Boston

Medical Library 8 The Fenway

j

\

WASHINGTON

(BIMONTHLY)

Journal of the Medical Society of the District of Columbia

Vol. XV, 1916.

Beresford, Printer, 605 F vStreet, N. W. City of Washington

INDEX

PAGE.

Abbe, Truman 48, 257

Adams, S. S 94, 145, 146, 149, 279, 344, 355

Address, Presidential 1

Amendments 69, 143, 149, 155, 204, 213, 287, 313, 360, 369

American First Aid Conference 59

American Red Cross 145

Ammermann, C. C 203

Annals, Washington Medical 143

Appropriations.... 58, 59, 62, 63, 147, 148, 204, 207, 278., 280, 281, 282, 361

Army Medical Museum 15

Army, U. S 75

Ashby; T. A 360

Atkinson, W. H 130, 206, 207, 335

Baby week 204

Baker, Frank 247

Baldwin, W. H 94, 146

Balloch, E. A ' 256

Barber, J. M 59

Barnes. N. P 236

Barton, W. M 62, 149, 202, 344

Beall, B. M. 158

Belgian physicians 69, 155

Bishop, F. B 215

Blue, Rupert 203, 207, 278

Body heat, elimination, &c 277

Body snatching 247

Bogle, K. B 58, 147

Borden, D. L 131, 132, 195

Borden, W. C 145

Bowen, W. S 181, 183

Braisted, W. C 203, 207

Briggs, J. B 203

Brooks, F. V 63, 360

Buck. j. R 203

Bullard, E. L 118

Burch, E. W 279, 335

Burton, Ralph 59, 60, 145

Butler, E. F 49

Butler, W. K 197, 246

Calculi, renal and ureteral 273

Cancer of breast, diagnosis of 362

Carr, W. B 183, 194

Carr, W. P 47, 48, 62, 131, 182, 192, 194, 246, 253, 254, 257, 279, 280

Cases :

•Actinomycosis 60, 61

Anastornosis, arterial, operative 131

Ankylosis of jaw 62

Aorta, aneurysm 150

Brain, syphilis 150

IV

INDEX

Cases, continued :

Calcaneum, fracture 208

Cerebro-spinal meningitis 280

Cripple, skeleton of 205

Cyst, dentigerous 61

Dilation of heart 343

Dislocation of semilunar bone 208

Dystocia following ventral suspension 181

Elephantiasis 60

Eye, tumor 144

Eyelid, epithelioma 144

Flat foot, traumatic, cured 253

Fracture of acetabulum 195

Intestine, foreign body in 63

Kidney, tumor 145

Malignancy, superficial, faulty treatment 255

Mastoiditis and cerebro-spinal meningitis 195

Meningitis, streptococcic 282

Neoplasm, intracerebral 103

Osteoarthritis : . . 60

Pelvis, fracture 208

Pin, transit of 278

Quintuplets 207

Stomach, ulcer 149

Stomach, ulceration and perforation 96

Streptococcic meningitis 299

Syphilitic myositis 60

Tetanus, postoperative 127

Tremor 97

Tuberculous peritonitis 282

Typhoid fever 206

Castelli, Enrico 59, 145, 146

Catalogue, Surgeon General’s Office 280, 281

Cautery in uterine cancer 132

Cavernous sinus thrombosis 204

Census Bureau 74

Centennial of Society 148

Central Citizens’ Association 206

Chamberlain, F. T 203

Chappell, J. W. 13, 130, 272, 344, 355

Chattanooga Medical Company, suit of 292

Chipman, C. N 127, 130

Christmas, W. W 143

Chronic headache 363

Citizens’ Welfare Committee, National Guard 362

Clark, Taliaferro 63

Claytor, T. A 12

Cobey, H. P 241

Collins, E. J 158

Columbia Optical Co 206

Committees :

American Red Cross 145, 148, 159, 288, 314, 369

Cancer 288, 314, 370

Censors 143, 149, 150

Centennial 280, 288, 314, 370

Control of contagious diseases 144, 369

Executive 59, 62, 63, 143, 147, 148, 149, 202, 206, 208, 278,

281, 283, 360, 361, 363

First Aid 158, 288, 314, 369

Historical 64, 143, 148, 358, 362

INDEX

V

Committees, continued :

