particularly the case when the term scarlatina is used in speaking of the illness, as this conveys to the popular mind the idea. of a peculiarly benign form of disease, assumed to be incommunicable. Yet experienced practitioners dread this form of scarlatina fully as much as that which displays its characteristics from the outset, this because of its tendency to assume, without the slightest warning, an aspect totally new, preventing the formulating of a prognosis with anything approaching certainty. Another point of great import is the fact that one of the most dangerous complications of the disease, nephritis, is likely to occur from the lack of care given to cases that seem to the inexperienced, scarcely worthy the title of disease. Complications and sequelae are fully as likely to occur in mild cases and these should be carefully watcht, not only during the acute stages, but also until the latest possible time when additional symptoms are possible to develop.

No matter how mild the case seems, proper care should be taken to prevent the carrying of the infection. Other children in the house should be prevented from coming into the sick-room, and, while residing in the house, should be prevented from attending schools, the church, or any other place of public resort. In addition, they should be kept under observation for a period corresponding to that of incubation, in order to see whether they have taken the infection. Here another source of popular error should be corrected, -the idea that scarlatina is only contagious during the stage of desquamation. It has been proven that, altho the disease is more readily communicable during this period, there is scarcely any time from its inception that it cannot be conveyed.

An important point is the observation of the most thoro cleanliness of patient, nurse and sick-room, this both as regards spreading the contagion and as regards the chances of the patient for recovery. Cases of infection thru the air are not so common as was thought several years ago,

and by the close observance of sanitary rules in the disinfection of the secretions and the excretions and the destruction of all possible carriers of disease germs, the spread of contagious diseases can be in a large measure controlled.

The selection of a room in which to keep the patient is of no small importance. It should be, so far as possible, a room without immediate communication to any other that is in ordinary use, preferably on the top floor and at the end of a hall. It need not be large, so long as it can be readily ventilated. If there is a communicating room, this should not be occupied, but should be used solely as an anteroom to that in which the patient lies. Where it is at all possible, the room should be heated by a stove, which will assist in ventilation, provide a handy means for destroying infected dressings, etc., and also be of great use in preparing food, heating water, etc.

It will not be out of place here to reiterate directions already so often given in the care of disease, as to the bedding, etc., since these, tho apparently unimportant points, exert a great influence upon the well-being of the patient, and thus, in no small degree, affect the prognosis. The room should contain no unnecessary furniture, hangings, etc., being particularly out of place, altho it is necessary to see that there is full opportunity for darkening the room when this should be necessary.

There should be no carpet on the floor. The bed should be a single one, with a woven wire spring and a light, but firm, mattress. The room should be kept moderately warm, in order to dispense with the necessity of having a great weight of covering over the sick person. The fullest and most explicit directions should be given to the nurse, putting, so far as possible, all directions in writing, in order to obviate all possibility of misunderstanding. This is an excellent rule in all cases of serious illness, not alone in scarlet fever, and should always be done when possible.

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It is now supposed to be caused by a germ of some kind, but this has not yet been isolated. It can be carried thru the clothing or conveyed in food, by personal contact, or by direct inoculation. It probably has more vitality than most germ-forms, since there have been authenticated instances of outbreaks of disease from infected clothing that had not been used for years, so long a time having elapsed in one instance as twenty years. It usually occurs in children under the age of puberty, but persons suffering from wounds and women recently confined are also particularly liable to be attackt when exposed to the infection. There is an opinion that an attack confers immunity, but this is not the case, altho second attacks are not common.

The throat is inflamed and sometimes ulcerated, the cervical lymphatic glands swollen, and the liver and spleen are engorged, and the kidneys, especially the glomeruli, show signs of hemorrhagic nephritis. The rash generally disappears with death and its sudden subsidence has been considered a very bad sign.

The period of incubation varies from a few hours to a week, usually being about five or six days. The onset is usually very sudden, often beginning with a chill, but more usually with convulsions or vomiting.

The child usually complains of the throat feeling sore and that it is hard to swallow even liquids. There is a fulness underneath the jaw and there is tenderness on pressure at this point. Examination of the tongue shows a heavy coating over the main portion, with a bright red color at the tip and edges. The coating almost disappears in a few days, and then the papillae become red and swollen, the so

the development of the rash on the skin, a punctiform efflorescence will be noted on the pillars, tonsils, uvula and the pharyngeal vault, and these are also deeply injected and often swollen. When the case is very severe from the outset, the tonsils may be the seat of follicular inflammation, or even may be covered with a false membrane. It is such cases that sometimes become confounded with diphtheria, and which, thru the difference in treatment of these two diseases, may be most likely to prove fatal, this because of the fact that important points in which scarlet fever differs from diphtheria are not sufficiently guarded against, as well as because of the initial severity of the attack.

