with small areas of incomplete consolidation, lobar in distribution, recognized not by percussion, but by auscultation, gradual onset, irregular fever, ending by lysis in from 10 to 20 days, but sometimes by crisis. d. Bronchial catarrh, with larger areas of incomplete consolidation, lobar in distribution, being a mixed type of a and c, the consolidation being extensive enough to be recognized by percussion; the dulness, however, not being so absolute as in the fibrinous form.

Epidemic Cerebrospinal Meningitis.-G. Schirmer reports in detail on 9 cases of epidemic cerebrospinal meningitis recovering under the use of unguentum Credé, 30 gm. being given daily for 3 days, and 10 gm. additional at each relapse.

Netter calls attention to the sign described by Kernig, in 1882, as pathognomonic of meningitis; briefly, it is the inability, while holding the child in the sitting posture, to extend the knee so that the popliteal space will rest on the bed. Netter has found it present in 90% of meningitis cases, and in nothing else.

Typhoid Fever.-J. P. C. Griffith, in a clinical lecture, reviews the subject of typhoid fever in children, as compared with adults. The infection is often by means of milk; but although the custom of cooking the milk probably prevents many cases in infants, yet if this were not done the disease would still be more uncommon in children than in adults; well-authenticated cases show that it does occur under 2 years of age. The pathologic characteristics are that ulceration is not extensive, but the mesenteric glands are decidedly enlarged. The symptoms tend to differ somewhat from those in adults in the following way: The onset usually is very uncharacteristic and indefinite, but may be very abrupt, the classic picture including spots developing in 2 or 3 days; the fever is apt to be more irregular. Abortive types may occur, but the average febrile period is from 14 to 20 days; headache often is present 2 N. Y. Med. Monatschrift, vol. x., No. 11.

Brit. Med. Jour., No. 1972, 1898.

3 Rev. mens des Mal. de l'Enfance, Sept., 1898. 4 Phila. Med. Jour., Oct. 15, 1898.

at the start, but soon ceases, and children may not feel ill at all during the course; apathy is often seen, but the typhoid state is rare; the rash is perhaps more frequent than in adults, appearing in the great majority of cases; enlargement of the spleen can be detected in about 90%; drying of the tongue is not common, but vomiting is not so rare as in adults; diarrhea and constipation are about equally present; hemorrhage is very rare; relapse occurs in about the same percentage of cases as in adults; otitis and cholera follow more frequently, and nephritis less commonly, than in older persons; the prognosis is very good, one epidemic of 192 cases having given a mortality of 1%; hydrotherapy is useful, but not necessary as a routine measure, and some children do not bear the tubbath well.

1

J. L. Morse and H. W. Thaver used the Widal reaction in examining 50 cases of enteric disturbances in infants, and conclude that this test confirms the accepted belief that typhoid fever is rare in infancy; they also believe it possible that women whose blood gives a positive reaction, even though it be years after the occurrence of the disease, may in some way transmit this to their infants.

Cassonte reports a case of typhoid fever in an infant 2 months old, the diagnosis being based on the positive Widal reaction and on the fact that the child came from a district where typhoid fever was epidemic; the autopsy tended to confirm the diagnosis, Peyer's patches being enlarged and ulcerated.

3

L. Guinon quotes Marfan's and Moussous's figures for the mortality of typhoid fever in children as being about 2%; while in the cases collected by J. L. Morse the mortality was about 7% in children over 10 years, and about 2% in those from 5 to 10 years. In the winter of 1897 and 1898 the author treated 23 patients, 4 of whom died, 2 of perforation, aged 9 and 10 years, 1 of hemorrhage, aged 8 years, and 1 of pulmonary congestion and septicemia, aged 3 years. Ŏf the cases which recovered, many were very severe, among the complications being myocarditis, ulcerative stomatitis, intestinal hemorrhages, recrudescences, from slight causes, of fever in convalescence, furuncles, violent delirium, with spasmodic retention of urine and abscess of the buttocks; and 1 case of the hemorrhagic nephritic type developing in the hospital in a patient with simple purpura, the roseolar eruption becoming confluent.