Meeting Place of Society 143, 144, 149, 159, 20G, 288, 314, 3G9

Memorial 58, GO, G2, 141, 142, 144, 148, 149, 204,

288, 314, 357. 358, 3G1, 3G9

National Legislative 159, 288, 314, 3G9

Preparedness 147, 283

Program 143, 147

Publication 62, 143, 148

Regulation for control of contagious diseases 159, 288, 314

Tuberculosis 360, 362, 370

Congestion at street crossings 147, 148

Congress, Pan American Scientific 60

Contagious diseases and Health Office 144

Cook, G. Wythe 62, 361

Copeland, E. P ' 258

Coroner, Deputy 183

Corrections in proof 143

Crane, A. B 227

Cullen, T. S 281

Custis, J. B. G 158

Dabney, Virginius 241

Davidson, E. Y 62, 293

Davis, C. L 131

Davis, W. T 104, 105

Deaths :

T. A. Ashby 360

B. M. Beall 158

F. B. Bishop 215, 282, 356

F. V. Brooks 360

E. J. Collins 158

J. B. G. Custis . 158

j. P. Dunnigan 60, 141

H. S. Dye 215, 275, 278

H. L. Eisner 158

J. D. Franzoni 214

B. F. Gibbs 158

N. D. Graham 357, 360, 362

G. M. Harding 216

A. L. Hunt 361

Henry Hurtt 158

H. L. E. Johnson 140, 142

E. F. King 360

R. L. Lynch 215, 278

E. P. Magruder 49

Thomas Miller 62, 141

J. A. Mudd 158

O. M. Muncaster 216

W. L. Rodman 205

G. M. Sternberg 81, 143, 146

C. G. Stone 58, 60

Allen Walker. 157, 203, 204

E. C. C. Winter 215, 278

F. J. Woodman 360

Delirium. &c., management of 208

Dental diagnosis 223

Dental instruments, sterilization of 72

Diabetes, Allen treatment 281

Dillenback, W. J 203

VI

INDEX

District of Columbia employees, compensation 148

Dollman, C. M 60

Donnally, H. H 148, 261

Drugs, narcotic 59

Dues 143

Dufour, C. R 104

Dugan, C. L 203

Dunnigan, J, P 60, 205

Dye, H. S 215

Earle, S. T 281

Editorial 64, 150, 209, 283, 309, 364

Eliot, Llewellin 35, 247, 279

Eisner, H. L. 158

Embryology 216

Fauntleroy, A, M 59, 147

Penning, Fred 63, 106, 117, 118, 278

Ferrell, J. A 282, 361

Fischer, M. B 280

Focal infection 236

Foley, T. M 203, 282, 303, 308

Fowler, H. A 273, 278, 279

Fractures of long bones, records of 200

Frankland, W. A 14, 138, 148

Franzoni, C. W 62, 148

Franzoni, J. D 214

Fraternitas medicorum 69, 156

Fremont-Smith, F 361, 362

Futcher, T. B 281

Gannon, L. A 275

Garrison, F. H 30

Gavel 205

Gearhart, C. M 223

Gibbs, B. F 158

Gleeson, J. K. P 145

Glushak, Leopold 14

Goiter and x-ray 203

Goiter and mouth infection C 230

Gorgas, W. C 59, 60

Graham, N. D 357, 360, 362

Grayson, C. T 59, 147

Grippe, so-called 354

Groover. T. A 104, 105, 335

Gude, W. F 277

Guerra, A. L 59, 147

Gwynn, W. C 118, 126

Hagner, Frank 241

Hahn, Milton 361, 362

Harding, H. T 216

Hawley, C. A 24

Hayes, H. L 147, 203

Hazen, H. H 60, 255, 258

Health office 124,202

Heart, Dilation of 343

Heitmuller, G. H 148

INDEX Vll

Henneberger, J. B 59, 147

Henning, Carl 204, 241, 246

Herbulis, A. O. 204

Hickling, D. P 116, 148, 336, 342

High, D. L 203

Hodge, E. R 33

Hoff, J. V. R 94, 146

Holden, R. T 62

Hooe, A. B 149

Hooe, R. A 105, 208, 335

Howard, D. C 361, 362 «

Hrdlicka, Ales 204, 281

Hunt, A. L 14, 62, 361, 362

Hunter, O. B 203,301

Hunter, W. D 59, 147

Huntington, W. H 195, 198, 355

Hurtt, Henry 158

Indicanuria 254

Infant mortality, symposium 258

Infant mortality, post natal causes 258

Institutional mortality among infants 261

