ized throat-symptoms.

Possibly, the pulse may be relatively more rapid in scarlatina than in diphtheria. In from twentyfour to thirty-six hours, however, the appearance of a scarlet rash, as well as the subsequent course of the disease, dispels all doubt.

In diphtheria, the symptoms centralize themselves about the throat; in scarlatina the throat disturbance represents but a part of the general derangement. The paralyses commonly seen after diphtheria are rare after scarlatina. More common during the course of scarlet fever or subsequently are suppurative ear-disease, nephritis and glandular enlargement.

Diphtheria and scarlatina may coëxist in the same patient. How is tonsillitis to be distinguished from diphtheria?

Deposits on the tonsil may appear diphtheritic. They show little or no tendency to spread, however. Extension is characteristic of the diphtheritic membrane. In lacunal tonsillitis, the discreteness of the plugs and their situation at the orifices of the ducts are characteristic, and their creamy color is different from that of the diphtheritic pseudomembrane. Microscopically, they will be seen to be made up of desquamated epithelium, of sebaceous material and of ordinary fungi. The diphtheritic membrane is constituted of meshes of fibrin containing necrotic tissue. In herpetic tonsillitis the eruption first appears as papules that soon become vesicles; but it is rarely seen at this stage; when ulcers and fibrinous deposits form and become confluent, the discrimination is difficult. Still, the herpetic patch is quite superficial, and more readily detached, leaving less erosion and causing less hemorrhage in its separation than does the diphtheritic patch. The former is usually the less extensive, and here and there, perhaps, the circular form of an isolated ulcer may give evidence of its origin. If necessary, inoculation-experiments and bacteriologic investigation may also help to discriminate. The constitutional symptoms of tonsillitis are less profound than those of diphtheria; local subjective symptoms, such as soreness, odynphagia and burning, are usually the more intense in tonsillitis, which is not, as a rule, followed by paralysis of the palate. Albuminuria is not usual.

How is membranous croup to be distinguished from diph

theria?

Until the physician acquires sufficient experience to warrant a personal opinion, he had best consider all cases of membranous croup diphtheritic. The discrimination is difficult and disputed.

How are diphtheria and stomatitis to be differentiated?

The deposits in stomatitis are seated upon the mucous surface of the lips and cheeks and upon the tongue, while the membrane of diphtheria is usually seated in the pharynx, from which, as a center, it is distributed. The constitutional derangement is not as profound in stomatitis as in diphtheria. Stomatitis readily yields to mild general and local measures, while diphtheria is more rebellious to treatment. The fatality and the severe sequelæ of diphtheria are wanting in stomatitis.

Glanders-Farcy-Equinia.

What are the clinical features of glanders?

Glanders, farcy or equinia is an infectious disease, especially peculiar to horses, asses, and mules, from which it is transmitted to man through abrasions of the skin and through the mucous surfaces of those that come in contact with the diseased animals.

The site of inoculation displays evidence of active inflammation; especially is this marked in the nasal passages. There are also malaise, headache, elevation of temperature and pains in the limbs; the urine may be albuminous. Soon there appears a macular eruption, which becomes vesicular, then pustular and finally umbilicated. The pustules may rupture and leave ugly ulcers. In addition, nodules form beneath the skin; these also soften and may rupture, discharging sanious pus and detritus. Another characteristic symptom of glanders is ozena. There is at first a moderate, thin discharge from the nostrils, soon, however, becoming profuse and purulent. The mucous membrane of the nares and contiguous structures is involved in intense inflammation and may become ulcerated. Catarrhal

pneumonia and purulent arthritis are occasional complications. Glanders may be transmitted from man to the lower animals by inoculation.

How are glanders and variola to be differentiated?

In glanders, there may be a history with the local evidences of inoculation with the specific virus of the disease. The eruption of variola does not appear until the third or fourth day; with its appearance the temperature falls. The eruption of glanders may appear within the first twenty-four or fortyeight hours of the disease; it reaches a pustular stage much earlier than that of variola; there is no decline of temperature with its appearance. The eczema and the subcutaneous nodules of glanders are wanting in variola.

How are the ozena of glanders and that of syphilitic disease to be differentiated?

Ozena is dependent upon destruction of the nasal structures and putrefactive decomposition of the secretions. It is thus not distinctive of a single disease. Occurring in syphilis, it is a late manifestation, and probably has been preceded by well-defined symptoms. As seen in glanders, it occurs at the height of the disease, and is associated with a pustular eruption and the presence of nodules beneath the skin. The mode of infection differs in the two diseases.

Anthrax-Wool-sorters' Disease.

What are the clinical features of anthrax ?

Anthrax, wool-sorters' disease, charbon, malignant pustule or splenic fever is an infectious disease, due to inoculation with the bacillus anthracis (Fig. 14.) It develops in butchers, wool-sorters, workers in hides, stevedores and others that, with cut or wounded or abraded hands, manipulate the wool or skins of animals that have died of splenic fever or charbon. The infection sometimes gains entrance through a scratch on the cheek or an abrasion of the lips. In butchers, the tongue is sometimes infected from a knife taken between the teeth. In those that carry hides upon their shoulders, the neck may be the site of

local infection; these cases are likely to be more than ordinarily dangerous. The disease may apparently result from eating the flesh or from drinking the milk of infected animals.

At the site of inoculation, a pimple appears; the skin in its neighborhood becomes red and infiltrated; the papule becomes vesicular and pustular, with subsequent gangrene; other vesicles or pustules form and also become gangrenous; there results a characteristic eschar, which presents the appearance of an elevated patch, consisting of a zone of low, whitish vesicles surrounding a depressed brownish, purplish, or black center, with an outer zone of red induration. Beyond this is usually a region of swelling and edema of variable extent. The spleen and the lymphatic glands in communication with the infected regions enlarge. There is often considerable local tenderness. The constitutional symptoms are those of septicopyemia malaise, headache, depression, fever. According to the mode of introduction of the poison, or the direction in which infection spreads, other manifestations appear. Sometimes the gastro-intestinal tract appears to bear the brunt of the disease and there are nausea, vomiting, abdominal pains and diarrhea, the stools being bloody. Death may take place from exhaustion or from septicemia. At other times, thoracic symptoms predominate. There are then dyspnea, a sense of oppression

of breathing, hemoptysis and cyanosis. Death may take place from edema of the larynx or of the mediastinum. Characteristic bacilli may often be found in the blood, pus, sputum, feces, or urine. Under proper treatment recovery frequently takes place.

Actinomycosis.

What is actinomycosis?

Actinomycosis is a condition dependent upon the presence of ray-fungi: actinomyces bovis. (Fig. 15.) The disease is more fre

quent in drovers and in those that have to do with cattle, from which the parasite, as found in man, is usually derived. The cattle become infected through their food. The fungus gains entrance through a breach in continuity of the surface and, finding its way to a suitable nidus, gives rise to the formation of a seropurulent collection; this manifests itself as a tumor that usually finds vent externally. In the matter discharged, yellowish miliary nodules, composed of fungi, can be detected. The lower jaw seems to be a favorite seat of the disease, infection taking place through decayed teeth; sometimes extensive destruction of bone results. At other times, purulent collections form in internal viscera. When the pleura is infected the ribs may suffer severely.