Tuberculosis.-G. Kuss discusses at length, in all of its points, Baumgarten's theory of the hereditary transmission of tuberculosis. After showing the defects of this theory, the author gives as his belief, based on anatomic and pathologie grounds, and on the fact that the tubercle-bacilli "leave their signature in the neighborhood of the port of entry," that the "immense majority" of cases of infantile tuberculosis are acquired, the entrance of the bacilli being almost always in the lungs, the next most common, but rather infrequent, seat of infection being the intestine.

Statistics from the continent of Europe and from America point so strongly to the respiratory tract as the avenue of entrance in children for the tubercle-bacillus, that the contradiction by the English Registrar

1 Boston M. and S. Jour., vol. cxxxix., No. 2.

2 Jour. de Clin. et de Therap. Inf., 1898; Arch. of Pediatrics, June, 1899. 3 Rev. mens. des Mal. de l'Enfance, July, 1899.

Ibid., Jan., 1899.

General's returns has led to the belief that English cattle must be extensively tuberculous. With reference to the subject, W. A. Wills' thinks that many cases of malnutrition from improper feeding are wrongly classed as tabes mesenterica; for even if it should be proved that the cattle are tuberculous, he claims that the custom of boiling the milk is almost universal among the poorer classes, as it is the only way in which they can keep it, and thus the tubercle-bacilli are destroyed.

S. G. Guthrie, however, after analyzing 77 postmortem records in cases of tuberculosis in children, with reference to the distribution and origin of the disease, concludes: 1. Thoracic tuberculosis in children is more common than abdominal, in the proportion of 3: 2. 2. Tabes mesenterica as a cause of death in young children is practically unknown. 3. The preponderance of thoracic over abdominal tuberculosis is not necessarily solely due to the direct entry of bacilli into the air-passages; for in addition to this mode of infection the lungs may be affected: (a) by bacilli entering the thoracic glands through the lymphatics of the pharynx, tonsils, or esophagus above, and through the lymphatics of the intestines to the abdominal glands below; (b) by the entry of bacilli through the thoracic duct into the pulmonary circulation by way of the right heart. 4. Primary infection through the alimentary tract does not prove that food has been the sole source of evil; therefore, tuberculosis in children is not likely to be materially checked by purification of milk-supply alone. 5. The alleged increase, of late years, of tuberculous meningitis is probably due to pulmonary tuberculosis set up by severe epidemics of measles.

A. A. Kanthack and E. Sladen 3 injected milk obtained from 16 dairies into guineapigs, the milk from 9 dairies causing tuberculosis.

G. N. Acker reports the cases of 2 colored children, 2 and 3 years old, with pulmonary tuberculosis, death resulting from hemoptysis.

E. Ausset reports a case in a boy, 8 years old; a partial review of the literature is given.

6

H. D. Chapin contributes an account of peculiar respiratory phenomena observed in 3 cases of tuberculous meningitis, in which, besides the usual disturbances of shallow, irregular, and sighing respiration, there was dyspnea just before death, so marked as to seem to be the immediate cause. Autopsies were performed in 2 of the cases, and, in addition to a tuberculous leptomeningitis, the bronchial glands were enlarged and caseous. Cultures from the throat and trachea for diphtheriabacilli were negative.

J. Comby gives the results of 211 autopsies on children under 2 years of age, 28 (13.27%) being tuberculous, the portal of infection being in all cases through the respiratory tract; none of the infants under 3 months of age were tuberculous. In this connection it is interesting to note the case, reported by Bonnet, of a child born prematurely at the seventh month, the mother being tuberculous and dying 2 months later; the child was nursed 3 days, and then fed on sterilized milk. After 10

Lancet, Jan. 7, 1899.

3 Ibid., Jan. 14, 1899.

2 Ibid., Feb. 4, 1899.

* Arch. of Pediatrics, Aug. and Oct., 1898.

5 Gaz. hebdom. de Méd. et de Chir., Mar. 16, 1899.

6 Arch. of Pediatrics, Feb., 1899.

Arch. de Méd. des Enfants, vol. i., No. 5. 8 Rev. Internat. de Méd. et de Chir., vol. ix., No. 11.