Volume 1 — GENERAL DISEASES. (continued 10)

A striking example of this fixity of the poison occurred in the practice of the late Kearney Rogers, formerly a prominent and much esteemed surgeon of New York City. Six children in a family had scarlet fever. Three and a half months subsequently another child, living at a distance, was allowed to return home and occupy the apartment in which the sickness had occurred. One week subsequently to the date of the return this child sickened with the same malady. Elliotson states that a patient with scarlet fever was admitted into one of the wards of St. Thomas's Hospital, and for two years subsequently young persons who were admitted into the ward were apt to take the disease. Richardson of London relates the following experiences of a family whom he attended in a rural district: "At a short distance from one of our villages there was situated on a slight eminence a small clump of laborers' cottages, with the thatch peering down on the beds of the sleepers. A man and his wife lived in one of these cottages with four lovely children. The poison of scarlet fever entered the poor man's door, and at once struck down one of the flock." The remaining children were now removed some miles away, and after several weeks one of them was allowed to return. Within twenty-four hours it also took the disease, and quickly died. The walls of the cottage were now thoroughly cleaned and whitewashed, the floors scoured, and all the wearing apparel either destroyed or washed. Four months elapsed after the last sickness when one of the remaining children returned. "He reached his father's cottage early in the morning; he seemed dull the next day, and at midnight I was sent for, to find him also the subject of scarlet fever. The disease again assumed the malignant type, and this child died." Richardson believes that the contagium was attached to the thatch, which could not be thoroughly disinfected. The fact of this remarkable long-continued attachment of the poison to objects, indicating by this fixity that it is a solid, is consonant with the theory that it is an organism.

INCUBATIVE PERIOD.—The duration of the incubative period varies in different cases. It is sometimes less than twenty-four hours, as in the above case reported by Richardson; in the following well-known case, observed by Trousseau, it was one day. A girl arrived in Paris from Pau, where there was no scarlet fever, and occupied the same apartment with her sister, who was sick with this disease. Twenty-four hours after her arrival she also was attacked with the same malady.

Russeberger attended a child who was exposed at noon to scarlet fever, and took the disease on the following night. B. W. Richardson (Clinical Essays, 1861, vol. i. p. 94) gives his own experience: He had applied his ear to the chest of a patient suffering from scarlet fever, and was conscious of a peculiar odor emitted from the patient. He was immediately nauseated and chilly, and from that moment he dated the beginning of an attack of scarlet fever. In the Transactions of the Clinical Society of London, vol. xi. 1878, the late Charles Murchison gives the statistics of 75 cases, showing the incubative period, as follows:

In 4 cases it was not more than 24 hours. In 2 cases it was not more than 30 hours. In 3 cases it was not more than 36 hours. In 4 cases it was not more than 40 hours. In 1 case it was not more than 41 hours. In 4 cases it was not more than 58 hours. In 1 case it was not more than 54 hours. In 1 case it was not more than 2½ days. In 31 cases it was within (time not accurately ascertained) 4 days. In 2 cases the incubation did not exceed 4½ days. In 17 cases the incubation did not exceed 5 days. In 2 cases the incubation did not exceed 6 days.

In three cases Murchison believes that the incubation was precisely fixed at thirty-six hours, three days, and four and a half days.

Watson says that a man reached Devonshire on mid-day to see his daughter, who had scarlet fever. Two days later he was also attacked. Rehn saw a child who was attacked two days after its grandmother returned from a case of scarlet fever; and Zengerle, a girl of ten years, residing at Wangen, where there was no scarlet fever, who took the disease two days after her mother had returned from visiting a family affected with it. Loochner states that a boy aged four and a half years was attacked one and a half days after admission into the infected wards of a hospital. Armistead, in his annual report on the health of the Newmarket rural district, states that three children, coming from a different part of the district, visited Westley, and stayed next door to a child who had scarlet fever six weeks previously, and who was allowed to play with these children on the evening of Aug. 13th and morning of the 14th. The family then returned home, and on the 18th, four days after the exposure, all three children sickened with scarlet fever (Brit Med. Jour., Sept. 30, 1882).

Ordinarily, therefore, the incubative period, though varying in different cases, is within six days. Many cases, however, occur in which it seems to be longer. Thus in my practice scarlet fever appeared in a family on April 26, 1882. The patient was immediately removed to the third floor and the other children to the basement. All communication between the infected room and the basement was forbidden, but on May 8th, twelve days after the separation, one of these children sickened with the disease. Many observers—among whom may be mentioned Niemeyer and Copland—believe that the incubative period may be longer than one week, but, on account of the subtlety of the poison and the many modes of transmission, it is possible that in the instances of an apparently long incubative period there were other and unsuspected exposures. When scarlet fever has been communicated by inoculation, as in the experiments of Rostan and others, the incubative period has been about seven days, but Gerhardt states that a man was attacked four days after an abscess was opened by a knife used upon a scarlatinous patient. This variation in the incubative period, which also occurs in some other infectious diseases, as diphtheria, is probably due mostly to individual differences, some being more susceptible than others; but it may be due partly to those obscure meteorological conditions which we designate the epidemic influence. Probably, as a rule, when the disease is quickly developed after exposure, the attack is more severe than when several days elapse.

CONTAGIOUSNESS.—The area of the contagiousness of scarlet fever is small. It apparently embraces only a few feet. Therefore, close proximity is the necessary condition of its propagation. Hence many who are exposed, particularly of those who are remotely exposed, do not contract the disease. There is also an idiosyncrasy in some children, so that they resist infection even when repeatedly and closely exposed. In the New York Medical Record for March 23, 1878, C. E. Billington states that of 90 children in 26 families who were exposed to scarlet fever, 43 contracted the disease and 47 escaped; whereas, as is well known, comparatively few unprotected children escape pertussis, variola, varicella, or measles if exposed to either of these diseases. By strict isolation, therefore, the spread of scarlet fever is more easily prevented than that of most other acute infectious maladies. In the New York Foundling Asylum for a number of years children with scarlet fever were isolated in a small room attached to one of the wards. The door between the two rooms was closed, and not opened during the continuance of the sickness. Entrance into the small room was through another door, and a nurse was assigned to the scarlet-fever cases, with strict directions that she should not mingle with the other children. These simple precautions were found sufficient in the various epidemics of scarlet fever which occurred in the city to prevent the spread of the malady through this institution; whereas, similar measures were much less effectual in arresting the spread of measles and pertussis. Consequently, an outbreak of scarlet fever in this institution was usually limited to a few cases, while the extension of measles and pertussis was arrested with difficulty till a more efficient quarantine was established.

