points out that they are often present from twelve hours to five days before the cutaneous eruption, and that their presence may enable us to isolate our cases earlier than formerly and aid us in distinguishing measles from other skin eruptions.

Another peculiarity of measles infection, according to the experience of the writer, is that the temperature curve in the preeruption stage may show a remission to normal or subnormal at irregular periods on the febrile days preceding the eruption, as shown in the chart. The knowledge of these points is important as regards the early recognition of the disease and the isolation of the patient. (Trans. of the Amer. Pad. Soc., June, 1898.)

Prognosis. Uncomplicated cases end in recovery. In the form known as hæmorrhagic, or black, measles death often results from an overwhelming

toxæmia. In adults measles is usually of a severe type; in infants and delicate children it is often fatal.

Differential Diagnosis. In rubella the rash appears earlier, it is evenly distributed and not blotchy, and all the symptoms are mild. Scarlet fever has a sudden onset and no preeruptive remission. The throat is sore and the rash is scarlet; the eyes are bright.

Prevention. One attack usually confers immunity. It is so highly contagious that it is extremely difficult to keep it out of children's hospitals and wards. Plastic operations should not be attempted on children who have not had measles and who have recently been exposed, on account of serious interference with the healing process in the event of their being attacked with measles.

Treatment. We have no specific medication for measles. The patient is given a warm bath and an enema or laxative, and kept in bed, isolated, for a week. The room should be well ventilated and not heated above 68° F. The patient should have a fever diet and cooling drinks. Very high fever is managed by hydrotherapeutics (see General Therapeutics). The nasopharynx is to be kept moist and clean by dropping salt water from a spoon or pipette into each nostril four times a day. This will also ameliorate the throat cough. A warm bath may be given daily, and the eyes may be frequently washed with boric acid solution. In extreme restlessness a single dose of antipyrine or phenacetine may be given at night. When the cough is very annoying, from 5 to 10 drops of paregoric may be given occasionally.

Complications and Clinical Varieties.-Incessant hacking cough; croupy cough; aphonia and stenosis of the larynx; active angina; follicular tonsillitis; visible diphtheria and croup; nasal diphtheria early or late (often overlooked); late membranous croup; pertussis; bronchopneumonia and lobar pneumonia or tuberculosis of the lung; severe conjunctivitis; stomatitis and gastroenteritis; gangrene in the mouth; gangrene elsewhere; otitis media.

If there is the slightest indication of a membrane in the throat or nose, or progressive hoarseness with stenosis, full and repeated doses of diphtheria antitoxine should be given (see Diphtheria and Croup). When a nasal discharge persists after the measly eruption has disappeared, and particularly if the discharge is bloody or offensive, a culture should be made and search. undertaken for the Klebs-Loeffler bacillus. If hoarseness and aphonia develop, with a nasal discharge, after measles, antitoxine is indicated at once, even if the throat is clean.

The various other complications of measles are discussed under the various headings. In rare instances hoarseness and a mild degree of stridulous breathing may persist for a long time following measles. This complication, which may be termed a chronic laryngitis, is not improved or cured by medication. In such a case the child should be sent to the country or to the seashore, away from a dust laden atmosphere. The administration of potassium iodide by the mouth or rectum, gr. 11 to 5 three times a day, is rational whenever syphilis is suspected as an underlying cause of such hoarseness.

RUBELLA; RÖTHELN; GERMAN MEASLES

This infection is seen in two types, one resembling mild measles and the other resembling mild scarlatina. The rash comes out in pinkish spots (maculo-papules) on the first or second day. It appears first on the face and spreads over the whole body. It persists from three to five days, and may be followed by a slightly perceptible desquamation. The temperature is seldom more than 100° or 102°. In the absence of a bacteriological test it cannot, except in theory, be distinguished from mild measles. It is contagious, and there is swelling of the posterior cervical glands. It occurs in epidemics, it is distinct from measles and scarlet fever, and it

may be confounded with measles, scarlatina, influenza, and erythema. multiforme. Complications and sequelæ are seldom observed.

