ticle to describe the symptoms present with the secondary fever of the severe cases of the ordinary type, as but few cases during the present epidemic, have developed a secondary fever.

This rapid drop in temperature on the appearance of the eruption is highly characteristic of small-pox.

The peculiar ordor of small-pox spoken of by some writers, has never been observed by the writer prior to the rupture of the pustules. Where the eruption is very plentiful, there comes a time when the stench arising from the decomposing pus (especially when scrupulous care is not taken to keep the patient and his bed-linen clean) is something not to be forgotten.

The broken pustules form thick, firmly adher

PLATE III. Small-pox-Pustular and Unbilicated Eruption. February, 1899.-Cincinnati Branch Hospital.

ing, dark colored scabs. The true skin is generally destroyed by a greater or less number of the pustules, leaving the well-known permanent mark of small-pox.

In all epidemics of small-pox, as in other diseases, the cases range from the most severe to the very mild, even in the unvaccinated. Heretofore mild cases in unvaccinated persons have been the exception; in the present epidemic they are the rule.

A description may now be given of the general run of cases of small-pox, as senn in Ohio during the past year and a half.

More or less fever is nearly always present, disappearing promptly as the eruption comes out. This may be slight, and especially in children. The mother will not infrequently tell you that she did not notice anything particularly wrong with the child until she saw the eruption. The

patient often is not confined to bed and may come to the table for meals as usual. Sickness of the stomach or vomiting is a common symptom, but not of as frequent occurrence as in the severer type of the disease. The majority of the patients do not have the severe backache, although headache and pains in the limbs are frequently present. The eruption makes its appearance at about the usual time, but may be delayed to the fourth or even the fifth day. It is impossible, in many cases, in eliciting a history of the disease from the parents, to get a description of a papular eruption in the beginning. They will tell you that the first thing noticed was "little blisters" or vesicles.

The eruption often does not become distinctly pustular. The contents of the pustules will be more nearly sero-purulent. The umbilicated eruption may be seen, usually, though in but few places. The mucous membrane of the fauces and hard palate usually present points of eruptions, in the shape of ragged ulcers, and sore throat is frequently complained of.

The eruption does not seem to be deep-seated. As a keen observer said, in examining a case early in the present epidemic: "This case certainly seems to be small-pox, and the only doubt raised in my mind is by the fact that the eruption does not involve the true skin."

When the scabs drop off, dark colored spots persisting for tome time, are usually noticed. The scabs drop off sooner and are not as thick as those usually seen. After recovery, superficial markings of the skin may be found on looking closely, but the deep pitting of small-pox, even in severe cases, is generally absent.

The rapidity with which the eruption may mature and disappear is surprising. A recent case will illustrate this: A man had small-pox, which was not recognized until nearly four weeks after he was taken ill. He was then quarantined. On investigation he was found entirely well. His two young children, who had contracted smallpox from him, had also gone through with the disease in this time; but their skin was free from scales. The father had had a very plentiful eruption and was quite sick prior to breaking out. The children had had a very mild attack, with but little eruption. None of the three had been vaccinated.

Secondary fever in the present type of the disease is most unusual. The "small-pox odor" (if by that is meant the odor of decomposing pus), is seldom noticed.

Abortive forms of the disease are common. The eruption may rapidly run its course of macule, papule, vesicle and pustule, or it may be cut short in the papular or vesicular stage. In a very large number of cases the patient feels as well as ordinary after the eruption appears. It is the exception, rather than the rule, to find the patient in bed during the eruptive period of the disease. No age is exempt from the disease. This is of the greatest importance in dis

tinguishing small-pox from chicken-pox. It should always be borne in mind that chickenpox in adults is rare-very rare. In the nineteenth annual report of the State Board of Health of South Carolina, the following quotations are given in the support of such a statement:

Osler, Principles and Practice, Second Edition, page 69: "Varicella is an acute contagious disease of children, it is a disease of childhood. A majority of the cases occur between the second and the sixth year. It is rarely seen in adults."