Infant welfare 265

Insane patients; responsibility of physician 106

Insurance death certificates 206

Irvine, R. L 361, 362

Jack, W. A * 48, 60, 61, 258, 335

Johnson, L. B. T 62, 198

Johnson, Paul B 241, 272, 279

Jones, L. T 60

Kearney, H. W 361

Kelley, J. T 206

Kemp, T. J 208, 361, 363

Kempf, H. D. C 59, 147

Kehr, H. H 131

King, E. F 360

Kober, G. M .33, 57, 61, 81, 117, 146, 272, 342

Lamb, D. S 15, 61, 62, 96, 148, 204, 205, 206, 207

Lamb, I. H 279

Lamb, R. S 105, 144

Lawson, H, W 273

Leech, D. 0 92, 146, 271

Leech, Frank 1, 14, 62, 63, 130

Lowe, T. F 353

Lynch, R. L 215

Lyon, M. W 302

Lyster, T. C. 147, 203

Macatee, H. C 14, 62, 91, 140, 146

Maddox, A. S 59, i46

Magruder, E. P 49

Malignancy, superficial 255

Mallory, W. J 149

INDEX

viii

Malsbury, G. E 278

Management of confusional states 345

Mankin, J. W 59, 147

Marbury, W. B 59, 147

Martin, T. C 63

Mason, W. M 355

Masterson, W. L. ^ 13, 130, 279

Medical Association District Columbia 148

Members, election of 59, 146, 203, 281

Members, list of 167

- Miles, M. A 94, 146

Miller, Thomas 62

Mistretta, F. H 59

Moran, J. F 182, 272

Morgan, E. L 279, 356

Morrison, E. L 59

Mouth infection 230

Mudd, J. A 158

Muncaster, O. M : 216

Murphy, J. A 363

Narcotic law 145, 208, 360

National Board First Aid Standardization 159

National Board Medical Examiners 291, 315

Navy Department 71, 75, 372

Neff, Wallace 203

Neuman, Lester 302

New Jersey Medical Society, Anniversary 292

Nichols, J. B 60, 277, 278

Noble, R. E 147, 203

O’Donnell, W. F 203

Office building 204

Officers, election of 62

Opticians and oculists 206

Oral sepsis 227

Pagan, A. E

Patterson, R. U

Personal notes

Pfender, C. A

Placenta, hemorrhage from

Pleadwell, F. L

Police surgeons

Poliomyelitis on Crow Reservation . .

Post mortem examinations

Pott’s disease in adults

Preparedness parade

Prizes

Proceedings of the Medical Society

Proctitis

Professional services, gratuitous

Prohibition bill

Prostatic obstruction

Psychoanalysis and psychiatry

Public Health Service

183

60

79, 165, 221, 296, 320, 380

41, 49, 246, 257, 323, 336

202

147, 203

145, 148

363

70, 156

303

273, 283

69, 155, 159, 214

58, 142, 202, 277, 360

63

360

149, 202, 206

208

336

73, 75, 157, 214, 289, 317, 371, 373

Publications of physicians of District Columbia. ,76, 162, 219, 294, 319, 377

INDEX

IX

Randolph, B. M 130, 205, 206, 282, 299, 302, 344, 354, 356

Reasoner, M. A, 150

Rectal examinations. Importance of 281

Rectum, foreign bodies in 35

Reede, E. H 105, 230

Reeves, W. P 139

Resignations from - membership 145, 282, 362

Reviews 70, 75, 160, 161, 216, 375

Richardson, C. W 361

Rodman, W. L 147, 205

Roentgenism and Roentgenization 323

Roentgenologist as consultant 41

Rogers, J. D 48, 62, 130, 132, 140

Roy, P. S 62, 104, 271, 343, 344

Rule, A. J 203

Saunders, C. H 59, 147

Scarlet fever, report of cases 5

Schaeffer, E. M 31, 355

School hygiene 118

Schroeder, E. C 93, 146

Seibert, E. G 204

Selby, J. H 47, 61, 104, 282, 308

Selinger, M. A 204, 281

Serbia, experience in 98

Shands, A. R 208

Simpson, C. A 47, 61, 203, 257, 258

Skin diseases 60

Smith, D. G 143

Smith, D. 0 204, 281

Smith, Edwin 59

Snyder, A. A 193, 206, 254

Societies :

