How are Rötheln and scarlatina to be differentiated?

Rötheln is inherently a mild disease; scarlatina is never without gravity. Rötheln lacks the rapid pulse, the high temperature, the " strawberry tongue" and the grave complications of scarlatina. The eruption of Rötheln more nearly resembles that of morbilli than that of scarlatina. Neither Rötheln nor scarlatina is protective against the other.

How are Rotheln and morbilli to be differentiated?

Rötheln resembles morbilli in its rash, in its mildness and in the catarrhal symptoms it presents. The eruption of Rötheln, however, does not show a tendency to crescentic arrangement, while it appears earlier and the individual papules are smaller than is the case in morbilli. Rötheln is milder than morbilli, even as relates to the catarrhal symptoms. An attack of either confers no immunity from the other.

Variola-Smallpox.

Upon what does the diagnosis of smallpox depend?

Smallpox or variola is an acute, contagious, epidemic disease, setting in with a chill, pains in the back, head and extremities, nausea and vomiting, elevation of temperature to 1020 or 103° F.,

FIG. 13.

40.0°

Temperature-chart of smallpox. (Strümpell.)

with marked exacerbations, increased rapidity of pulse, and a diffuse, red rash that is followed on the third or fourth day by the appearance of papules; when the temperature declines.

The papules commonly appear first on the lips and forehead. The preceding red rash usually appears first on the arms, and in the neighborhood of the groin. The fauces are apt to be reddened. There may be decided catarrhal symptoms. In the course of the succeeding four or five days, the papules become vesicles and the vesicles, in turn, pustules. The surface of the pustule is depressed at the middle-umbilicated. Each pustule is surrounded by an area of redness, constituting an areola. On the eighth or ninth day the pustules rupture and discharge their contents, and the temperature again rises (secondary or pyemic fever). (Fig. 13.) Secondary fever is sometimes announced by rigor, and its temperature-course is remittent. The evening temperature reaches from 103° to 105° F. The period of maturation and discharge lasts from three to five days, when crusts form and the temperature declines; in the course of a week the scabs fall off, leaving red cicatrices, which in the course of time become whiter and contracted, leaving "pits."

Ulceration of the larynx and trachea, bronchitis, pneumonia or pleurisy may complicate variola. Secondary inflammations are most likely to occur coincidently with the secondary fever. The eye frequently suffers permanent injury as the result of an attack of smallpox. The period of incubation of variola is about twelve days.

What are the varieties of smallpox?

Smallpox may be simple or discrete, confluent or hemorrhagic; it may assume a malignant charaeter.

What are the characteristics of discrete smallpox?

Discrete smallpox is the mildest type of smallpox; the eruption is least profuse, the pustules occurring isolated. Sometimes the pustules are in contact at their periphery, when the disease is said to be coherent.

What are the characteristics of confluent smallpox?

In confluent smallpox, the pustules are numerous and run into one another. The temperature fails to decline with the appearance of the eruption and is apt to be decidedly high during the period of maturation. The gravity of the case is greater than

in discrete smallpox. Typhoid symptoms, delirium, stupor and fatal coma may develop; or death may be brought about by diarrhea, ulceration of the larynx or trachea, endocarditis or other complication.

What are the characteristics of hemorrhagic variola ?

In hemorrhagic variola the exanthem is from the first constituted of ecchymoses, while hemorrhages may take place from any of the mucous membranes. This is the gravest form. Few

cases recover.

What is malignant smallpox?

The epithet malignant is sometimes applied to a variety of smallpox, most frequently encountered at the beginning of an epidemic, in which death may occur early in stupor, following delirium, the eruption being ill-defined and perhaps only developed post-mortem.

What is varioloid?

Varioloid is smallpox modified by vaccination or by a previous attack of smallpox. The symptoms of the disease are similar to those of smallpox, but milder in degree and shorter in duration; secondary fever is absent. The eruption of varioloid commonly appears on the second or third day; that of variola on the fourth day. The course of varioloid is completed in about fourteen days; that of variola in about twenty-one days.