At the end of the first, or at the beginning of the second day after the illness of the child is noticed, a scarlet-red, puncti. form rash appears, first on the neck and chest, rapidly spreading over the entire body. When pressure is made it disappears temporarily, and if the finger nail is drawn thru it a white line appears. The rash may occur in discrete patches, surrounded with healthy skin, or it may be uniform over the entire body. The red color remains about six days and then begins to fade, scaly desquamation following. If the rash is petechial, extra care must be taken to guard the patient, as this is considered pathognomonic of what is called the malignant type of the disease. In other cases the rash may be pale and scarcely visible, possibly due to some characteristic of the skin of the patient, and again it may be slightly vesicular or papular, constituting the form of the disease known as scarlatina miliaris.

The fever which is so characteristic a symptom of the disorder rises abruptly to 104 or 105 degrees in less than 48 hours, and remains at that point for three or four days with very little variation, then falling by lysis, a half degree, sometimes a full degree a day. The duration of the febrile period, including the rise and decline, is about nine days. There is great

disproportion between the pulse and the temperature, the beat running sometimes so high as 180 per minute, sometimes being insusceptible of being counted. The respirations are hurried and somewhat shallow, there is no appetite, altho this may be partly because the throat is inflamed. There is constipation and the urine is scanty and high colored, and usually contains albumin.

Great restlessness, headache, insomnia, delirium and convulsions may occur dur ing the progress of the disease, and are characteristic symptoms. If the convulsions occur late in the disease, it is generally indicative of uremic poisoning and entails a grave prognosis.

The

The anginoid form of scarlet fever is that in which all the throat symptoms are greatly exaggerated, with swelling of the lymphatic glands. The membrane on the throat is very distinct and thick, and the tonsils are very much swollen. The prostration is most profound, and the fever runs an exceptionally high course. throat often ulcerates. Death is the usual termination of this form, either by exhaustion, aspiration pneumonia or from hemorrhage from the carotid artery becoming involved in the ulcerative process. The so-called malignant scarlet fever is exceedingly rapid in its course, death often ensuing in 24 or 48 hours, before even the appearance of the rash. onset is very abrupt, and the fever rapidly mounts to 106 or 107 degrees, with an exceedingly rapid and feeble pulse. There is every symptom of an acute general toxemia. Delirium sets in and coma rapidly

follows.

The

Differential Diagnosis of Scarlet Fever. There may be a resemblance between acute tonsillitis and scarlet fever, especially when an erythematous rash is associated with the former disease. The history of the case will determine the diagnosis, since in tonsillitis there is no evidence of exposure to contagion. The pulse is in due proportion to the degree of

fever, there is not the "strawberry " tongue, if there is a rash it is not punctiform, and there is no tendency to nephritis.

The onset of diphtheria is less abrupt, and there is more prostration. The false membrane is always present instead of being an occasional symptom, and there is no cutaneous eruption. The tongue does not present a strawberry appearance.

In measles, the sore throat, tho present, is less markt, and the rash is later in appearance, and of a different type, being distinctly papular, and forming into crescent-shaped patches. The fever remits decidedly on the second or third day, and there is no disproportion between the pulse and the fever.

Rotheln is a little more difficult to distinguish from scarlatina, but the fever is not so high nor the pulse so rapid. There is less swelling of the post-cervical glands, no tendency to nephritis, and the rash has not the characteristic punctiform appearance of that in scarlet fever.

There are many accidental rashes that may at first occasion doubt, such as those caused by belladonna, quinin, copaiba, certain rich foods, as oysters, etc., but these are not punctiform and are not associated with fever of an unusual degree, rapid pulse, or sore throat.

Scarlatinal Complications.

The chief and most dangerous complication of scarlatina is nephritis, which usually develops during convalescence, and frequently leads to a fatal termination of the attack. It may be unassociated with any subjective symptoms, and hence there is necessity for daily examination of the urine, in order to detect, at the earliest possible time, its presence. When the subjective symptoms occur, its advent is characterized by the suppression of urine, by uremia or by the appearance of dropsy. Nephritis generally terminates in recovery, but frequently acts as the immediate cause of death, and sometimes leads to chronic renal disease.

Other complications apart from the dis

ease itself and yet incident to it, are hyperpyrexia; suppuration of the lymphatic glands; inflammation of the middle-ear, leading to perforation of the tympanum and subsequent deafness; pericarditis; endocarditis; pneumonia; ophthalmia; chorea; and a peculiar inflammation of the joints, which is probably due to infection of the synovial fluids, and which closely resembles articular rheumatism.

Diphtheria.-Further Considerations. In diphtheria, the false membrane is usually found on the tonsils, pillars and the pharynx, but it may extend to the mouth, nose and larynx. The bacillus has a most destructive action upon the superficial cells in the localities infected, leading to coagulation-necrosis; and the consequent migration of the leucocytes terminates in their death also and consequent transformation by the same process. In this manner the characteristic membrane is formed. It is more or less adherent, and when torn off leaves a raw surface. This enables the necrosis to extend to the deeper tissues, and thus cause extended ulceration and even gangrene.

Microscopic examination of the membrane will show it to be composed of fibrin, bacteria, the remains of epithelial cells, and leucocytes, living, or in the process of disintegration.