Alienists and neurologists *. 157

American Association Medical Jurisprudence 156

American Medical Association 62, 198, 203, 361

American Society for control of cancer 214

Association American Medical Colleges 145

Association for Prevention of Tuberculosis 146

Association for study of internal secretions 372

Baltimore County Medical Society 147, 202, 205, 206, 277, 278, 281

Casualty Hospital Medical Society 365

Clinical Society 65, 151, 210, 284, 310, 365

Clinico-pathological Society 65, 151, 210, 284, 310, 365

Congress American Physicians and Surgeons 280

Dental Society 207, 223,280

Emergency Hospital Club 65, 151, 210, 284, 310, 365

Freedmen’s Hospital Medical Society 65, 151, 210, 284, 310, 365

Galen Society 66, 152, 210, 284, 310, 365

Georgetown Clinical Society 66, 152, 210, 284, 310, 366

Georgetown University Medical Society 66, 152, 210, 284, 310, 366

George Washington University Medical Society 66, 152, 210, 285, 311, 366

Hippocrates Society 66, 152, 211, 285, 311, 366

Instructing Visiting Nurses 159

Medical Association, D. C 358, 362

Medical History Club 66, 152, 211, 285, 311, 366

Medical and Surgical Society 67, 153, 211, 285, 311, 366

X

INDEX

Societies, continued : '