Keating, Ency. Diseases of Children, article Varicella, by Dr. Chas. G. Jennings: "An acute specific infectious disease peculiar to infancy and childhood. In children over ten years of age

PLATE IV. Small-pox-Pustular and Umbilicated Eruption. Feb. ruary, 1899.-Cincinnati Branch Hospital.

the disease is rare, while in adult life it is so infrequent that many observers of large experience have not met with it. Varicella is particularly a disease of infancy and early childhood. Any varicella-like eruption in an adult should be looked upon with the greatest suspicion and the patients strictly isolated until by the history of the case, its source and the course of the disease, all doubt as to the diagnosis is dispelled."

Dr. James Nevens Hyde, in Pepper's System of Medicine, says: "Varicella is essentially a disease of early life, occurring almost exclusively in infants and young children."

Alix. Collie (Quain's Dictionary of Medicine), says: "It is certain it arises from contagion, and childhood is a predisposing cause. It occurs in children at the breast, and is seen with increasing

frequency up to the fourth year, at which period it attains its maximum. It is less often found between four and twelve, and after twelve it may be said to disappear, although it is occasionally seen in adults."

Bartholow's Practice of Medicine, Fifth Edition, page 717: "It is a disease of childhood, and rarely attacks any above ten years of age."

Dr. Louis Thomas (Liepzig Ziemssen's Cyclopaedia), says: "Varicella is a disease of childhood and attacks by preference young children and even sucklings. In children over ten years of age attacks are infrequent, and I never saw an adult suffering from varicella. Eruptions resembling varicella in adults always indicated variola."

Vaccination is an important factor in diagnosis. When the disease has prevailed in a community for some time, masking under the name of chicken-pox (as has happened frequently of late), a report upon the vaccinal status of the members of all families where the disease has occurred will show that vaccination has afforded almost perfect protection against it. Two examples of recent occurrence may be cited. Two families were living in adjoining houses. In one there were seven persons, all unvaccinated; all had the disease. In the other there were six persons, one of them only was unvaccinated, and he was the only one affected. There was free intercourse between these families, small-pox not being suspected.

In another case there were ten members of a family living in a small house. Eight of them were down with, or rather were having small-pox at the same time. All of these were unvaccinated. The two vaccinated members of the family escaped.

The question of a previous attack of chickenpox should be considered. Second attacks of this disease are rare. It is often possible to find the peculiar pits of a former attack of chickenpox on the skin of a person broken out with small-pox.

It is quite easy to be deceived on seeing a single case of this mild type of small-pox which is now prevailing. When the disease appears in a community physicians should endeavor to see as many cases as possible. In every outbreak of this disease in Ohio where any considerable number of cases developed, some of them were fairly well marked cases of small-pox, easy of recognition.

Physicians, on being called to a suspected case of small-pox, should bear in mind the maxim: "The public is entitled to the doubt." If there is a suspicion that a case may be smallpox it should be treated as such until that suspicion is wholly removed. By promptly reporting to the local health authorities all cases, and suspected cases, so that proper restrictive measures may be at once enforced, an epidemic may be averted.

A NOVEL MATERNAL IMPRESSION.

Mr. John Booth, house surgeon to the South Charitable Infirmary and County Hospital, Cork (British Medical Journal), relates the following: "A very handsome thoroughbred fox terrier bitch, belonging to a friend of mine, got her right fore leg broken, which was set, and the dog made a good recovery. Several weeks afterward she gave birth to a puppy whose right fore leg-corresponding to the mother's broken limb-was ill developed and was minus the paw. The literature is full of cases of maternal impressions in the human family, but this contribution from the lower creation is, so far as I am aware, unique.

SCHOOL DOCTORS IN GERMANY.

Some of the primary schools in Germany have their own doctor. He watches over the classrooms, and is there to show that questions of warming, ventilation, lighting, and cleaning have entered into the kingdom of science, whereof he is king. Once in every fortnight he gives instruction in every class in the school, and the text he preaches from is Sanitas sanitatum, omnia sanitas. In short, he is the health officer of the whole establishment, the priest of Hygeia, and the philosopher and friend of the teacher and the taught.