VARIATIONS IN TYPE.—The type of scarlet fever varies greatly in different epidemics, and frequently also in cases which occur in the same epidemic, even in the same family. One child may have scarlatina so mildly that little treatment is required and convalescence soon begins, while another has the malignant form, and soon succumbs, notwithstanding the prompt employment of the most efficient and appropriate measures. Ordinarily, however, if the first case in a family be very severe, subsequent cases will present a similar type; but there are notable exceptions. This variation in type in different years and different epidemics is probably not equalled in any other infectious malady. Consecutive epidemics may present this variation, or the same type may continue for a series of years, and then, from some unknown cause, change to one milder or more severe. In England, during Sydenham's life, scarlet fever was so mild that he regarded it as a trivial affection, requiring little attention, like rötheln of the present time, but after the death of Sydenham, Morton and his contemporaries in London found, to their sorrow, that the type of scarlet fever was very different from that described by Sydenham's pen. The late Graves of Dublin and his contemporaries treated a mild type of scarlet fever with a very small percentage of deaths—much less than that during the preceding generation—and they attributed their success to their greater knowledge and more appropriate use of remedies than their ancestors possessed and employed. By and by the type changed, the mortality of former years was restored, and they discovered that their previous success in saving life had been due not to their skill, but to the mild form of the malady. A distinguished physician of New York treated more than fifty cases of scarlet fever in one of the institutions without a single death. A few months afterward the type of the malady changed, and his own son perished from it.

SURGICAL AND OBSTETRICAL SCARLATINA.—After surgical operations, and sometimes in surgical cases not requiring operative measures, a scarlatinous efflorescence occasionally appears upon the whole or nearly the whole body, and remains for several days. The following were cases of the kind alluded to. They occurred in Guy's Hospital, and were published by H. G. Howse in Guy's Hospital Reports for 1879: On March 15, 1878, Jacobson performed osteotomy upon a child suffering from extreme rachitis. The operation was followed by a moderate febrile movement (100° to 101°), and after three days by the appearance of an efflorescence, with sore throat and the strawberry tongue. The osteotomy had been performed under carbolic acid spray and with all the details of antiseptic surgery. The rash soon faded, the temperature fell, and the child, temporarily separated from the other patients from the suspicion that the disease was scarlet fever, was brought back to the ward. The subsequent history confirmed the diagnosis of scarlet fever, for the skin desquamated, and on April 1st abundant albumen was found in the urine. The case terminated favorably. Three months previously the same operation had been performed on the other leg, with no unfavorable symptoms. On April 5th, three weeks after the osteotomy, a lipoma was removed from another patient aged twenty-one years. The following day the temperature rose to 101°, and remained at that till April 8th, when it suddenly increased to 103°, and a rose-rash occurred over the body, with sore throat. On April 9th, Howse excised the elbow-joint of a girl of sixteen years having pulpy disease. On the 10th her temperature began to increase, and on the 11th reached 105.8°. Toward evening a roseoloid eruption appeared over her body, and she was isolated. On April 12th, Dr. H. excised a fibroid bursa patellaë from a woman of twenty-nine years. On the following day her temperature was 99°, but on the 14th it rose to 100°, and on the evening of the 15th she had rigors and headache. On the morning of the 16th the temperature was 102.5°, and a roseoloid eruption occurred over the face and chest. The surgeons now perceived that an epidemic of the so-called surgical scarlatina was occurring, so as to justify the postponement of other operations.

In the same volume of Guy's Hospital Reports, James F. Goodhart gives the histories of nearly thirty cases of this disease occurring during a series of years in the same hospital. The patients were chiefly children, having the most diverse surgical ailments, among which may be mentioned hip disease and abscess, genu valgum without operation, necrosis of femur, hydrocele with explorative operation, a scald, a sinus over the great trochanter, spinal disease with abscess, tenotomy for club-foot, and vesical calculus with operation. The most common disease was caries or necrosis with abscess. In cases operated on the intervals between the operations and the occurrence of the efflorescence varied from two days to more than two weeks. Goodhart, after a careful examination of these cases, came to the conclusion that they were for the most part examples of true scarlet fever, especially as a considerable proportion of them occurred in groups, and there was a known exposure of some of the patients to children admitted into the hospital with the sequelæ of scarlet fever.

In the British Med. Jour. for Jan., 1879, George May, Jr., reported a case of efflorescence in surgical practice which appears to have been scarlatinous. A child was operated on for the radical cure of hernia on Dec. 4th. Toward the close of the same day he became restless, vomited, and his pulse on the following day rose to 136. Forty-eight hours after the operation a rash appeared on the chest and arms, the abdomen became tense and painful, and on the following day he died. The poison, however, in this case may have been septic.

Hillier remarks (Diseases of Children): "In the hospital for sick children, of the children who contract scarlatina a very large proportion have been the subjects of a surgical operation within a week before the rash appears." Gee says (Reynolds's System of Medicine): "It has been doubted by some whether the scarlatiniform rash which sometimes follows operations is really scarlatinal. The eruption appears from the second to the sixth day after the operation, and in the cases which have caused the doubt is very fugitive and the first and only symptom. Yet that the disease really is scarlet fever would seem to be proved by the following observations: first, that the disease occurs in epidemics; secondly, that in a given epidemic a severe case occasionally relieves the monotonous recurrence of the very mild form; thirdly, that a precisely similar scarlatinilla attacks in the same epidemic patients who have not been subjected to operation and who have no open sore; and lastly, by way of a veritable experimentum crucis, that, however freely these patients are exposed to ordinary scarlet fever contagion afterward, they do not contract that disease." Paget and other distinguished London surgeons who have observed this complication of surgical cases, believe that the patients have been previously exposed to the scarlatinous poison, and that the surgical diseases or operations furnish favorable conditions for the occurrence of scarlet fever, so that the exposure, which probably would have been without result in ordinary health, causes an outbreak of the malady.

Those who have reported cases of this form of efflorescence have for the most part neglected to state whether the patients had had scarlet fever previously, knowledge of which would have aided in the diagnosis; but from an examination of the histories of cases, especially those published in the London journals in the last four or five years, there can, I think, be little doubt that surgical maladies of a certain kind, especially traumatism, do produce a state of system which predisposes to scarlet fever, so that this class of patients are especially liable to contract it. Therefore, in my opinion, a considerable proportion of reported cases of surgical scarlatina are genuine, but in a considerable number, perhaps an equal number of such cases, the histories and symptoms indicated a septic rather than scarlatinous efflorescence, and in not a few instances, when consultations have been held, opinions differed, some diagnosticating scarlet fever, others septicæmia. In some of the cases I find it stated that the fauces presented the normal appearance. Now, faucial redness is so generally present in scarlet fever, antedating that of the skin and coexisting with it, that its absence is strong evidence that the disease is not scarlatinous. Moreover, when, as was true of certain of the reported cases, the rash appeared irregularly upon the surface, and faded away in two or three days with the abatement of the fever, and the conditions for septic absorption were present, the efflorescence was probably septicæmic.

The following were apparently cases of septicæmia efflorescence: A child aged five years (Brit. Med. Jour., Feb. 15, 1879) had inflammation of the lymphatic glands in the groin, which suppurated. At the time when the abscess was fully formed a rash appeared over the entire body. It consisted of numerous red points, but was paler than that of ordinary scarlet fever; temperature never above 99°; no sore throat nor desquamation of cuticle. No child exposed to her took scarlet fever, and her sickness could not be traced to infection. In the British Med. Jour., Jan. 4, 1879, L. Braxton Hicks states that his son, attending school at Reading, was seized with a severe attack of pyrexia, accompanied on the second day by delirium and the occurrence of a rash like scarlet fever over the entire surface. He had no decided redness of the fauces, though it was perhaps slightly flushed. The right buttock was swollen from inflammation, and a large, deep-seated abscess formed near the tuberosity of the ischium. When the delirium abated the boy said that he was standing the day before the fever began with his legs far apart, when a schoolfellow stretched them farther by suddenly pulling on one of them. The rash, which was nearly universal, lasted three days, and was not followed by desquamation. No case of scarlet fever occurred in the school before or afterward. In the same volume of the British Medical Journal, Surgeon Frolliott of the East India Service relates the case of a private, aged twenty-three years, and three years in India, who, when on duty in the Punjab, was injured by the explosion of an Afghan powder-magazine. The accident occurred Dec. 21, 1878. On Dec. 25th a bright scarlet rash appeared upon the abdomen and spread over the entire body. The following day the eruption was very vivid, like a boiled lobster, and it lasted five days. The temperature, which in the beginning had been 101°, abated to the normal after the rash appeared. No soreness of throat nor redness of the buccal surface occurred, but the epidermis desquamated even from the palms of the hands and soles of the feet. Now, the febrile movement of scarlet fever does not cease while the efflorescence is distinct. It does not even diminish when the eruption appears, while in the above case it fell to the normal—a common occurrence in septicæmia, even when the blood-poisoning is profound. Moreover, scarlet fever is so rare in India that Frolliott, after twelve years' service, had only heard of one case among Europeans and natives. The surgeons who consulted over the case of this private disagreed in opinion, some regarding the disease as septicæmic, others as scarlatinous. But a better knowledge of the clinical history of scarlet fever on the part of these army surgeons would, I think, have removed all doubt as to the diagnosis.

It is the opinion of some reputable surgeons that the exposure of traumatic patients to the scarlatinous poison sometimes aggravates the inflammation of wounds, causing them to assume an unhealthy appearance even though no scarlatina be produced. The late Solly made the remark, "Whenever a case of surgery in private practice takes on a highly phlegmonous appearance I am always sure to find break out, in the inmates of the house, either erysipelas or scarlet fever" (British Med. Jour., Feb. 15, 1879). We will see that the scarlatinous poison sometimes causes pharyngitis or nephritis without producing the general disease. In a similar manner it seems that it may aggravate open wounds, intensifying the inflammation in them, while there is no efflorescence or other symptom to show that scarlatina itself is present. The poison appears to act entirely locally in such cases.

Paget, in his Clinical Lectures, says: "I think it not improbable that in some cases results occurring with obscure symptoms within two or three days after operations have been due to the scarlet-fever poison, hindered in some way from its usual progress." Playfair, in his remarks on the puerperal state, adds: "Mr. Spencer Wells informs me that he has seen cases of surgical pyæmia which he had reason to believe originated in the scarlatinal poison; and his well-known success as an ovariotomist is no doubt, in a great measure, to be attributed to his extreme care in seeing that no one likely to come in contact with his patients has been exposed to any such source of infection." Opinions like these, held by such prominent members of the profession and sustained by many observations, should certainly induce physicians to prevent, so far as possible, any exposure of their surgical patients, especially if they have any sores or wounds, whether by traumatism or the scalpel, to the scarlatinal poison.

OBSTETRICAL SCARLATINA.—Women during convalescence after childbirth are very liable to contract scarlet fever. In the New York Infant Asylum, which has maternity wards, a woman was admitted from a house in which scarlet fever was prevailing, and assigned to a cot next that occupied by one of the waiting women, who was confined soon afterward. Her labor was favorable, but three days afterward she took scarlet fever, and another lying-in-patient contracted it from her. The sore throat and desquamation were characteristic. It has come to my knowledge that a physician of New York, in whose family scarlet fever was occurring, attended three women in succession in their confinement, and all contracted scarlet fever, which presented the characteristic symptoms, and two of them died. Experienced and cautious physicians of New York, aware of the danger, do not go directly from a scarlatinous patient to an obstetrical case, but avoid the risk by intermediate visits to other patients or by remaining for a time in the open air.

Playfair, remarking on this subject, says: "There is good reason to believe that the contagium of zymotic diseases may produce a form of disease indistinguishable from ordinary puerperal septicæmia, and presenting none of the characteristic features of the specific complaint from which the contagium was derived. This is admitted to be a fact by the majority of our most eminent British obstetricians, although it does not seem to be allowed by continental authorities, and it is strongly controverted by some writers in this country. It is certainly difficult to reconcile this with the theory of septicæmia, and we are not in a position to give a satisfactory explanation of it. I believe, however, that the evidence in favor of the possibility of puerperal septicæmia originating in this way is too strong to be assailable. The scarlatinal poison is that regarding which the greatest number of observations has been made. Numerous cases of this kind are to be found scattered through our obstetric literature, but the largest number are to be met with in a paper by Braxton Hicks. Out of 68 cases of puerperal disease seen in consultation, no less than 37 were distinctly traceable to the scarlatinal poison. Of these, 20 had the characteristic rash of the disease, but the remaining 17, although the history clearly proved exposure to the contagium of scarlet fever, showed none of its usual symptoms, and were not to be distinguished from ordinary typical cases of the so-called puerperal fever. On the theory that it is impossible for the specific contagious diseases to be modified by the puerperal state, we have to admit that one physician met with 17 cases of puerperal septicæmia in which, by a mere coincidence, the contagion of scarlet fever had been traced, and that the disease nevertheless originated from some other source—a hypothesis so improbable that its mere mention carries its own refutation."

Parturition, like traumatism, furnishes in an eminent degree the conditions in which septic poisoning occurs, and the efflorescence which often accompanies septicæmia bears, as we have seen, a very close resemblance to that of scarlet fever. Hence in many instances the same difficulty is present in making a differential diagnosis between septic and scarlatinous blood-poisoning in obstetrical cases which occurs in surgical practice. But, according to my observations, an efflorescence occurring during the week following parturition is in most instances septic. It is only in exceptional cases that it is scarlatinous, and there is little danger that the accoucheur, engaged in general practice and visiting scarlatinous patients, will communicate scarlet fever through his person or clothing if he exercise proper precautions. His short stay in the sick room and his out-door exercise in visiting cases prevent infection of his person or dress. But if, as Playfair believes, the scarlatinal poison sometimes produces in parturient women a puerperal fever in which the characteristic scarlatinal symptoms are lacking, and which, in the present state of our knowledge, is not distinguishable from ordinary septic fever, certainly the scarlatinous virus sustains a much more frequent causative relation to childbed fever than has been heretofore supposed.

Infants under the age of six months do not ordinarily contract scarlet fever, although fully exposed, and those under four months nearly possess immunity. Still, this disease has been observed in new-born infants, contracted, apparently, through the placental circulation. Tourtual states that a woman waited upon her own husband and child, both of whom had scarlet fever, during the eighth and ninth months of her pregnancy, till near her confinement. Though she had no symptoms of scarlet fever, her infant had unusual redness of the skin and buccal surface and difficulty of swallowing up to the fifth day. On the ninth day desquamation began, and at a later stage the nails of the fingers and toes separated. A case having a history in some respects similar is related by Megnert, but the symptoms were anomalous for scarlet fever, and the disease may have been ordinary septic fever. On the other hand, in one instance in my practice a mother had scarlet fever, beginning about the third day after her confinement, and although she suckled her infant and it was constantly in bed with her, it had no symptoms of scarlet fever, although it became affected immediately afterward by a severe form of eczema, probably from the altered quality of the milk; and in two instances observed by Murchison new-born infants remained healthy, although their mothers suffered from scarlet fever.

After the age of six months the liability to scarlet fever increases till the close of infancy, children between the ages of six months and one year being less liable to contract the malady than during the second year, and those in the second year being less liable to it than those in the third year. Murchison collected the statistics of deaths from scarlet fever in England and Wales during a series of years ending with 1861. The number of deaths aggregated 148,829, and the percentage of deaths at different ages was as follows:

Deaths under 1 year, 6.7 per cent.

Deaths between 1 and 2 years, 14.09 per cent.

Deaths between 2 and 3 years, 16.00 per cent.

Deaths between 3 and 4 years, 15.13 per cent.

Deaths between 4 and 5 years, 11.9 per cent.

Deaths between 5 and 10 years, 25.9 per cent.

Deaths between 10 and 15 years, 5.8 per cent.

Deaths between 15 and 25 years, 2.6 per cent.

Deaths between 25 and 35 years, 0.8 per cent.

Deaths over age of 35 years, 0.8 per cent.

Among the deaths were ten cases above the age of eighty-five years, so that scarlet fever, though especially a disease of childhood, may occur in any decade of life; but old age, like early infancy, almost possesses immunity from it.

I have preserved the records of the ages of 145 consecutive cases occurring in private practice. If we add to these 58 cases observed by Prof. Octerlony (Amer. Jour. of Med. Sci., July, 1882) we have the statistics of the ages of 203 cases, which are embraced in the following table:

Under 1 year, 3

From 1 to 2 years, 25

From 2 to 3 years, 43

From 3 to 5 years, 57

From 5 to 10 years, 53

From 10 to 15 years, 13

From 15 to 20 years, 3

From 20 to 30 years, 4

From 30 to 40 years, 2

Total, 203

CLINICAL FACTS REGARDING SCARLET FEVER.—As a rule, scarlet fever occurs but once, one attack conferring immunity from the disease for life; but there are exceptions. In 1869, I attended a child with fatal scarlet fever who three years previously, it was stated, had passed through a first attack with all the characteristic symptoms. The following case occurred in a family attended by the late Dr. Herzog: R——, a boy of six years, had scarlet fever in a mild form in January and February, 1875, followed by moderate desquamation. In July of the same year he was kicked by a horse in the street, receiving a deep scalp-wound which required three stitches. Three days afterward he had, to appearance, a second attack of scarlet fever, attended by high febrile movement, and followed also by desquamation. It was believed by Dr. H. to be a genuine case, and was so treated. I am not able to state as regards the presence of soreness of the throat, and doubt arises whether this second attack may not have been septicæmic. In April, 1876, a third attack occurred, which I saw from the beginning. It was accompanied by all the characteristic symptoms—injection of the fauces, an efflorescence continuing the usual time, followed by desquamation and albuminuria, the latter continuing several weeks. Richardson states that three distinct attacks occurred in his own person, and a student attending the lecture at which this was mentioned informed the doctor that he also had had scarlet fever three times.

Sometimes a second attack occurs so soon after the first that it has been described as a relapse. The following was a case in point in the practice of Godneff (Meditz. Vestnik., No. iv., N.Y. Med. Rec., April 30, 1881): A youth of seventeen years contracted scarlet fever while taking care of a child. It began with a chill, and he had the usual efflorescence, sore throat, and tumefaction of the cervical glands. An exudation appeared upon his tonsils and uvula, and his temperature reached 104°. The urine contained a trace of albumen, the rash in due time faded, and the epidermis exfoliated. On the fifteenth day, when he was about ready to leave the hospital, he again had a chill, followed by fever. The temperature reached 105.2°, the rash reappeared over the entire surface except the face, diphtheritic exudations occurred upon the fauces, and the urine, the quantity of which was diminished, again became albuminous. This second efflorescence faded on the twenty-fourth day, and on the twenty-seventh exfoliation began. Hillier says: "I have seen a young woman in the fever hospital suffering from a second attack of scarlatina, the first attack having occurred five weeks previously. She had quite recovered from her first illness, and was acting as nurse. In both seizures the rash, the sore throat, and other symptoms were characteristic. The relapse or recurrence was less severe than the primary disease." Cases of a fourth, or even of a greater number of attacks, have been reported. The first seizure is sometimes milder, but in other instances is more severe, than those which follow.

Exposure to the scarlatinous poison not infrequently produces pharyngitis without the occurrence of scarlatina, and the inflammation is apt to be severe, accompanied by pain in swallowing and marked febrile movement. This phlegmasia is distinguished from scarlet fever by its shorter duration and the absence of the efflorescence. It occurs in adults as well as in children, and in those who have had, as well as in those who have not had scarlatina. So far as I have observed, it is very seldom accompanied or followed by any of the complications or sequelæ so common in and after scarlet fever. It cannot be distinguished from ordinary pharyngitis except in the manner in which it occurs, and one attack does not preclude another. The late George B. Wood made the remark that he never attended a case of scarlet fever without suffering from sore throat. The following were examples of this form of pharyngitis: On Jan. 17th, 1882, I was called to a boy of three years with severe scarlet fever, ushered in by convulsions. On the following day his sister, aged seven and three-fourths years, whom I had attended a year previously during a severe attack of scarlatina, and who had been almost constantly with the brother, became very ill, with a temperature of 103.5°. Examination revealed severe inflammation of the fauces, without pseudo-membrane or any other exudation except muco-pus. On Jan. 19th an older brother, nine years, whom I had attended in scarlet fever three years previously, was affected in the same way, his temperature being 104° and his respiration guttural and noisy, especially during sleep, in consequence of the great amount of faucial swelling. At times he was delirious. The inflammation in both cases began to abate about the third day, and had disappeared by the close of the week. That the contagium of scarlet fever may be received into the system and cause pharyngitis, while the patient has immunity from scarlet fever through a previous attack, and that this inflammation may occur any number of times, as in the case of Dr. Wood, are remarkable facts.

Now and then cases occur which appear to show that the scarlatinous poison may affect the kidneys, producing nephritis, while there is no other manifestation of its influence. Thus in my practice a lady of about forty-five years constantly attended her son, sleeping by his side, during an attack of scarlet fever. Her health had previously been good. When the boy was convalescent, as her appetite failed and she was indisposed, a careful examination revealed the fact that she had albuminuria, although she had had no sore throat or other symptom of scarlet fever. After several weeks of treatment her disease was removed, and she has remained well since. In the British Med. Jour. for Nov. 29, 1879, it is stated that in a family four girls were found to be suffering from desquamative nephritis. One of them had recently had scarlet fever, but the other three had presented no symptoms whatever of this disease. Such cases, although probably rare, appear to show that, as the scarlatinous poison may produce inflammation of the fauces without the occurrence of scarlet fever, so it may cause nephritis without producing the general disease, or apparently disturbing the functions, or changing the state of other parts, except the kidneys.

SYMPTOMS.—ORDINARY FORM. Scarlet fever usually begins abruptly, so that the exact time of its commencement can be fixed. If any premonitory symptoms occur, they are slight, so as scarcely to attract attention, as languor or the appearance of fatigue. A dusky aspect of the surface may occasionally be observed during the few hours preceding the attack. In some children the first symptom is chilliness, and occasionally a distinct chill occurs. In the adult a chill is ordinarily the first symptom. With or without the initial chilliness, febrile movement occurs, of variable intensity according to the severity of the type, and accompanied by such symptoms as usually arise in a febrile state of system, as cephalalgia, anorexia, and thirst. The pulse rises to 110, 120, or more per minute, the temperature to 102°, 103°, or 104°; the skin is hot, face flushed, and the eyes bright. Even in cases that are not malignant or grave, and that give indications of a favorable result, there is often more or less stupor, with transient delirium and sudden starting or twitching of the extremities, showing that the cerebro-spinal axis is involved.

Vomiting is a common symptom in the beginning of scarlet fever, occurring before the appearance of the efflorescence. It therefore has diagnostic value when the nature of the case is still doubtful. In some patients it is an initial symptom, but in others some hours have elapsed when it occurs. I recorded its presence or absence in 214 patients, with the following result: present in 162 patients, absent in 52. In severe forms of the disease it is rarely absent, and if it do not occur it is probable that the case will be mild, requiring little treatment and having a favorable termination. In epidemics of unusual mildness the number of cases without vomiting may be in excess of those in which this symptom occurs. It appears to be due to functional disturbance of the cerebro-spinal system, and it may therefore be properly regarded as a nervous symptom. In severe cases the vomiting is apt to be repeated, not only on the first but on subsequent days, and we shall see that in cases of great gravity, in which a fatal termination is not improbable, persistent vomiting, by which the food and stimulants so urgently required are rejected, interferes seriously with successful treatment. In a few cases embraced in my statistics nausea without vomiting was recorded. The bowels in ordinary scarlatina act regularly or are slightly constipated. Diarrhoea, which so commonly accompanies the persistent vomiting in malignant cases, if it occur in this form of the malady is slight and transient and due to accidental causes. The food, if it be given in the liquid form and cool, is usually taken readily, on account of the thirst, except when deglutition is rendered painful by the pharyngitis.

The symptoms pertaining to the nervous system vary according to the severity of the disease and the temperament of the patient. Many children during the progress of the common form of scarlet fever present a dull or apathetic appearance. They lie much of the time with their eyes closed; others are more restless, and not a few, if the fever be considerable, have occasional twitching of the limbs and more or less headache. Eclampsia sometimes occurs on the first day, especially in those predisposed to it, even when the subsequent course of the disease is mild and favorable. This complication, very grave and usually fatal when it occurs at a later stage, is in most instances, when it takes place on the first day, readily controlled by proper remedies and with little detriment to the patient. But if it be attended by high elevation of temperature and marked drowsiness, approaching the comatose state, it is very serious upon the first as well as upon subsequent days. Nervous symptoms occurring in the beginning of scarlet fever, when it has the ordinary favorable type, begin to abate in three or four days, but if they supervene at a later date, and especially in the declining stage, they possess more gravity, since they then not infrequently result from and indicate renal complication.

Early in the disease, nearly as soon as the commencement of the fever, the faucial and buccal surfaces become inflamed, as shown by redness, swelling, and tenderness. The physician summoned in the beginning of an attack will already, at his first visit, observe hyperæmia of the fauces, with points of deeper injection than over the general faucial surface, and soon the buccal surface also participates. The inflammation at first produces preternatural dryness, and this is followed by a viscid secretion. The papillæ of the tongue enlarge and become prominent, giving rise to the appearance known as strawberry tongue which is so common in scarlet fever. This state of the buccal and faucial membrane continues throughout the disease. A thin fur appears upon the tongue on the first day, and it increases on the second and third days, after which it is apt to be detached, exposing the surface of the organ, which has a deep red hue, but in not a few patients the fur remains or is reproduced as soon as shed. Except in the mildest cases the Schneiderian membrane also participates in the inflammation as the disease advances, so that a thin, irritating discharge, containing leucocytes or pus-cells, flows from the nostrils. The skin is hot and dry, and cutaneous transpiration nearly checked. The respiratory system is rarely involved in any notable manner unless there be a complication. Many have no cough whatever, while others have a slight cough, due to the fact that the inflammation, of a catarrhal form, has extended from the fauces to the surface of the glottis. Slight acceleration of respiration, corresponding with the degree of fever, may also be observed. The kidneys commonly act regularly and normally during the first days, any serious impairment of their functions being rare before the close of the first week.

When the symptoms described above have continued from six to eighteen hours the efflorescence appears. It is first observed about the ears, neck, and shoulders, in reddish patches fading into the normal hue. These patches extend and unite, and in the course of a few hours the trunk and upper extremities, and finally the legs, are covered. The scarlatinous rash usually, when fully developed, resembles that produced by external heat or the application of a sinapism. It has been likened to the appearance of a boiled lobster, but there are numerous minute points of a deeper or duskier hue than the surface generally. In many patients the rash appears, especially over the abdomen and lower extremities, as minute, thickly-set points, with the skin of normal appearance between them. Henoch of Berlin says of scarlet fever: "In general, the moderate grades of eruption prevail, the skin, when seen from a distance, presenting a diffuse, more or less scarlet redness, while on closer inspection it is found that this redness is composed of innumerable red points closely situated together, and separated from one another by very small paler portions of skin. The dark-red points appear to correspond to the hair-follicles." On passing the finger over the efflorescence no distinct prominences are observed, but a sensation of roughness is sometimes imparted from engorgement of the cutaneous papillæ. The rash disappears on pressure, but it immediately reappears when the pressure is removed. Its slow return is evidence of sluggish circulation, and it indicates a grave and dangerous form of the malady. The color is then usually a dusky instead of a bright red. The efflorescence is most marked in dependent parts, as along the back, over the chest and abdomen, and in the flexures of the joints. Parts pressed upon by the bed-clothes, which confine and intensify the heat, present a deeper coloration than other portions of the surface. Often, especially in mild cases, the rash is absent from portions of the surface where it commonly appears, while it presents a typical character elsewhere. Tardy and incomplete establishment of the rash when the symptoms indicate an attack of ordinary or more than ordinary severity is commonly due to some perturbating cause, especially diarrhoea. In the London Lancet for Aug. 16, 1879, cases are related of supposed scarlet fever without the rash, cases in which pharyngitis and stomatitis with the strawberry tongue occurred, without efflorescence upon the skin; but it is to be remembered, as stated above, that the inflammations which commonly attend or follow scarlet fever, particularly the pharyngitis and nephritis, not infrequently occur in those who have already had scarlatina, and occur more than once from fresh exposure to scarlatina patients. These inflammations, occurring under such circumstances, appear to be purely local maladies, produced by the scarlatinous virus; and it seems to me a question whether, in the so-called scarlatina without efflorescence, the inflammations which are present, and which undoubtedly have a scarlatinous origin, are not local in their nature, instead of being local manifestations of the constitutional disease. The burning and itching sensation produced by the rash increases the restlessness of the patient, and is sometimes the most annoying of the symptoms.

The temperature in the common favorable forms of scarlet fever usually varies from 101° in the mildest cases to 103° or 104° in those more severe. If it attain 105° or over, the case is properly designated grave or severe. The febrile movement commonly fluctuates but little from day to day till the fourth or fifth day, when, if the case be favorable and no complication occur, it begins to decline. The temperature is as high in the beginning of the attack as subsequently.

The symptoms pertaining to the digestive system during the initial period of scarlet fever have been sufficiently described. The subsequent symptoms referable to this system do not differ materially from those present in the beginning, except the absence of vomiting. The lips are dry and often cracked. The inflammation of the mouth and throat continues, with anorexia and thirst. With the decline of the disease the appetite gradually returns, but it is not till the close of the second week that it is fully restored. Great and continued disturbance of the digestive apparatus, seriously interfering with the nutrition, pertains to the malignant forms of scarlet fever.

The urine is high-colored, and in robust children during the first days of scarlet fever it frequently deposits urates on cooling. Gee, who has carefully investigated the state of the urine in scarlet fever, says that the quantity of water is diminished and the urea is not necessarily increased during the pyrexia; that the chloride of sodium is diminished till the fourth, fifth, or sixth day, and that the phosphoric acid is diminished during the climax of the pyrexia, though not during the first three or four days. In one case he made a daily estimation of the amount of uric acid, and found it greatly diminished on the second and third days, normal on the fourth, and much increased on the fifth. He believes that similar variations are common in the quantity of the products excreted in the urine. Bile may also appear in the urine, coincident with a yellow tinge of the conjunctiva.¹

¹ Article on scarlatina in Reynolds's System of Medicine.

The duration of scarlet fever varies in different cases. If the attack be very mild, with little efflorescence, the febrile movement may decline by the fourth or fifth day; but if the disease be severe, little or no amelioration of symptoms may occur before the twelfth or fourteenth day, even when no complication has occurred to increase the temperature or cause aggravation of symptoms. Octerlony, who estimated the duration of scarlet fever from the commencement of febrile symptoms to "the disappearance of fever, with marked improvement in leading symptoms," ... "found that the average duration of the disease in forty cases was six and one-sixth days. The minimum duration in a very slightly-marked case was three days: the maximum duration was fourteen days." In general, prolongation of fever beyond the usual time is due to some complication—more frequently to unusually severe pharyngitis, with accompanying cellulitis, than to any other cause.

The malady whose commencement was so abrupt declines gradually. In ordinary cases, by the close of the first week or in the beginning of the second the rash becomes less and less distinct, and finally disappears, as do also the redness and swelling of the buccal and faucial surfaces. The engorgement of the tonsils and of the papillæ of the tongue subsides, the appetite returns, the countenance brightens and becomes natural, and the child, who during the height of the fever scarcely noticed objects or noticed them with indifference or even repugnance, can be amused as before his sickness.

Desquamation succeeds. This begins at about the sixth day, and is not completed till the tenth or twelfth day; often not till the close of the third or in the fourth week. The amount of desquamation corresponds with the intensity and duration of the efflorescence, or rather of the dermatitis which produces the efflorescence. If the efflorescence have been slight and partial, it will be slight, perhaps scarcely appreciable, but if the rash have been general, full, and protracted, exfoliation occurs upon every part. It begins about the face and neck, and within a day or two appears upon other parts. Where the skin is thin the epidermis as it is detached presents a furfuracous appearance; where it is thick, as upon the palms of the hands or soles of the feet, it separates in layers of considerable thickness.

Such is a brief description of scarlet fever when it pursues its normal course without any disturbing element, but there is no other disease in which complications and sequelæ so frequently occur. The liability to them renders the prognosis in every case doubtful. They largely increase the percentage of deaths. They occur both in mild and severe forms of scarlatina.

The difference in type in different cases and epidemics has already been alluded to. Scarlet fever is sometimes so mild, and its symptoms so slight, that the diagnosis is necessarily uncertain. In the spring of 1866 I was called to an infant thirteen months old who had slight pharyngitis and an indistinct rash over a part of the surface. In two days the eruption had disappeared, and the health within a day or two later was apparently fully restored. Diagnosis would have been doubtful except for sequelæ which clearly indicated the scarlatinous nature of the attack. In another instance two children passed through the entire course of scarlet fever playing every day in the street. Although the intelligent grandmother saw the rash upon them, its nature was not suspected, as it was midsummer and cases of prickly heat common, till nearly two weeks afterward, when one of the children had nephritis and anasarca ending fatally. In cases so mild as these the heat of surface is but slightly increased, the pulse but little accelerated, and the rash usually does not occupy so much of the surface as in ordinary cases; the appetite is not lost, though diminished, and the thirst is moderate.

Between scarlet fever so mild that it terminates in four or five days, and that of the grave or malignant type presently to be described, all grades of severity exist. Scarlet fever occurs in all forms from mild to severe, but certain symptoms characterize grave or malignant cases—symptoms which are absent or much less prominent in ordinary scarlet fever. Therefore the grouping of cases according to the type is proper, and facilitates the studying of the disease.

GRAVE FORM (malignant scarlet fever).—This form of the disease is in some epidemics common, while in others it is rare. The symptoms which characterize it are severe from the beginning, those of the nervous system predominating at first, such as intense cephalalgia, restlessness or stupor, sudden twitching of the muscles, and perhaps delirium, or even convulsions. Many pass rapidly into coma and die within two or three days, succumbing to the intensity of the scarlatinous poison while the malady is still in its commencement. The rash is dusky. It disappears by pressure, and returns slowly when the pressure is removed, showing extreme sluggishness of the capillary circulation. Some patients are very drowsy, lying in a semi-comatose state except when aroused, and if aroused are very restless. Others are constantly restless. If placed in one position on the bed, they throw themselves in another in a half-conscious or unconscious state. They do not speak, or they mutter like those affected by the graver forms of typhus, calling the names of playmates or talking incoherently about things which interested them when well. The thermometer placed in the axilla is found to rise above 103°, which is a safe average, to 105° or even 107°, and the heat of the surface is pungent except when the case approaches a fatal termination, when the extremities, ears, and nose may be cool while the trunk and head are extremely hot. The pulse from the first is rapid, ranging from 130 as the minimum in a malignant case to a frequency which can scarcely be counted. A very frequent pulse is nearly always feeble and compressible. Irritability of the stomach is one of the most common symptoms in grave cases, so that many patients immediately reject the nutriment and stimulants which are so urgently required to sustain the vital powers. The vomiting, therefore, if frequent and severe, greatly increases the danger, and in not a few instances this symptom is associated with diarrhoea, which also tends to increase the prostration.

Severe and dangerous nervous symptoms, due to the intensity or activity of the scarlatinous poison, occur chiefly within the first three or four days. Grinding the teeth, sudden muscular twitching, delirium, convulsions, and profound stupor occur for the most part within this time. Afterward the danger is mainly from exhaustion, unless in the second week or subsequently, when nervous symptoms may arise from uræmia.

Those who survive the onset of malignant scarlet fever often have in the course of a few days severe pharyngitis, with extension of the inflammation to the lymphatic glands and connective tissue around the angle of the jaw. These inflammations cause more or less external swelling. The faucial turgescence around the entrance of the larynx, with the accompanying secretion of viscid mucus or muco-pus, often causes noisy respiration, and many at this stage of the attack breathe with the mouth constantly open to facilitate the ingress of air.

Ordinarily, no discharge occurs at first from the nasal surface, but as the disease continues, if the type remain severe, defluxion of thin muco-pus takes place from the Schneiderian surface, which frequently excoriates the cheek. The lips also are apt to be sore and swollen.

In malignant cases the disease is more protracted than when the type is mild. Thus in a recent case in my practice the rash was still distinct at the close of the second week, though the temperature had fallen from 105° to 102° and some desquamation had appeared. Long continuance of the febrile movement is, however, oftener attributable to some inflammatory complication than to the primary disease.

In all epidemics of a severe type cases now and then occur in which the poison is so intense, or it acts with such frightful energy, that death occurs even within the first day. The patient is overpowered at the outset of the disease by the virulence of the specific principle, perishing in coma, preceded perhaps by convulsions. The autopsy in such cases reveals hyperæmia of the brain and cranial sinuses, blood of a dark-red color, capillary hemorrhages in various parts, a flabby heart, and perhaps some engorgement of the spleen and kidneys.

Usually, malignant scarlet fever exhibits its severe type from the first, but cases sometimes occur which seem mild and favorable for a few days, when severe symptoms suddenly supervene. This change from a mild to a dangerous disease is, however, most frequently, I think, due to some complication.

IRREGULAR FORMS.—Deviation from the normal type in scarlet fever is usually due to some perturbating cause, which is often a pre-existing or co-existing disease, or a disordered state of system through causes distinct from the scarlatinous disease. Thus, a little girl in my practice had the symptoms of scarlet fever, such as febrile movement and inflammation of the buccal and faucial surfaces, nearly a week before the scarlatinous eruption appeared. During this time the patient had an intestinal catarrh, with diarrhoea, which declined when the rash occurred. This intestinal disease was the apparent cause of the irregularity in the malady. If scarlatina occur during a severe attack of entero-colitis attended by purging, the defluxion from the external surface may be such that no efflorescence appears. Severe scarlet fever itself sometimes appears to cause gastro-intestinal catarrh so as to produce an afflux of blood toward the intestinal tract and away from the skin. Practitioners occasionally meet cases like the following, which I recall to mind: In a family where scarlatina was prevailing a little child early after the commencement of symptoms which seemed to be plainly referable to this exanthem was seized with vomiting and purging, which continued till death occurred on the third day. No efflorescence appeared upon the skin, but the symptoms indicated the presence of severe intestinal catarrh, complicating and masking scarlatina. We are aided in the diagnosis of such cases by observing the faucial redness, and we may discover a faint efflorescence upon parts of the surface, as about the groin or in the flexures of the joints. In another instance an infant in the warm months having protracted entero-colitis, the usual summer epidemic of the cities, had the characteristic symptoms of scarlet fever, which was present in the family, but the diarrhoea continued and no rash appeared.

In one who is much reduced by an antecedent disease, as phthisis, or who has a disease, chronic or acute, which produces a decided afflux of blood away from the surface and toward the interior of the body, the eruption is commonly tardy in its appearance, indistinct, or wholly absent. Thus, severe inflammations of internal organs not infrequently render scarlet fever irregular. On the other hand, some maladies occurring in connection with this exanthem do not change its symptoms, but themselves undergo modification. Pertussis may be cited as an example, the cough of which is sometimes modified by an intercurrent attack of scarlet fever, the symptoms of the latter disease undergoing little change.

Scarlet fever may also be irregular without any apparent perturbating cause. In 1867 I attended a young lady whose previous health had been good, and whose brother was sick at the time with scarlet fever. She had considerable febrile movement, with severe pharyngitis, and, though her surface was repeatedly examined, no efflorescence was seen. Two weeks subsequently she was affected with severe nephritis, anasarca, effusion into at least one of the pleural cavities, oedema of the lungs, and probably hydro-pericardium, the case ending fatally. Rilliet and Barthez state that a second attack of scarlet fever is more apt to be irregular than the first. Probably this opinion is correct, especially if only a short time have elapsed between the two seizures. Still, as we have already stated, both seizures may be typical, and the second more severe than the first.

It would be impossible to make a clear and positive diagnosis of certain cases of irregular scarlet fever, in which cerebral, pulmonary, or gastro-intestinal symptoms predominate, were it not for the fact that they occur in connection with other cases of scarlet fever or are followed by sequelæ which evidently have a scarlatinous origin.

Occasionally, the eruption, if it be intense or if a certain condition of system be present in the patient, is accompanied by more or less extravasation of blood-corpuscles from the capillaries, so that the redness does not entirely disappear on pressure, usually in points. In rare instances certain of the exanthematic fevers present an extreme hemorrhagic character, so as to be beyond the reach of remedies, and of necessity speedily fatal. Hemorrhagic cases of this severe form are probably more common in variola than in the other fevers, but I have met a notable case in what was diagnosticated scarlatina. In June, 1881, a man in his thirty-second year, whose previous health had not been good, though he had no defined ailment and had been able to follow his occupation of harness-maker, suddenly became very ill, with high febrile movement and faucial inflammation, attended by marked prostration. After some hours an intense eruption of a scarlatinous appearance covered nearly the entire surface, and on the following day hemorrhages began to occur. The urine contained a large proportion of blood; each conjunctiva was raised by hemorrhages underneath (ecchymosis), so that its natural color was lost and the eyelids closed with difficulty; and blood flowed from the nostrils, gums, and under the skin, forming hemorrhagic points and blotches. One of the consulting physicians, perceiving the resemblance to hemorrhagic variola as described by Hebra, suspected that we had a case of this formidable malady to deal with, but the time for the appearance of the variolous eruption passed by without its occurrence. Death took place on the fifth day. The temperature during the sickness was high, though the record of it has been mislaid. Fortunately, such severe hemorrhagic cases, which are necessarily fatal, are rare.

COMPLICATIONS AND SEQUELÆ.—Scarlet fever, if its type be severe, is in itself dangerous to life. Many, as we have seen, perish from its direct effects when it produces profound blood-poisoning. But, while the ordinary epidemics of this malady are necessarily attended by a large mortality from the virulence and depressing effect of the specific principle, unfortunately, of all the diseases of modern times, scarlatina ranks first as regards the number and gravity of its complications and sequelæ, so that nearly or quite as many perish from these as from the direct effect of the poison.