National Social Unit Organization 362

Society of Medical Jurisprudence 67, 153, 211, 285, 311, 366

Society Mental Hygiene 67, 153, 211, 286, 312, 367

Society Ophthalmologists and Otologists 67, 153, 211, 285, 311, 367

Society Social Hygiene 67, 153, 212, 286, 312, 367

Therapeutic Society 68, 154, 212, 286, 312, 367

Walter Reed Medical Society 68, 154, 212, 286, 312, 368

Washington Medical and Surgical Society. .. .68, 154, 212, 286, 312, 368

Washington Obstetrical and Gynecological Society 68, 154, 212,

287, 313, 368

Washington Psychoanalytic Society 154, 212, 287, 313, 368

Washington Society Mental and Nervous Diseases 68, 154, 213,

287, 313, 368

Washington Surgical Society 154, 213, 287, '313, 368

Women’s Medical Society 68, 155, 213, 287, 313, 368

Some observations and conclusions of the Deputy Coroner 183

Sparks, W. C 59

Starmont sanatorium 288, 314, 370

Sternberg, G. M 58

Stone, C. G 58, 60, 62

Sullivan, R. Y 138

Surgical instruments of W. P. Carr 280

Suter, Henderson 143

Syme, W. H 363

Symposium on Dental Diagnosis and Oral Sepsis 223

Tayler-Jones, Louise 98

Tetanus Fourth July 291

Thomas, J. D 145, 150

Thompson, H. C 241

Thompson, J. L 149, 204 , 363

Thompson, M. F 63

Thomson, L. B ^ 147, 278, 280

Thrombosis of cavernous sinus 241

Thyroid and thymus, histology 203

Treasurer 62, 63, 142, 148, 203, 278, 360

Tuberculosis, blood test in 145

Tuberculosis, treatment of 160

Tuberculosis of spine 282

Turton, W. E 282

Ufford, W. S 93, 146

Vaccination 59

Van Swearingen, Walter 49

Vaughan, G. T 200

Verbrycke, J. R 241, 254, 278

Wagner, W. F 145

Walker, Allen 157, 203

Wall, J. S 12, 204 265, 273

Wall, M. C 282

Wall M. E 282

Wallace, C. R 282

Walsh, F. C 145

INDEX

XI

Warner, J. W 361,

Washington Post

Wellington, J. R

Wetmore, W. 0 204,

Whaley, A. M 59,

What constitutes a dental diagnosis

White, C. S 139,

White, W. A

Wiley, H. W 124,

Williams, A. W ...59,

Williams, J. W

Williams, T. A 14, 48, 49, 59, 61, 69, 97, 103, 105, 117,

192, 208, 302, 308, 341, 345, 353,

Willson, Prentiss 182, 202,

Winter, E. C. C

Wolfe, J. T

Woodward, W. C 13, 126,

Zinkham, A. M 147,

362

204

308

281

147

223

362

115

126

147

202

363

273

215

130

271

203

* ,M ‘

•i

WASHINGTON MEDICAL ANNALS

PRESIDENTIAL ADDRESS, 1915.*

By Frank Leech, M. D.,

Washington, D. C.

Ladies and Gentlemen of the Medical Society of the District of Columbia:

When I assumed charge of this Society on January first it was with a feeling that I should do all in my, power to make the year a successful one. As I look back and consider the work done by all for the good of the Society, and the results that have accrued, I feel more than satisfied.

A brief review of what has been accomplished will, I believe, not be amiss. The Executive Committee is to be congratulated on the excellent character of its reports to the Society, and de- serves much praise for its arduous labors, which the great mass of the members fail to realize amount to anything more than per- functory duty. A legislative sub-committee of the Executive Committee has been appointed and is being most watchful of all matters that concern the Society as a whole, especially as regards Congressional legislation. Certain things have arisen in the Ex- ecutive Committee which make me feel that our Society does not hold the place it should in the minds of our legislators in Congress or the Commissioners of the District of Columbia. On several occasions our representatives have been refused hearings on affairs which directly concern the welfare of our members and our interest in medical legislation. If we are to be ignored in this way what chance have we to accomplish anything, as a body, in the making of laws concerning medicine? I feel that each member, individually, must, whenever the opportunity arises, impress on his or her friends, who hold legislative or official posi- tions, the fact that our organization is a representative body and one which should receive consideration.

The Committee of Censors has done its work well, and the Society has thus been saved any acrimonious debate in regard to the admission of new members.

*Delivered before the Medical Society of the District of Columbia, Dec. 15, 1915.

I

2

WASHINGTON MEDICAL ANNALS.

The Committee on Publication has continued to do fine work, which a review of the Medical Ann.^ls for the year will show. The question as to whether our Society should undertake jour- nalism on a larger scale has frequently been brought forward. I am personally of the belief that there is no field for anything further in this line than our present publication. To enter this field would require the expenditure of a large amount of money; It would be a constant care and worry to those who had it in charge, and, in a body whose members are engaged solely in_ the practice of medicine, who would there be to give it undivided attention? And that is what it would need. I feel sure that it would be an undertaking which would not be of any particular advantage to our Society, and would not prove successful from a financial standpoint. Furthermore, the national journals, such as the Journal of the American Medical Association, supply all needs. I have heard it said that we did not even need the present publication, but I believe that to be a mistake. There are a num- ber of our members who are frequently unable to be present at the regular meetings, who get a great amount of good from a perusal of its pages, and are able in this way to know what is being done by the Society, and also to gain much valuable in- formation from the articles on medical subjects which our journal contains.

The Committee on Program is particularly to be congratulated for the excellent class of papers which have been presented dur- ing the year. With, possibly, one exception, they have been of the first order, and I am sure that no one could say that it has been green fruit. The papers presented by our out-of-town guests have been by men who are at the top of their specialties, although, again I will say, with one exception. One evening was devoted to clinical cases, and, from my point of view, was a great success. I would suggest that more meetings of the same character be arranged for the coming year. It has been sug- gested to me that it would also be advisable to have papers from time to time which would review the principal specialties in medicine and surgery. This was carried out in this Society a few years ago and was much appreciated. I would also submit this to the Committee on Program for its consideration.