TREATMENT.

A peculiar operation which has excited much interest among American surgeons was performeed in the Memorial Hospital by cementing a woman's upper and low jaws together so that broken bones of the under-jaw might be held firmly in place until the fractures are healed and the bone tissue knitted together. Dr. Brewster, who performed the operation, is a dentist. He first made an impression of the upper and lower teeth, and from this made a rubber splint, which fitted perfectly the impressions of the teeth. This splint was cemented to the teeth, closing the jaws together firmly. Nourishment in liquid form is given her through the small apertures left by several teeth being broken out.-London Health.

AN INSIDIOUS ADULTERANT. The fact that saccharin is three hundred times as sweet as cane sugar, and that it is chiefly produced from coal-tar, renders it a very convenient substitute for sugar in sweetening fruits, and in various other ways. It has by some been declared harmless because it does not produce immediately fatal symptoms when taken in moderate doses, but Payen ("Hare's Practical System of Therapeutics") calls attention to the fact that when taken in more than extremely minute doses (one and one-half grains per day), violent gastric pains are produced. A drug that is capable of producing violent gastric pains in so small a quantity as indicated is certainly dangerous for ordinary use, and is not a fit substitute for a food substance.-Modern Medicine.

The publishers will not be responsible, under any circumstances, for the opinions expressed or statements made by correspondents. Contributors will be furnished, gratis, with sample copies containing their articles, under an agreement to distribute at once to physicians in actual practice. To avoid duplication publishers should be informed of the field to be covered. Reprints, giving The Medical Dial full credit, may be obtained at actual cost.

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SPECIAL NOTICE.-Copy for the insertion or change of advertisements must be in hand by the 25th of the preceding month to insure attention. All changes or new work received after that date will be inserted only if convenient in the mechanical department. Notices for the Publishers' Department should be at office of publication by the 20th of the preceding month, and we cannot guarantee insertion if received after that date.

Soon after the discovery of the x-rays, attempts were made to skiagraph calculi in the urinary bladder and kidney, also stones in the liver, gall bladder and ducts. The results were very discouraging. Most observers came to the conclusion that biliary calculi, at least, were completely permeated by the Röntgen rays, and, therefore, could not be demonstrated. Gocht, of Wurzburg, the cradle of the x-rays, states, in his work on the use of the Rontgen rays in medicine and surgery, that neither he nor any other experimenter had been able to represent biliary calculi in a living subject.

In the detection of renal and vesical calculi better results were obtained, for it was soon found that a fairly good skiagraph could be obtained when the calculus consisted of a hard and firm layer like the oxalates. The urates being less opaque threw a faint shade upon the plate, while phosphatic stones, being completely penetrable, threw no shade at all.

Dr. Carl Beck, of New York City, (N. Y. Med. Jour. Jan, 20, 1900), contributes a very interesting paper upon the detection of calculi in the liver and gall bladder, in which he shows that by improved technique more satisfactory results can be obtained than past experience has led us to believe possible. The patient should lie on his abdomen, with a pillow underneath the symphisis, as well as underneath the clavicles. This causes protrusion of the region of the gall bladder, thus bringing the calculi nearer the photographic plate. The approximation is still more increased by turning the body slightly to the right and raising the left side.

The rays

must not penetrate the abdomen in a vertical direction, but from the side, so that the thick and less transparent tissue of the liver is not permeated in its whole diameter. The rays should be so directed as to form an angle of forty-five degrees with the plate.

Ever since February, 1896, Dr. Beck has been experimenting in this direction, making ninetyseven skiagraphs in ninety-eight cases of suspected cholelithiasis. In only two of these was he able to obtain slight shades on the plates, and they were so indistinct that they were of no value for diagnostic purposes. He then hit upon a happy expedient. Four different photographic plates were employed at the same time. On the upper plate, situated below the region of the gall bladder, the outlines of the liver were well shown, while in the fourth and most remote it appeared only faintly, but the calculi were cleary represented.