What is vaccination?

Vaccination consists in the introduction of the virus of cowpock' into the lymphatic system of man, usually through the skin denuded of its epithelium, as a protection against variola. The protective influence continues for a period of about seven years, at the end of which time vaccination should be repeated.

1 What is meant by humanized virus?

Humanized virus is vaccine-lymph that is not taken directly from the cow (or calf), but from the vaccine-pustule of a human being, usually a child, who may have been inoculated with matter obtained from another child, or from the cow. Unless one is sure as to the purity of the antecedents of the source of the humanized virus, bovine virus is to be preferred.

What is vaccinia?

Vaccinia is the result of the inoculation of cowpock in human beings, and is protective against smallpox. For two or three days following vaccination, little is to be observed, locally or constitutionally. At the end of this time, the site of inoculation presents an appearance of slight redness, which in the next few days becomes intensified, as a vesicle forms and becomes transformed into a pustule, umbilicated and surrounded by a distinct areola. This process goes on for four or five days, when the pustule ruptures and the intensity of the inflammation gradually subsides. In the course of a week or ten days, the crust falls off and leaves a reddish cicatrix, which subsequently becomes white and depressed.

How does smallpox differ from measles?

The eruption of measles is coarsely papular throughout, with a tendency to crescentic arrangement, and is followed by branny desquamation; that of smallpox is irregular in arrangement and passes from the papular into a vesicular and then into a pustular stage, sometimes leaving disfiguring cicatrices. In measles, after a previous decline in temperature, the appearance of the eruption is attended with renewed elevation; in smallpox, the temperature declines with the appearance of the rash and reascends with the occurrence of pustulation. Smallpox is a grave disease, lasting three weeks; measles is a mild disease, lasting less than two weeks.

How are variola and scarlatina to be differentiated?

Smallpox may be attended with a primary, diffuse red rash, not unlike that of scarlatina, but, at the end of three or four days, papules appear, in turn to be succeeded by vesicles and pustules, finally leaving disfiguring cicatrices. With the appearance of the secondary rash, the temperature declines. The eruption of scarlatina undergoes no change and terminates in desquamation. The temperature is high from the outset and is continuous. Variola is not characterized by the same rapidity of pulse or by the typical "strawberry tongue" of scarlatina. Uncomplicated scarlatina is a disease of less than two weeks' duration; variola rarely lasts less than three.

Varicella-Chickenpox.

What are the characteristics of varicella?

Varicella or chickenpox is a mild, contagious disease of childhood, attended with moderate elevation of temperature and the appearance on the first or second day of an eruption of papules, which in turn become transformed into vesicles. The eruption appears on the trunk and extremities, on the scalp and face. It comes out in crops and continues for three or four days, the vesicles desiccating and falling off, occasionally leaving cicatrices. How does varicella differ from smallpox ?

Varicella is a mild disease; variola a grave disease. The eruption of smallpox appears on the third or fourth day and passes through papular and vesicular stages to become pustular; that of varicella appears on the first or second day and does not pass beyond a vesicular stage. The appearance of the eruption in smallpox is attended with a fall in the temperature; in varicella, the temperature, rarely high, is uninfluenced by the appearance of the rash. Varicella is a disease of scarcely a week; smallpox is a disease of three weeks. Neither is protective against the other.

How are varicella and varioloid to be differentiated?

There may be a close similarity between the manifestations of varicella and those of varioloid. Varicella is rare in adults because of the immunity conferred by an attack in childhood. Varioloid does not respect age; it is likely to appear in the course of an epidemic of variola in those that have been protected by vaccination. Varicella is the milder affection, and is of the shorter duration. Varioloid is but an attenuation and abbreviation of variola. Both varicella and varioloid are contagious. The existence of parallel cases may be decisive in diagnosis. An attack of the one does not protect against invasion by the other.

How are varicella and morbilli to be differentiated?

The eruption of measles is coarsely papular; it appears on the third or fourth day and displays a special proclivity to invade