Under Article IV (Meetings), Section 4, of the Constitution and By-Laws, it is provided that social sessions may be held. During the past year one smoker was given, at a cost to each member attending of $1.50. It seems to me that a committee might be appointed to consider the advisability of providing so- cial entertainments of a less elaborate nature, at regular intervals during the year. Several societies, with a much smaller mem- bership than ours, have carried this on successfully for a number of years. Our dues are small, and by the addition of, say, one

WASHINGTON MEDICAL ANNALS.

3

dollar per year, at least four smokers could be given. I believe this would add a pleasant feature to our already successful So- ciety. “All work and no play makes Jack xi dull boy.”

During the year the statement was made to me that our Society was not anxious to extend any courtesies to members of the Army, Navy and Public Health Services stationed in and about Washington. In September I was selected by the Committee of Arrangements for the annual meeting of the Association of Mili- tary Surgeons of the United States, held in this city, to deliver the address of welcome on behalf ' of the Medical Society of the District of Columbia. In the course of my remarks I took occasion to make the following statement:

“As President of the Medical Society of the District of Co- lumbia, which comprises a membership of over five hundred phy- sicians and surgeons, engaged solely in the practice of medicine, I wish to state that, except in a very few individual instances, there is absolutely no foundation in fact for this opinion. Every medical man residing in the District of Columbia, if following the lines of regular medicine, is entitled to apply for either active or associate membership in our Society. At present every medical officer of the United States Army stationed in or near the Dis- trict of Columbia is sent a notice of our regular meetings, and, I am glad to say that a number of them are frequent attendants, reading papers and taking part in our discussions. As soon as our sessions are resumed in October I propose, in addition, to have all of the officers of the Medical Corps of the Navy and of the Public Health and Marine Hospital Services, stationed here, notified regularly of our meetings, and shall expect to have them present whenever there are papers of interest to them on the program. I beg you to forget any trivial incidents which may have arisen in the past, and join with us in the future in our fight, and yours, for the prevention and cure of disease, both from a civil and military viewpoint. It is our aim to establish the best of relations between all the Services and our Society, as we feel that it will be reciprocally beneficial.”

Since our sessions were resumed in October a regular notice has been sent to these gentlemen, and, I am glad to say that a number of them are with us at each meeting. Further, a num- ber have applied for membership and been admitted, including the very distinguished Surgeon General, William C. Gorgas. I feel that it should be our aim always to be on the best of terms with these gentlemen, as a glance at the history of these Services will show that some of the best work in medicine and surgery has been done by men from their ranks. We can ill afford to do anything which might mar our now pleasant relations with them.

Your Special Committees have had little to do. I feel, how- ever, that we are under great obligations to the Chairman of the

4

WASHINGTON MEDICAL ANNALS.

Committee on Public Instruction for his very excellent report of the meeting of the Committee on Medical Education, Legislation and Public Health, of -the American Medical Association, held in Chicago in February last.

In \iew of the fact that these committees, except the Plistorical Committee, have no duties, I would suggest that they be discon- tinued, and that when matters arise which need special attention, committees be then appointed.

I feel that I should call attention to the hall in which we meet. It has for 'a number of years been thought that we should erect a building, with suitable quarters for scientific and social pur- poses. On several occasions subscriptions have been called for, but, for lack of financial support, the project has fallen through. It seems that this would be the ideal solution; but I am afraid that we should again meet with the same results as in former years, if it were tried. When we consider the poor acoustics, lighting, heating and seating arrangements of our present quar- ters, I feel that something should be done to improve conditions. The lack of space for lantern and moving picture machines is a great drawback, as those who were present at our last meeting can testify. I would suggest that a special committee be appointed in the near future, to consider this matter from every viewpoint, and report their findings at as early a date as possible.

During the year we have lost by death the following members : Drs. Ralph Walsh, Louis M. Babendreier, Louis Kolipinski, Ernest P. Magruder, George N. Perry, L. L. Friedrich, Warwick Evans, Charles G. Stone, John P. Dunnigan and Thomas Miller, active members, and General George M. Sternberg, honorary member.

There have been seventeen new active, five associate and one honorary member added to our rolls. Six members were dropped for non-payment of dues. Our total membership to date is 556 active, 27 associate and 7 honorary members, making a total of 590.