The treatment is by isolation and rest in bed for a week, liquid diet, fresh air, and attention to the bowels.

VARICELLA (CHICKEN POX)

A papular eruption ushered in with slight fever and malaise and occasionally a temperature of 103°. The eruption becomes vesicular in a short time, and the vesicles are frequently surrounded by a narrow area, or circle, of hyperæmia. The vesicles may hold a clear or cloudy fluid and may become umbilicated. In drying up they form a crust which drops off without, as a rule, leaving a scar. The vesicles may appear in successive groups. The contagium of the disease has not as yet been isolated, and it is at times very difficult to discriminate between varicella and varioloid. Chickenpox is not rare in adults.

The symptoms are those of a mild infection, with general malaise and slight fever before the eruption. In discriminating between varioloid and varicella we should be guided by the following points: In varicella the eruption usually appears first upon the trunk, rarely on the forehead or face. The vesicles vary in size, break readily, and are superficial with a very slightly marked red areola. They develop in successive crops. All stages can be seen side by side. There is usually a history of exposure to varicella. The constitutional symptoms are mild. In variola there is a more sharply defined hyperæmic area surrounding the variola vesicle. In the early stage of its eruption the forming vesicle feels like "shot" underneath the skin. In smallpox the hands and feet usually show hard and circumscribed papules. Varicella and scarlet fever may occur together. In rare instances the skin becomes infected through a broken vesicle, or pock, and erysipelas or gangrene of a patch of tissue may result. Uncomplicated cases of chickenpox get well.

Treatment.-Direct quarantine in a well ventilated, sunny room, order soft diet, and open the bowels. The eruption in the mouth requires a mouth wash of chlorate of potassium (2 per cent solution). For varicella of the vulva we apply cold cream.

SCARLET FEVER

Introductory Remarks.-Scarlet fever is an infectious disease the specific poison of which, highly contagious and capable of reproducing itself, has not as yet been isolated. It probably enters the system through the nasopharynx and respiratory tract, and may be conveyed in all the ways in which contagious disease is distributed. The main factor in the causation of epidemics is personal intercourse. It is believed, but not proved, that domestic animals may contract scarlet fever transmissible to man. Milk epidemics and drinking water epidemics, as reported in literature, lack bacteriological proof. The common mode of infection is by direct or intermediate contact with a scarlatinous patient, and by contact with the secretions, excretions, and exhalations of the body, and by means of books, toys,

etc., soiled by patients having scarlet fever. The period at which scarlet fever is most contagious and the duration of capacity for infection are not definitely known. The susceptibility and immunity of individuals and families, and the period of incubation, are inconstant; the latter varies from a few hours to a few weeks. No age, sex, or race is exempt. Few cases, however, occur in adults. Ill ventilated and filthy localities are favorable for the propagation of scarlet fever. Most cases occur during the cold season of the year, when the closing of windows prevents proper renewal of air in the houses.

The severest forms are observed in children of a lymphatic diathesis whose nasopharynx is not normal (croupy children). On the other hand, scarlet fever complicated with diphtheria may run a comparatively safe course in children afflicted with adenoids and enlarged tonsils and generally of anæmic appearance. This would naturally lead to the inference that the contagion had various degrees of virulence, and that the blood offered more resistance to the infection in one case than in another. Regarding this important question we are still in the dark.

The mortality may be as low as 5 per cent in some epidemics, and as high as from 30 to 40 per cent in others. According to the reports of the New York State Board of Health, scarlet fever is most prevalent in the first four months of the year.

Infection ceases with the termination of desquamation and convalescence. The failure to establish the origin of sporadic cases is due to defective methods of investigation in the absence of positive knowledge as to the exact nature of the poison.

