rubella, whose points of similarity are, also, more striking than those of the three diseases omitted.

Of minor importance, perhaps, is a consideration of the stage of incubation, owing to the fact that there is no very marked difference, the extreme range of any one of the five reaching within the possible range of any other one, and, also, to the fact that, in many cases, the patient is not aware of having been exposed. Smallpox and scarlatina have, on the average, shorter periods of incubation than the other three diseases. This period may, in the case of scarlet fever, be only a few hours, or it may be as long as two weeks, the average being about one week. In the case of small-pox it ranges from one to two weeks, but is usually one week. Varicella has a range of from two to three weeks, measles from one to three weeks, usually not exceeding two, and rubella running between two and three weeks.

Prodromal symptoms are usually wanting or confined to slight indisposition in variola, varicella and rubeola, and wanting in scarlatina and rubella. In measles, however, if under observation during the stage of incubation, Koplik's sign will be observed for from three to five days before the onset of the disease. This sign consists of rosered spots on the mucous membrane of the buccal cavity, somewhat brighter than the surrounding membrane and containing in the center of each a bluish-white speck. These spots are at first discrete, but may coalesce near the time of the onset of the disease, the buccal eruption which is confined to the inner surface of the cheeks and lips being at its height when the skin eruption first appears. This eruption should not be mistaken for aphthous stomatitis, in which the hue of the mucous membrane is more nearly normal and the yellow spot in the center is much larger.

Were he permitted to watch his case through the incipient stages less excuse might be offered in case of a mistaken diagnosis than when, as is usually the case, the physician is first called after the eruption has put in its appearance and finds his efforts to obtain an exact history of the case unavailing.

Suppose, however, he is called to a patient who complains of severe headache, back-ache and pain in the extremities, which were preceded by a chill and are accompanied by a temperature of from 102° to 104° F., a rapid pulse, coated tongue, nausea and vomiting, constipation, perspiration and prostration, with a scarlatiniform rash upon the abdomen, arms, groin and inner part of the thighs, he would almost be warranted in making a diagnosis of small-pox without further delay. On the third or fourth day the diagnosis will be clinched beyond a peradventure, if there appear upon the forehead the char

1

acteristic papules feeling like a shot beneath the skin, with a simultaneous decline of the temperature to near the normal point.

These papules pass into the vesicular stage within the next fivedays and proceed from this to the pustular stage, in which they present an umbilicated appearance. On the eighth or ninth day a discharge of the contents of the pustules takes place, accompanied by a secondary rise of temperature to 103° or 105° F., which may be ushered in by rigors. The following desquamation is usually completed on about the eighteenth day, leaving the characteristic pit wherever the true skin has been involved by the ulcer.

Three varieties of variola are mentioned,-discrete, confluent and malignant. The first two of these terms are self-explanatory, the last refers to the ecchymotic or hemorrhagic form and may be accompanied by hemorrhage from the stomach, lungs, bowels and kidneys. The eruption is not infrequently suppressed in this, the most fatal form. Pneumonia, pleurisy, bronchitis, or orchitis may be encountered in conjunction with variola. Sequelæ are not common, though the eye-sight is sometimes permanently impaired.

Varicella more closely resembles small-pox than any of the other exanthemata, but it is scarcely ever met with in adults. Its symptoms are much milder than those of variola, its eruption appears on the first or second day, lacks the hard, shot-like feeling of the variola papule, is not announced by a decline of the temperature, usually appears in crops, and is rapid in evolution, seldom leaving conspicuous pits. The temperature is but slightly elevated and the disease is of about a week's duration.

When called to a case in which the rash appears as a uniform scarlet flush attacking first the neck and chest, the diagnostician may justly be in doubt as to whether the case is one of small-pox in the early stage, or scarlatina. The sudden onset, vomiting and early rise of temperature to 104° or 105° F., also resemble closely the early symptoms of small-pox, but the extremely rapid pulse (120-140), the extremely red and sore throat with its varnished appearance, the strawberry tongue with red papillæ projecting through its white coating all favor scarlatina. In addition to the above symptoms we have in scarlatina a decided preference for children, greater tendency to nervous symptoms, even to convulsions, which are common in the early stages, and the failure of the eruption to attack the face or to pass from its primary stage to that of vesicle and pustule.

Two varieties-scarlatina anginosa and malignant scarlatinapresent some deviations from the typical form. In rare cases the eruption is suppressed. In these cases diarrhea is commonly present.

In the anginose form the throat and glandular symptoms are especially prominent. The eruption in the malignant form may be pale or dark and livid.

Nephritis, endocarditis, cedema, uremia, scarlatinal rheumatism, pleuritis, and meningitis are frequent complications, and various. forms of paralysis, as well as nephritis, endocarditis and rheumatism occur as sequelæ.

In measles the onset is more gradual than in scarlatina, the rash first appears upon the face, the throat symptoms, if present, are milder in type, coryza, sneezing, cough and conjunctivitis are present, while chill, extremely high temperature, extreme rapidity of pulse, vomiting and sore throat are wanting. The rash of measles also has a tendency to appear in crescentic form, interrupted by patches of healthy skin.