A single plate was next used, and an exposure made with a quick-penetrating focus tube on a single plate, lasting ten minutes. Having found how long it took with this tube to represent the liver, a second plate was exposed for six minutes, with the result that the calculi were clearly defined, while the outlines of the liver were faintly marked. By several exposures of varying lengths of time it was demonstrated that the longer the time of exposure the clearer the liver, and the obscurer the calculi appeared.

Dr. Beck recommends making a short as well

as a long exposure-say five minutes and ten minutes—in every case of suspected gallstones. The most powerful focus tubes should be employed, and as land marks to outline the organs, especially the liver, thin wires should be attached to the plate before the final skiagraph is taken.

THE MINNEAPOLIS SMALL-POX EPI

DEMIC.

We regret to learn of the unnecessary controversy which has arisen between the Health Commissioner of Minneapolis and the Secretary of the State Board of Health regarding certain cases of infectious disease claimed by the former to be chicken pox, by the latter, small pox. The daily papers have not been slow in fomenting what they consider a doctors' quarrel, but in so far as the profession of the city is concerned there is no danger of any serious breach of good feeling among its members. Any personal feeling between the Health Commissioner and the Secretary of the State Board of Health should stand in abeyance while so serious a calamity as a small-pox epidemic is threatening the community.

Chicken-pox is epidemic in the city, and this no one questions. But that there are cases of smallpox there is overwhelming evidence, and it is to the best interests of the city and the country that we awake to this fact and act accordingly. A mild type of small-pox has been prevailing in many parts of the United States, and has visited Minneapolis as it has many other cities. The mildness of the epidemic should not lead us to treat it carelessly, for it frequently happens in epidemic diseases of any kind that the first cases are mild, but as the epidemic gains strength the cases become more and more severe, until the most virulent form of the disease is developed, and the mortality becomes terrible. This has been observed over and over again, and, as was pointed out by Dr. Thorne-Thorne, of the Local Government Board of London, we should learn the lesson from it, of stamping out at its beginning the mildest epidemic and deal as rigidly with it as we would with an infectious disease of the most virulent type.

The position of a health officer is a responsible and trying one. He naturally hesitates to announce that small-pox has visited his city, and should he do so unnecessarily, a storm of adverse criticism would fall upon his head. This consideration, together with the mild type of the dis

ease, the prevalence of chicken-pox, and the opinions expressed by several physicians who saw only chicken-pox, has probably influenced Dr. Norton to take the position which he has held. Now, however, that there is no doubt of the existence of small-pox, the strictest quarantine should be enforced, and the community should to a man stand behind the health authorities in every measure they adopt for the public safety.

The first case of small-pox came to Minneapolis in October, since which time sixty-seven cases have been reported, thirty are nominally quarantined at the present time, but the quarantine is not strict enough to be of sufficient protection to the public, indeed, quarantine measures seem to have been adopted by the city Board of Health in a half-hearted way and more as a compromise with the state authorities than from a proper realization of the danger. Cards are placed upon the doors of the infected houses and we are informed on good authority that these cards are disregarded. Friends and acquaintances come and go at pleasure, and the smallpox patients are attended by their family physicians. Two cases of small-pox are reported each day and with the present half-hearted method of quarantine, we may expect that this rate will speedily increase and ere long the epidemic will become an epidemic beyond control. If there is still doubt in the minds of the City Health authorities of the existence of small-pox that point should be settled at once, and the strictest measures taken to quarantine every suspected case and have it attended by physicians employed by the city and who are not allowed to visit patients indiscriminately.

PRETTY GIRLS AS TRAINED NURSES. No one can walk through a modern hospital without being struck by the number of pretty girls who have adopted nursing as their life work. Some are drawn to the training school by a romantic taste acquired by reading tales and studying pictures of Red Cross nurses. Many of these are destined to remain in hospital or private nursing for but a short time, when their hearts and hands are won by sentimental patients or love-sick internes, and they settle down to domestic duties. Others, however, enter the ranks and follow their chosen work from pure love of their calling, and are proof against Cupid's darts. The following from a writer in the New Orleans Times-Democrat is a case in point: