of the eruption, after which, usually in the second day of the eruption, the temperature begins to fall, frequently by crisis. Restlessness, sleeplessness, or even general convulsions and delirium, may accompany the exacerbation of the fever. The catarrhal symptoms attain their maximum while the eruption is developing, and then gradually subside.

Variations in its Course.-I. In rare cases there may be no catarrhal symptoms during the period of invasion.

2. There are very light cases in which there may be no eruption. After the regular period of incubation the patient becomes indisposed, feverish, and has a coryza-as it is said, "sickens for the disease," but the eruption is not developed.

3. In some cases the eruption appears as early as thirtysix hours, or it may be deferred until the sixth day.

4. There are cases of marked severity characterized by high fever (105° or 106° F.) and cerebral symptoms, convulsions, delirium, and stupor.

5. In some epidemics, especially in armies and in savage tribes where measles appears for the first time, may appear malignant cases, the so-called "hemorrhagic" or "black" measles. The invasion is sudden and intense; prostration is extreme; there are convulsions or delirium. or even coma. The eruption becomes hemorrhagic; hemorrhages occur in the skin and from mucous membranes, These cases are almost always fatal.

Complications and Sequelæ.-The most important are those of the respiratory system. A mild form of bronchitis is common to the disease, but in debilitated subjects, in asylum children, and in severe forms of the disease the inflammation is apt to extend and to lead to broncho-pneumonia. This complication runs a regular course, and is the cause of death in the vast majority of fatal eases. There may be a swelling of the bronchial glands that render them liable to tubercular infections, which may be the origin of acute

miliary tuberculosis. Thus in asylums fatal cases of tuberculosis frequently follow epidemics of measles after a little interval. In some cases there may be a tubercular broncho-pneumonia at the start from added tubercular infection. Lobar pneumonia and pleurisy may less commonly occur. There may be protracted and severe conjunctivitis. Croupous laryngitis may occur. There may be otitis media.

In weakly children there occurs rarely gangrene of the cheeks or of the vulva (cancrum oris or noma). In some cases there is exhausting diarrhoea, which may assume a dysenteric character with bloody, slimy passages. True nephritis is rare, although albuminuria is common in the height of the disease. The disease may be complicated by whooping-cough.

Prognosis. The prognosis is generally good except when severe epidemics occur in tenements, armies, and among savage races in virgin soil. Death seldom occurs from the disease itself, but from pulmonary complications. The prognosis is not good in children under the age of two years. The possibility of subsequent tuberculosis must be considered.

Treatment. The patient should be isolated until desquamation is completed. Especial care should be exercised to to prevent delicate children with weak lungs or a tubercular predisposition from being exposed to the disease. The room should be of an even temperature (about 70° F.) and well ventilated. There is no advantage in keeping the room too hot. The patient should remain in bed until three or four days after the fever has gone, and during the febrile period should be kept on a milk diet. Water may be given freely. The majority of uncomplicated cases need no further treatment, though special symptoms may be treated as they arise.

The fever rarely needs treatment.

Should it be high

(over 104° F.), it may be reduced by sponging with water. Cool baths may be employed with benefit.

Conjunctivitis is best treated by careful cleansing of the eyes with a saturated boric-acid solution; or a few drops of a solution of atropia (gr. j : 3j) or of alumnol (gr. v: 3j) may be employed. For the redness of the eyelids the unguentum hydrargyri oxidi flavi (U. S. P.) may be used. In severe cases the room may be darkened slightly by blinds or by screens to relieve the photophobia.

Restlessness, delirium, and sleeplessness are best controlled by sodium bromide or phenacetine.

The cough, if troublesome, is best treated by paregoric and syrup of ipecac in small doses.

The itching of the skin may be relieved by washing with a solution of bicarbonate of soda or by oiling the skin with lard or with cacao butter.

Other symptoms as they arise are to be treated on general principles. During desquamation the skin should be oiled daily to prevent dissemination of the branny scales.

During convalescence great care should be taken to build the child up and to avoid most especially the least possibility of tubercular infection. Too much care cannot be taken in this regard.

RUBELLA.

Etiology and Synonyms.--Rubella is rather rare, occurring chiefly as epidemics, which are frequently extensive. Sporadic and endemic cases are exceedingly infrequent. It is a disease entirely distinct from measles, although closely resembling it in many of its clinical features. It is contagious to both adults and children, and one attack procures

future immunity. Synonyms: German measles; Roscola; Rötheln.

Symptoms. Incubation.-The period of incubation is usually two weeks.

Invasion. The symptoms of the invasion resemble those of measles, but are much milder and are of shorter duration. There is a slight fever, rarely over 100° F., with headache, nausea and vomiting, coryza, sore throat, and swelling of the glands at the back of the neck that is almost characteristic. These symptoms rarely continue longer than twenty-four hours. In many cases they are so slight as to be unnoticed.

The eruption, which appears in from twenty-four to fortyeight hours, is first seen on the face and chest, thence spreading generally. It consists of small round, raised spots, of a pinkish rose-color, which are usually discrete and which frequently are seen on the palate. They are rarely crescentic. They may become confluent, the consequent reddening of the skin closely resembling the scarlatina rash; but the eruption is more erythematous, is not punctiform, and in places shows a papular character. In a certain number of cases there are developed from the papules a few vesicles which may become pustules. This is never the case with scarlatina nor with measles.

The eruption lasts for two or three days and then fades. There may be a slight branny desquamation.

During the eruption there may be some feverishness, an aggravation of the pharyngitis, and swelling of the glands at the back of the neck. In many cases, however, the only symptom is the eruption.

The prognosis is perfectly good.

Treatment. Few diseases need so little treatment as rubella. The case should be isolated to avoid the spread of the disease.

EPIDEMIC PAROTITIS.

Definition and Synonym.-Epidemic parotitis is an acute contagious disease characterized by inflammation of the salivary glands. Synonym: Mumps.

Etiology.-Parotitis occurs both as an endemic and an epidemic disease, epidemics being usually extensive. It is a disease of childhood and adolescence, attacking infants and elderly people but rarely. It is more frequent among males than among females. It is personally contagious from the last few days of the period of incubation until the subsidence of the symptoms. The exact poison. has not been absolutely proven, although a bacillus parotidis has been described.

Lesion. The lesion consists in the swelling and congestion of one or of both parotid glands, and occasionally of the submaxillary glands as well.

Symptoms.-The period of incubation is between two and three weeks and is unattended by symptoms. The disease begins with fever-usually not over 101° F., but it may be as high as 103° or 104° F.—and attendant febrile symptoms, nausea, restlessness, and prostration. The local symptoms become noticeable in from twenty-four to thirty-six hours, although in some cases they may precede the fever. The patient complains of a feeling of tension, more rarely of actual pain with tenderness, referred to the parotid gland of one side. The gland is swollen, giving the patient a characteristically comical appearance. Deglutition and speaking aggravate the pain. There may be pharyngitis or earache.

The inflammation reaches its height in from three to six days and then subsides. It is usual for the inflammation to start on one side, the other parotid gland becoming affected in a day or so. More rarely both glands may be