In its onset measles presents a striking similarity to small-pox. It has a similar initial rise of temperature, though not quite so high. as is usual in small-pox, the recession on the second day to near the normal point and the exacerbation on the fourth or fifth day in conjunction with the appearance of the rash. It lacks, however, the initial rash upon the abdomen and thighs which is characteristic of small-pox, and also the shot-like feeling of the eruption upon the face, which is characteristic of the secondary eruption of small-pox.

The varieties are benign and malignant. The latter is sometimes hemorrhagic and occasionally terminates in convulsions, coma and death. In some cases the eruption is suppressed, when diagnosis will be made chiefly upon the symptoms of coryza and the peculiar temperature curve, with the knowledge that there are existing cases of the disease in the neighborhood. Bronchitis, pneumonia, diarrhea, epistaxis, otitis media and cancrum oris may complicate rubeola, while chronic catarrh, impaired digestion, tuberculosis, and various forms of paralysis occur as sequelæ.

Rubella, or German measles, is gradual in onset. Its rash resembles that of measles in appearance and point of attack, beginning on the face and extending over the entire body. It also resembles measles in that catarrhal symptoms are usually present. It differs from measles, however, in that it is a milder disease, its rash appears on the first or second day instead of the fourth, as in measles, it does not have the recession of temperature following the initial rise, and the disease is of shorter duration than measles. On the other hand, the throat symptoms of rubella may approach, in severity, those of the scarlatinal throat, and the itching of the skin accompanying the eruption is another point of similarity. The sudden onset, vomiting,

convulsions, high temperature and rapid pulse of scarlatina are all wanting in rubella.

Thus, after a brief review of some of the most striking symptoms of these various diseases, it would seem that a mistaken diagnosis would be unpardonable, even in a novice, and so it would, if the diseases as found in every-day practice mirrored precisely the stereotyped forms which characterize the typical case as pictured in our books on diagnosis. The manufacturer of these little diversions from the highways of health and happiness seems, however, to have at his command nearly as many patterns for each one of them as there are diversities in the elements which go to make up the character and disposition of the individual afflicted. And, in these diversities, in these departures from the typical forms of the various diseases lie the difficulties which so often present themselves, rendering impossible a positive diagnosis until late in the course of the disease.

SOLANACEAE.

By Rosa C. Turnbull.

Remedies obtained from plants of the same botanical family, while possessing each a peculiar symptomatology, are found to have many properties in common. This is well illustrated by comparing drugs obtained from the natural order solanaceæ. These drugs, when taken into the system, have a prompt action, the conditions produced are most acute. Their action is of short duration, as they are rapidly eliminated from the system, the composition of the blood and the general nutrition not being affected unless a drug habit is formed. Their action is spent upon the nervous system, where they produce high nervous tension, hyperemia, irritation, hyperesthesia, narcosis, paresis and paralysis-one or more of these conditions, or all of them in successive stages, yet each has its points of difference from all others.

These drugs differ in the especial group of nerves most prominently affected by each. Tabacum prefers the motor nerves throughout their entire length from the medulla to the periphery, the pneumogastric, the optic nerves and the iris. It differs from others of this group in having no direct effect upon the cerebrum, and in producing contraction of the pupil, due to spasm of those nerves given off from the motor oculi to the iris. The atrophy of the optic nerve is also peculiar to this drug.

Capsicum selects the posterior portion of the spinal cord, in this respect standing apart from the rest of the family. Belladonna does

produce chilliness, followed by some sensory paralysis, but this is a late symptom and not one of the keynotes of Belladonna. Capsicum affects also the peripheral vaso-motor nerves, and in the cerebrum produces excitement and then narcosis. Through its action upon the vaso-motor nerves, it is regarded as having greater power to reslove inflammation than has Belladonna, because it not only restroes capillary circulation, but also, in its later stages, promotes exudation. While not possessing the general usefulness of Belladonna, it has a more marked action upon many inflammatory processes where mucous membrane is involved.

It has more effect upon the

Dulcamara is slightly narcotic. medulla than have others of this family, being a depressant to the medulla and the vagi. It renders the entire nervous system hypersensitive to the effects of cold and moisture, with paresis of the motor nerves. In its irritation of the skin it resembles all the other drugs of this group, except Tabacum.

Hyoscyamus has special affinity for the cerebrum, anterior portion of the cord, the auditory nerve, and the nerves controlling the muscular coats of the intestines, the sphincters and the iris. Stramonium has a similar action, their difference being largely one of degree. Belladonna affects very markedly the entire nervous system, giving a preference to nerves controlling the muscles of the hollow viscera.

The peculiar symptomatology of each drug depends largely upon the comparative length of the different stages in the condition produced. As would be expected in drugs acting so promptly, the nerves most quickly affected often pass on to the stage of paralysis, while the less susceptible nerves are still in the stage of irritation. Hence the varied symptoms presented during the course of poisoning by one of them.

Tabacum prefers the stage of irritation. This is made more manifest by the manner of its proving, our indications being taken largely from symptoms noted in habitual users. In such cases where the system has gradually, during a period of thirty to forty years, developed a tolerance for a drug, changing an acute condition into a chronic one, many symptoms are developed which do not occur in an ordinary proving. The stage of irritation comes on quickly, not preceded by any marked exaltation. In most of the nerves this irritation continues while the drug remains in the system, paresis occurring late in a few parts only. Sometimes in old tobacco users we find constipation from paresis of the bowel tract, but diarrhea is the first, and usually the continuous symptom. As a late condition we get paralysis of the nerve-endings in the skin.