Scarlet fever is very prevalent and has a large mortality and many and dangerous sequela; thus the wisdom and necessity of preventive measures are self-evident. The poison of scarlet fever may be diluted and rendered innocuous by persistent ventilation and disinfection; this, together with isolation of the patient, limits the spread of infectious disease in a household, institution, or community. The fact that some contagious diseases are infective during the preeruptive stage is no argument against the necessity of taking active preventive measures for the three or four weeks following, during which time infection still continues. At least three weeks should elapse from the date of exposure before freedom from danger of an attack is secured.

THE PERIOD OF INCUBATION is supposed to vary from one to seven days. A child exposed to scarlet fever contagium and remaining free for two weeks may be considered out of danger. The utmost care should be exercised to keep scarlet fever out of lying-in and operating rooms.

Mother and infant may have scarlet fever after childbirth, and in many instances the results of plastic operations are marred by flaps sloughing from scarlatinal disease following operation.

After the discovery and isolation of the specific poison of scarlet fever, which is not unlikely to take place in the near future, we may also hope to obtain specific means to immunize and cure. Under all circumstances it is the duty of the general practitioner to inform himself as regards the best methods of prevention and disinfection, and to urge their adoption in every case coming under his notice and care. These methods of prevention are

applicable to all infectious diseases and are discussed in a special chapter on Infective Fevers.

Onset and Symptoms.-The disease begins abruptly as a rule with vomiting and thirst, rarely with a chill; young children may have convulsions. The fever rises to 104° or 105°, the pulse is rapid (120-150), the respiration is increased in frequency, and the child complains of sore throat. The scarlet rash appears on the second day, on the neck and chest first, and may spread over the entire body within the next twenty-four hours. The rash is punctate or finely papular, diffuse or in patches, and slowly disappears after persisting from two to five days. The throat looks red and swollen, and the tonsils may be covered with a punctate exudate. Pseudomembranes and diphtheritic patches are often seen on the tonsils and pharynx. From the gross appearance of these patches one is unable to say whether they are Klebs-Loeffler or streptococci patches. As a rule they are of a mixed nature. Minute macules of a dark red color are generally seen on the hard or soft palate. The lymphatic glands of the neck are swollen. The tongue is at first covered with a fur, and after a few days. exfoliates and becomes red ("strawberry tongue"). Headache, general restlessness, insomnia, and delirium are present in severe cases. The urine is scanty and may contain albumin and hyaline casts. In favorable cases the temperature becomes normal on the seventh or eighth day, and desquamation sets in, lasting three weeks on an average and occasionally from six to eight weeks.

Differential Diagnosis. In the absence of a bacteriological test, it may be difficult and often impossible (except by those who can see the grass grow) to distinguish a scarlet fever rash from a scarlatiniform rash, such as we occasionally observe after the administration of certain drugs: Belladonna, quinine, antipyrine, iodoform, balsam of copaiba, etc., and also in cases of intestinal indigestion. Slight desquamation may even take place in a skin which has been the seat of a scarlatiniform rash, and desquamation following measles is nothing rare.

The measles rash is of a brown red color, and presents itself in large irregular spots. The patient has coryza, cough, sneezing, and dull eyes. In German measles the throat symptoms are absent.

Diphtheria with a scarlatiniform eruption cannot be distinguished clinically from a scarlet fever infection with diphtheritic sore throat; and as regards the drug and indigestion rashes, each case must be judged upon its merits. With a clear throat and normal temperature, it would seem unnecessary to quarantine a patient who happens to have a suspicious rash.

Prognosis is uncertain. The mortality varies from 5 to 30 per cent. We have no means of gauging the power of resistance of the individual as regards sepsis, and, even when the acute stage is safely passed, subsequent complications may endanger and destroy life. Severe throat symptoms, early delirium, uncontrollable vomiting, high temperature, and high pulse are unfavorable symptoms. This is a brief pen picture of a moderately severe case of scarlet fever terminating favorably in due time. Apart from this form, we observe every variety as regards severity, complications, and sequelæ.