And Mr. Thomas Smith tells me he has performed Lithotomy on forty-three children under ten years of age, and of these seven had scarlatina. In CASE 1:-the eruption appeared on the day after the operation, and there were rigors, and a temperature of 104°6. CASE 2-eruption on second day, followed by general desquamation. CASE 3-eruption on second day, death on thirty-first day from albuminuria, and anasarca. CASE 4:-eruption very soon after operation, followed by desquamation. CASE 5-eruption on third day, severe albuminuria. CASE 6:-slight eruption very soon after operation, followed on thirteenth day by general desquamation, and by severe albuminuria. CASE 7:-eruption on second day, beginning at the wound, and spreading over trunk and limbs. This proportion of seven in forty-three cases is very high, yet the real proportion was even larger than these figures represent, for among the thirty-six children that escaped there were, as Mr. Smith remarks, no doubt some who, having already had the disease, were in great part if not completely protected against a second attack. 6 It has been questioned whether the affection is true scarlet fever. In many instances, however, it certainly is, for its features are well marked and characteristic. Of others, which might be very doubtful if seen as isolated cases, Dr. Gee, whose authority will be recognised, and who has closely studied the subject, says in his article in Reynold's System of Medicine,' 'that the disease really is scarlet fever seems to be proved by the following observations: first, it occurs in epidemics (of scarlatina): secondly, that in a given epidemic a severe case occasionally relieves the monotonous recurrence of the very mild forms: thirdly, that a precisely similar scarlatinilla attacks, in the same epidemic, patients who have not been subjected to operation, and who have no open sore: and lastly, by way of a veritable experimentum crucis, that however freely these patients are exposed to ordinary scarlet fever afterwards, they do not contract that disease.' The cases related above illustrate many of the points relied on by Dr. Gee. In not a few the attack was severe and followed by albuminuria: the majority were seen during the prevalence of scarlet fever in town, and almost all, if not every one, as soon as the illness appeared, were transferred to a ward used for the treatment of scarlet fever, and which generally contained recent cases; yet I believe none of the patients suffered from any further contagion. In expressing my own opinion that the disease is scarlet fever I am conscious of being strongly biassed by the belief of those in whose sound judgment I place complete reliance; but I think an independent examination of the facts could scarcely lead to any other conclusion. 6 Sir James Paget has mentioned two views as to the explanation of this connection between operations and the appearance of scarlet fever; and the evidence derived from the cases related above goes to prove that both are correct, though of course in different cases. That a peculiar liability to contagion is induced by an operation, and that the poison produces its specific effects in much less than the usual period of incubation' seems clear from such cases as the following. A boy (case 4 in the table) was admitted on January 31. On February 14 he underwent an operation on a deformed hand, and on the 16th the rash appeared. No scarlet fever had occurred, so far as his parents knew, near his residence for some time before he came into the Hospital, and, indeed, he had been in for a period that was more than long enough to complete the incubation of the disease, without showing any symptom of illness. But on the same day (Feb. 14) on which his operation was performed a boy, who was admitted into the ward with bronchitis, was found three hours later with the eruption of scarlet fever. Again, a child was seized with scarlet fever the day after an operation had been performed on her mouth. Her mother knew nothing of any source of previous infection, but the surgeon who performed the operation was at the time nursing his own children with the disease. Now it seems nearly certain that the first child derived the fever, either just before or just after his operation, from the patient in whom the rash was just coming out and that the second was infected at the very time from the clothes of the surgeon who performed the operation. On the other hand, in several instances very careful search has E E failed to discover any source of recent infection; and in such the only probable explanation seemed to be that, as Sir James Paget suggests, the patients had previously imbibed the poison, but would not have manifested its effects so soon, if at all, unless their health had been exhausted or disturbed.' The interval between the operation and the appearance of the rash has been quite as short as that recorded in the text. In several the eruption has come out on the next day, and the period (from twelve to thirty-six hours, Gee) by which vomiting and high temperature commonly precede the eruption has been comparatively seldom distinctly marked. To anticipate the possible objection that fever may have been already on the point of breaking-out when the operation was performed, I may state that this source of fallacy has been carefully borne in mind: it is a standing rule to examine the temperature, and if it is found in any degree above the natural standard the operation is invariably postponed. Scarlet fever apparently stands alone among the eruptive fevers in its proneness to attack patients immediately after operations; for although outbreaks of measles have been noticed under similar circumstances, their occurrence has been so rare that they may well be regarded as mere coincidences; and the same may be said of chicken pox. Great help may be gained in the study of this subject from a very able and valuable paper (in the 12th volume of the Obstetrical Society's Transactions') by Dr. Braxton Hicks, in which he discusses the occurrence of scarlet fever immediately after parturition, with the purpose of investigating its relation to puerperal fever. In this essay, and the cases that accompany it, Dr. Hicks shows: I. That patients are frequently attacked with scarlet fever after labour. II. That the disorder appears very speedily—generally within four days. III. That the usual premonitory symptoms are often absent. IV. That contagion is in some cases conveyed at the time of labour, in others that it has, so far as can be ascertained, occurred some time before. V. That in many instances the disorder deviates widely from the normal type. INDEX. ABD BDOMEN, condition of, in strangu- AB lated hernia, 112 Acute disease, operations during, 20 Adhesions formed in joints after long Age, its influence on operations, 5 Amputations for injury and disease com- abdominal aorta, 238; condition of Ankle, stiffened by involuntary mus- Ankylosis treated by bone-setters, 85 Antagonism in disease, 389 Antiseptic treatment, Mr. Lister's, 76 Bandages, tight, over joints often mis- Barwell, Mr., on gonorrheal rheuma- Bedrooms, water-closets in, 67 Birkett, Mr., on hernia, 123 Blizard, Mr., fatal operation by, 65 loid disease, 29; chiefly affected in Breast, operations on, during lactation 31 Brinton, Dr., his paper on disease of the BRO Brodie, Sir B., on hysterical joints, 196; Budd, Dr., on malignant pustule, 266 Bursæ, imitated by residual abscess, 319 CALAMITIES of surgery, 51; not always accidents, 55; rules for Callender, Mr., his statistics of amputa- Cancer, mimicry of, 181, 183, 241; in Cancerous persons, operations on, 13 what this means, 252; incisions Carbuncular inflammation of the lip, Catheterism, need for care in, 43, 57; CON Cautery, actual, for hæmorrhoids, 71 Chloride of zinc for wounds, 76 under, 51; its use in neuromimesis, Chorea, diagnosis of, from joint disease, 212. Chronic pyæmia, relations of, to acute, 155, 164; chiefly affecting the bones, Cold applications mischievous in nervous Cold-blooded persons, operations on, 18; recover from injury slowly, 395 rated, 27; too profuse action after, |