vitis), febrile elevation of temperature and a characteristic exanthem.

The period of incubation is from seven to fourteen days. The onset is somewhat abrupt, with a quick rise of temperature to from 102° to 104° F., more or less headache, restlessness, injection and watering of the eyes, sneezing, running from the nose, often swelling of the nose and lip, perhaps cough and slight sorethroat. Digestion is commonly disturbed, and the urine may be scanty. The temperature (Fig. 11) undergoes a considerable ele

Temperature-chart of measles. (Strümpell.)

vation with the onset of the attack, declining on the second or third day, to rise again on the fourth, with the appearance of the eruption. This consists of coarse, pink papules, primarily discrete, then becoming surrounded by a somewhat paler border and soon coalescing, to form slightly elevated patches arranged in crescentic form, with intervening healthy skin. The eruption first appears upon the face and neck, then upon the body. The fever declines and the eruption begins to disappear between the fifth and the seventh day. Branny desquamation follows as the attack comes to an end on the ninth day. The eruption may

usually be detected in the throat a day or two in advance of its appearance on the skin.

An attack of measles commonly protects against subsequent infection; though second attacks are not rare and third attacks not remarkable. The disease is ordinarily mild and benign; sometimes, however, it is malignant and hemorrhagic (black measles). Lobular pneumonia and catarrhal otitis media are not uncommon complications. An attack of measles is likely to precipitate the development of tuberculosis in one predisposed and to accelerate the course of the disease when it already exists.

How does morbilli differ from typhus fever?

Typhus fever is of longer duration and decidedly more grave than measles, than which it is relatively less common in children. While the eruption of measles in some degree resembles that of typhus, it appears earlier and, as a rule, has no tendency to become petechial; it begins on the face, while in typhus the face escapes. The catarrhal symptoms of measles are wanting in typhus; the profound nervous depression of typhus is not seen in measles. Typhus in North America is rare and as a rule imported, most frequently by emigrant-ships.

Scarlatina-Scarlet Fever.

What are the symptoms of scarlatina?

Scarlatina is an acute, contagious disease, to which children and young persons evince a special predisposition. An attack confers relative immunity from subsequent infection.

The period of incubation may be short. It varies from twentyfour hours to a week, rarely ten days. The onset is usually abrupt, perhaps attended with vomiting or convulsions. The temperature at once rises to a considerable height (1040 or 105° F.) and the pulse attains a striking frequency. In the first twenty-four hours, or sometimes a little later, a diffuse, fine, punctiform, red rash appears, at first on the neck and breast and in the flexures of the joints, soon spreading as a uniform scarlet flush over the greater part of the body. Pressure causes tempo

rary dissipation of the redness. There are intense subjective burning and itching of the skin.

The throat is usually sore and swallowing is painful. The fauces and palate are reddened, the tonsils and uvula and the adjacent cervical glands are enlarged and there is stiffness of the muscles of the neck. The scarlet discoloration may sometimes be detected in the throat, especially on the free border of the soft palate and on the uvula, in advance of its appearance on the skin. The throat-affection is often ulcerative or pseudomembranous in character. The larynx is rarely invaded. The nose is usually involved and there is more or less serous or seropurulent discharge. The inflammation may extend into the Eustachian tube and involve the auditory apparatus. Suppurative otitis is not an uncommon complication, and perforation and deafness may result.

Temperature-chart of scarlatina. (Strümpell.)

The tongue is at first heavily coated, but, in the course of a little while, the dense fur is cast off, exposing the surface of the reddened organ, with its enlarged and prominent papillæ-an appearance characteristically described by the designation "strawberry tongue." Thirst is often great. Digestion is deranged. The urine is scanty.

Severe nervous symptoms may occur, twitchings or convulsions, restlessness, insomnia, delirium, stupor, fatal coma; or the nervous disturbances may be very mild and cease with the setting in of convalescence.

In favorable cases, the eruption fades by the fourth or fifth day. The temperature, which has remained high, begins to decline; defervescence taking place by somewhat rapid lysis (Fig. 12). At the end of a week or nine days, the skin undergoes a furfuraceous or membranaceous desquamation, the temperature falls to the normal and convalescence may set in. Persistence of high temperature into the second week is not common and usually denotes a complication. So, too, a sudden recrudescence of pyrexia, after decline has begun, indicates suppuration or other accident. Convalescence may be interrupted by the appearance of symptoms of an acute nephritis. Edema of the face and body, with diminished elimination of a dense, highcolored or smoky-looking urine, containing considerable albumin and blood, as well as blood-casts and epithelial casts of the uriniferous tubules. Not rarely, albuminuria and other evidences of renal congestion or inflammation may be detected prior to the appearance of edema. With or without suppression of urine, there may occur convulsions, delirium, stupor, coma and death. Another rather frequent complication is arthritis, which may involve a single joint or several joints. Sometimes, with or without joint-symptoms, there is endocarditis, pericarditis or pleuritis. Permanent valvular lesions of the heart may be sequelae. Various types of scarlatina are observed in addition to the ordinary form. When throat-symptoms predominate, the attack is called "anginose." Sometimes the disease is mild or abortive. At other times it is malignant in virulence. In malignant cases, the rash may be delayed; it may be pale and indistinct or dark and livid. Cases in which the rash is wanting may be mild or severe. This form is called "larval" or 66 scarlatina sine exanthemate." In these cases, dropsy or suppression of urine may be the first symptom to attract attention. Anasarca may occur without nephritis, but its dissociated occurrence is not common. Scarlatina is said occasionally to be hemorrhagic.

How are scarlatina and measles to be differentiated?

Scarlatina usually sets in with vomiting or convulsions; measles rarely so begins. Rather severe sore-throat and glandular enlargement characterize scarlatina; catarrhal symptoms are present in measles. The great rapidity of pulse and elevation of temperature commonly observed in scarlatina are wanting in measles The eruption of scarlatina appears on the first or second day of the disease and is finely punctate, occasioning an appearance of diffuse redness; the eruption of measles appears not before the third day and is commonly papular, arranged crescentically, with areas of intervening healthy skin. After a preliminary elevation, the temperature of measles falls on the second or third day, to rise again with the appearance of the eruption, then to subside rapidly; the temperature of scarlatina at once mounts high and, after a few days, declines gradually. Nervous symptoms are decided in scarlatina, wanting in measles.

Rötheln,

What are the symptoms of Rotheln?

Rötheln, also called roseola, German measles, French measles and, incorrectly, rubella or rubeola, is an acute, contagious exanthem, presenting an eruption resembling that of morbilli and throat-symptoms like those of scarlatina. An attack protects from subsequent attacks, but not from measles or scarlatina; neither does an attack of scarlatina or one of measles confer immunity from Rötheln. The period of incubation of Rötheln is said to be about fourteen days. The onset is usually abrupt. The temperature is moderate; the pulse not very rapid. In the course of a day or two, there appears, first upon the face and then progressively invading the trunk and the extremities, an eruption of small papules usually separated from one another by skin of normal appearance. Sometimes, the intervening skin is erythematous. The eruption lasts for from four days to a week, is attended with itching and is sometimes followed by slight desquamation. The throat is usually sore, the fauces reddened and the cervical glands enlarged. Catarrhal symptoms are common. The course of the disease is usually mild and uncomplicated.