There is much inflammation of the lymph-glands, and the spleen becomes engorged. Post-mortem examination of the lungs shows capillary bronchitis, catarrhal pneumonia and collapse, while the various muscles and organs reveal fatty and parenchymatous degeneration. In some cases the blood is dark and fluid, while in other cases, particularly where the death has been rather sudden, firm clots are found within and distending the heart.

The constitutional symptoms do not develop from the direct action of the bacillus, but are the results of its toxins. One attack does not protect or confer immunity, but rather predisposes to future attacks.

Different Types of Diphtherial Infection. According to the location of the exudate, diphtheria may be divided into faucial, laryngeal, nasal and cutaneous. The most common type is where the lesion is principally located in the fauces, and this variety is used to typify the symptoms. There are chills, moderate fever (102 to 104 degrees), quite regular in its course, general malaise and sore throat, tho frequently the last named is the least prominent symptom. The pulse is rapid and feeble, the bowels constipated, the urine scanty, etc., and the prostration and pallor frequently altogether disproportionate to the severity of the infection, or to the febrile symptoms. The child has difficulty of swallowing, the muscles of the throat are stiff, and there is great tenderness, externally, as well as internally.

Laryngeal diphtheria is usually secondary by extension from the fauces, but is occasionally of primary occurrence. It may be recognized by hoarseness or even entire loss of the voice, by the presence of a croupy cough, increasing difficulty of breathing, and stridulous respiration. The alae of the nose play, the sternocleido-mastoids become rigid and prominent, the suprasternal notch is deepened and the base of the chest is retracted.. Violent fits of coughing result from efforts to get breath, and, in these, shreds of the false membrane are expelled. There is seldom much fever. In these cases death. results often from suffocation, and recovery without intubation or operation is very

rare.

Nasal diphtheria, also, is usually secondary. It is accompanied with grave constitutional symptoms, high fever, markt glandular involvement, and the utmost prostration There is epistaxis, and an offensive discharge from the nose, while the lips are often excoriated. The membrane can be seen in the nose.

Cutaneous diphtheria may be either primary or secondary. It usually appears at the site of a wound, sometimes on the genitalia. The constitutional symptoms

types.

Complications and Sequelae of Diphtheria. Among the complications and sequelae may be mentioned capillary bronchitis, catarrhal pneumonia, pulmonary collapse, endocarditis, heart-clot, nephritis, and the characteristic paralysis.

Diphtheritic paralysis generally occurs during convalescence, and is observed in about fifteen per cent. of all cases. There is no relation between the severity of the attack and the liability to the occurrence of this complication, since mild cases, even those which have been diagnosed and treated as simple pharyngitis, sometimes first show their true character as diphtheria by the occurrence of a troublesome paralysis.

The pharynx is the most common seat, and the trouble is usually noticed first by difficulty in using the muscles of deglutition, and the regurgitation of liquids thru the nose. There is a peculiar nasal tone to the voice, and a difficulty in pronouncing d and b, which are sounded as n and m respectively, directly opposite to what occurs in the usual cold in the head.

Next in frequency the eyes are involved, and strabismus or ptosis develops. Sometimes the pupils are unnaturally dilated, and there is generally some degree of paralysis of the muscles of accommodation.

The heart may be affected, and in this event, if sudden death does not result, the condition may be manifested by a remarkable slowing of the pulse, or by intermittency. The extremities are rarely involved. The paralysis results solely from a toxic neuritis, and is very obstinate in yielding to treatment, instances being recorded where the symptoms persisted during a period of nearly a year.

Prognosis of Diphtheria.

The prognosis of diphtheria must always be guarded, since the mortality averages 25 per cent., and includes cases apparently mild, as well as those severe in their clinical

symptoms are not striking, and the membrane is confined strictly to the fauces and does not show a disposition to extend, there is but little risk in venturing a favorable opinion, that is, always taking into consideration the possibility of the occurrence of complications and sequelae. The nasal and laryngeal forms are always grave, and should be watched with the utmost care, without the practitioner committing himself to any statements as to the probability of recovery. Final and complete recovery can seldom be placed at under six months.

Mumps.

Mumps, or epidemic parotiditis, is a disease that may occur at any time of the year, but as it is most frequently met with in the late winter or the early spring, a few words as to treatment may not be amiss at this period.

It is characterized by an inflammatory process, catarrhal in nature, involving the parenchyma and the salivary ducts of the parotid and the other salivary glands. Usually the starting point is in the excretory canals of the gland, resulting in the retention of the saliva within them, in some cases finally leading to suppuration.

The disease is infectious and is supposed to be bacterial in its origin, altho no specific organism to which it can be attributed has yet been isolated. It is possible that the infectious agents are present in the atmosphere, and enter thru the mouth, altho some claim that infection enters the parotid gland thru the circulation. This does not seem probable in the ordinary case of mumps, but may be the method when the parotiditis is the result of pyemia and septicemia, or from typhoid fever, small-pox or any other infectious disease.

The disease occurs sporadically and epidemically, more frequently in young children, altho adults are not exempt. A peculiar point is that males are more susceptible to the infection than females. Immunity is conferred by an attack.