Our Society is one of which every member should be proud. Where is there another medical society which meets weekly, in which the interest is maintained as it is with ours ? The average attendance at each meeting during the year has been in excess of one hundred. I esteem it a privilege to have had the honor of presiding over this body for the past year, and I wish to express my sincere thanks to one and all for the support that has been given me during the entire year. I wish to extend to our Presi- dent-elect my best wishes for as pleasant and successful a regime as the one which I am about to relinquish.

As my preliminary remarks have been short, I wish to pre- sent for your consideration a paper on the subject of Scarlet Fever.

WASHINGTON MEDICAL ANNALS.

5

Scarlet Fever, with a Report oe 220 Cases Coming Under My Care, During the Year Ending September 1, lOR).

Scarlet Fever is an acute, specific, infectious and highly con- tagious disease. It is self-limited and one attack usually protects the individual throughout life. The period of incubation varies from one to seven days, although occasionally we find the time as long as eleven days. Invasion lasts from twelve to twenty-four hours. Eruption covers a period of from four to six days. Desquamation lasts from three to seven weeks. It is character- ized by fever, rapid pulse, sore throat, an erythematous rash, and a marked tendency to nephritis. It varies much in intensity. Attacks may be so mild as to go unrecognized, and again so severe as to prove fatal in a few hours'

The activity of the germ of infection varies in different years and in different localities. Some epidemics are characterized by their mildness and others by their severity. Dr. H. H. Don- nally, in a recent paper, read before this Society, on Morbidity and Mortality in Scarlet Fever, has shown this conclusively.

Etiology. — It is essentially a disease of childhood, although it does occur in a small number of cases in those of mature years, one of my cases being a man of over sixty-five years. I had no cases under one year of age. Over 40 per cent, of my cases were between the ages of five and ten years. It is endemic in all

Age.— 220 Cases.

large cities and frequently epidemic in the fall and winter months, although in my series of cases February, March, April, May and June gave the largest number.

Until recently it was thought that the erupted and desquamat- ing skin was the principal carrier for the transmission of the contagium. Even now the majority of physicians are unwilling to believe otherwise. They fail to consider that secretions from the nose, throat and ears contaminate articles that may be put

6

WASHINGTON MEDICAG ANNALS.

away indefinitely. In New York City a thirty-day quarantine is all that is required, if the secretions from the nose, threat and ears are entirely cleared up. The authorities absolutely ignore desquamation after that period and their record of secondary infections is less than when a longer quarantine was insisted on. I believe that it is now a well established fact that the skin does not spread the contagium except as it becomes contaminated by the secretions from the nose, throat and ears. The exciting cause of the disease has not as yet been definitely established. A great many observers believe that the streptococcus plays a distinct role, but the majority are agreed that this is secondary, the true germ not having as yet been discovered.

Number of Cases per Month.— 220 Cases From September i, 1914, TO September i, 1915.

There is no doubt in the minds of almost all that the secretions from die nose, throat and ears cause the spread of the disease. I believe that the secretions from the ears, where an otitis has existed, and also those from suppurating glands, are an import- ant factor in the transmission of the contagium. •

The streptococcus plays an important role in all complications. The disease is highly contagious and spreads rapidly, though not so fast as measles, or so widely. Infection is usually acquired through inhalation ; sometimes through swallowing or wounds.

Several epidemics have been traced to milk from diseased cows. It is a question whether these cases were true scarlatina, or a scarlatiniform eruption, with septic sore throat, due to the strep- tococcus or staphylococcus.

Symptoms. — The invasion is sudden. Initial vomiting or nau-

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sea, fever (in most cases an initial temperature of not over 102 degrees; 79 per cent, of my cases), sore throat, with pain on swallowing, swelling and tenderness of the glands at the angles of the jaw, and rapid pulse. On the second day, sometimes sooner, the characteristic rash appears, first on the chest and neck, then spreading rapidly over the entire body. The rash appears as a multitude of minute red points, set in a diffusely

Temperature at Onset. — 215 Cases.

hyperemic and slightly swollen skin. On pressure over the hyperemic skin an anaemia is produced, which, when relieved, begins at once to show the petechial spots as the hyperemia re- turns. Rumpel, in 1909, described a test, which he claimed was diagnostic in nearly every case. The test is made as follows : A passive hyperemia is caused by a broad rubber band placed around the arm, just above the elbow joint, not sufficiently tight to obstruct the arterial flow. This band is loosened in about fifteen minutes, and the skin on the inner surface of the elbow joint, on being stretched until it appears anaemic, will show petechiae, if the reaction is positive.

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WASHINGTON MEDICAT ANNAES.

Scarlet fever has usually been divided into three classes : mild, anginose and malignant. After seeing a great many cases of the disease, I have come to the conclusion that it would be better to divide it into four classes, viz : mild, anginose, severe anginose and malignant.

My classification is based on' the fact that there is a marked difference in the anginose type of the disease. Many of this class of cases start out with a severe sore throat and a slight glandular involvement in the neck, which, in a few days, com- pletely subside, with a subsidence of all other symptoms. The severe type starts much the same way; but, instead of a sub- sidence in a few days, the glandular conditions proceed to sup- puration, the throat condition remains severe and the kidneys are apt to become involved.

Diagnosis. — The diagnosis of well defined scarlet fever is prob- ably as easy to make as any of the so-called eruptive fevers. The initial nausea or vomiting, sore throat, fever of a mild or severe type, and the appearance of a pin point eruption on a hyperemic and swollen skin, can not be mistaken for anything else. On the other hand, the mild cases, where some of the cardinal symptoms fail to appear, are the ones which cause trouble. I am fully con- vinced that no case should ever be diagnosed scarlet fever, unless well defined throat symptoms are present. Many conditions will produce a scarlatiniform eruption, and, in the presence of an epi- demic, will easily be mistaken for scarlet fever. Many cases will be seen where the rash is of an indefinite nature and the throat symptoms are overlooked. These cases are frequently not diag- nosed until desquamation is established. Right here, I wish to make a plea for a routine examination of the throat of every child under the age of twelve years that comes under our care. It is surprising how frequently we find a diseased condition of the tonsils when we least expect it. Such examination often saves much embarrassment later.

The so-called strawberry tongue is by no means a constant symptom. I should say that we see more cases without it than with it. Kerley states that it is of little value, and that he has seen many other illnesses that have shown it. From my expe- rience I can quite agree with him.

While one attack, as I have previously stated, usually protects through life, still we do occasionally see a second attack in the same individual. One of the fatal cases in my series was a well authenticated second attack. I have within the past month, seen a case in which there seemed to be no doubt of its being a second attack. The blood shows a leucocytosis, ranging from 10,000 to 40,000. So-called inclusion bodies were first demonstrated by Dohle, in the polymorphonuclear leucocytes, but are not to be relied on, as they are found in numerous other septic conditions.

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Until a definite organism is found we will continue to have difficulty in making a definite early diagnosis, in many cases.

Complications. — The most interesting and dangerous features of scarlet fever are its complications and sequelae. In the 220 cases reported by me this evening, 66 had complications of a more or less serious nature, three ending fatally. These do not include the simple cases of albuminuria in the toxic stage, of which there were 31, making a total of 97, or 44.1 per cent, of complications.

The most important complications and sequelae are nephritis and inflammations of the serous membranes. The albuminuria found in the toxic stage does not preclude the development of a true nephritis later. Albuminuria during the early stages is, as a rule, not serious, and the great majority of cases clear up within a few weeks. Those cases coming on during the third and fourth weeks are the ones that prove serious and usually cause a protracted convalescence. The onset in these cases may come on gradually; or suddenly (without oedema), and very pronounced symptoms, as convulsions, suppression of urine and high tem- perature. Septic nephritis, as a part of a general pyaemia, some- times occurs. Oedema, without any kidney lesions, is sometimes found, the result of an impoverishment of the blood. Chronic nephritis rarely develops out of the acute condition ; but, for a long time, a tendency is left for such development, under favor- able conditions.

In my cases there were only 31 instances of simple albuminuria, and only 2 of post-scarlatinal nephritis, both of which recovered. Otitis media and mastoiditis are responsible for much of the deafness in after years. I had 13 cases of otitis media and 3 of mastoiditis, all of which recovered. Arthritis is a not uncom- mon complication; 7 of my series showed this condition. Ar- thritis is to be differentiated from simple joint pains, which are very common