Nervous accidents occur chiefly at two periods—to wit, in the first days, when they are due to the severity and malignancy of the malady and to the impressible nervous temperament of the child, and in the declining stage, or after the termination of the fever, when they occur from uræmia. If the type be malignant, delirium, jactitation, profound stupor, and convulsions frequently occur on the first and second days; and they are symptoms which properly excite the utmost alarm and demand all the resources of our art, since they indicate a form of the disease which is apt to end in speedy death. The eyes have a dull or wild expression, the conjunctiva is suffused, the heat of surface pungent, the pulse rapid and compressible or feeble, rising above 150, even to 200, per minute, and the temperature is always elevated to a degree that involves danger, the thermometer not infrequently indicating 105° or 106°. But this severe form of scarlet fever, attended by so great elevation of temperature, is much less dangerous than in former times, even though it be complicated by delirium and convulsions, since we no longer hesitate to reduce bodily heat, when excessive, by the free use of cold baths, and have discovered potent agents in the bromides and chloral for controlling convulsions. Nevertheless, not a few perish in the commencement of scarlet fever with predominating cerebral symptoms, as delirium or eclampsia, followed by coma, under the best possible treatment. Sometimes the symptoms have closely simulated those of acute meningitis, and if the rash have been delayed and the sore throat is as yet slight, the physician may suspect that he is dealing with this disease; but autopsies in such cases show no inflammatory lesions, but only congestion of the cerebral and meningeal vessels.

As is stated in a preceding page, in every case of normal scarlet fever inflammation of the faucial surface is present, as indicated by redness, tenderness, and increased secretion of mucus or muco-pus. It precedes the efflorescence on the skin, and is announced by pain in swallowing and on pressure with the fingers behind and below the angles of the jaw. In that form of scarlet fever which has been designated anginose the pharyngitis is severe, and is a prominent element in the malady, the uvula, the pillars of the fauces, and the faucial surface in general being infiltrated and swollen. Nevertheless, this inflammation, with the accompanying tumefaction, is properly a part of the disease, rather than a complication, if it abates with the subsidence of the scarlet fever or begin to abate soon after, and if it produce but slight destructive change in the tissues of the neck. The secretions from the fauces may be foul and offensive; even superficial ulcerations or gangrene may occur upon the faucial surface, causing it to present a dark brown or jagged appearance, and the tissues of the neck may be infiltrated to a certain extent, and we designate the disease a form of scarlet fever under the title anginose. But when this condition is greatly aggravated, so that there is extensive infiltration and swelling of the tissues of the neck, with an amount of ulceration or gangrene which in itself involves danger, continuing after the primary disease abates, prolonging the fever and reducing the strength, it is proper to regard the state of the throat as a complication. In addition to the pharyngitis, which is severe as described above, the sides of the neck around the angles of the jaw become swollen, hard, and tender. The inflammation has been propagated to the deeper structures of the neck. Poisonous substances, the result of decomposition or vitiated secretions, traverse the lymphatic vessels from the faucial surface, and, being intercepted in the lymphatic glands, cause adenitis, and the inflammation extends from the glands to the adjacent connective tissue, which becomes hard, tender, swollen, and infiltrated with inflammatory products. This tumefaction sometimes begins by the second or third day, but it is usually about the close of the first week or in the beginning of the second week that it becomes so considerable as to constitute a source of danger and anxiety. It is in most cases bilateral, though one side may begin to swell before the other and remain larger throughout.

In severe cases of this complication the tumefaction extends from ear to ear, filling up the space below and around the angles of the jaw and under the chin. Not only is deglutition difficult, but it is difficult to open the mouth sufficiently to inspect the fauces, and attempts to do so cause much pain. The lymphatic glands, which lie in the inflamed area and participate in the inflammation, are greatly enlarged by hyperplasia, the round granular lymph-cells multiplying so abundantly that the glands increase to many times their normal size. Most of the tumefaction is, however, due to extension of the inflammation to the connective tissue of the neck. The cellulitis, which resembles that occurring in other conditions, is attended by distension of the capillaries, the abundant formation of young round cells, and transudation of serum (Billroth). A moderate amount of tumefaction may disappear by resolution, but if it be considerable it seldom abates in this way, but by the tedious and exhausting process of suppuration or gangrene. If the swelling at its most prominent point present a reddish hue, all hope of producing resolution must be abandoned; it cannot be effected by any medicine or appliance within the resources of our art. The abscess which forms is apt to be diffuse, so as to involve danger of pyæmia, unless it be soon opened and properly washed out. With the discharge of the pus the swelling gradually softens and declines. In other cases gangrene results. The vessels in the inflamed part are compressed by the inflammatory products, so that they no longer convey the blood which is required for the purpose of nutrition. It is a law of the economy that whenever the circulation ceases, the tissues which receive their nutritive supply through the obstructed vessels lose their vitality. Hence gangrene occurs in all that portion of the swelling in which the circulation is arrested. The skin over it peels off, the dead tissue underneath is brown or dark, and soon, if life be prolonged, the slough begins to separate. The prognosis as regards this complication depends largely on the size of the slough. If it be large, death will probably result, since the strength of the system is already reduced by the primary disease, and the reparative process will necessarily be slow, while abundant suppuration tends to increase the exhaustion. In some of the worst cases of cervical gangrene which I have seen the slough has laid bare the muscles and vessels of the neck, producing in one case a cavity or excavation sufficiently large to admit a hen's egg. Often the slough extends under the skin, so that the deepest recesses of the cavity are not visible, and occasionally in cases which have ended fatally in my practice severe hemorrhage occurred from the concealed vessels. If the ulcerative or gangrenous process extends so deeply into the tissues of the neck that hemorrhages occur, death is the common result; but if the destructive action be of moderate extent and other conditions favorable, we may expect recovery through cicatrization, with perhaps some deformity by contraction of the cicatrix.

When the inflammation of the connective tissue of the neck is extensive, involving both the lateral and anterior regions of the neck, the patient is in a perilous state. The cellulitis, when extensive and accompanied by much swelling, may produce oedema of the glottis, may obstruct respiration by compressing the air-passages or the laryngeal nerves, may cause compression of the jugular veins, and thus give rise to dangerous cerebral symptoms, or may lay bare and injure important muscles and nerves, as we have seen. If the ulceration or gangrene be extensive, and death do not occur by hemorrhage from arterial or venous twigs, septic poisoning may occur, increasing still more the fatal nature of the malady.

Some cases of this complication are melancholy in the extreme, as one related by Cremen, in which ulceration of the pharynx occurred, allowing the escape of food and preventing deglutition. In severe scarlatinous pharyngitis the inflammation is apt to extend along the Eustachian tube, causing its occlusion. This accident will be considered when we treat of otitis media, another grave complication. It often also extends into the nares, causing catarrh of the Schneiderian mucous membrane, with discharge of muco-pus from this surface. Not infrequently ulceration or gangrene occurs in the faucial surface, producing more or less destruction of tissue and forming excavations which connect with the throat, while the cutaneous surface retains its integrity and is not even reddened. The following case shows how grave the complication which we are now considering sometimes is when the external surface of the neck is not involved, and how the inflammation by extension outward from the fauces may involve the middle ear.

Case 1.—Annie K——, aged two and a half years, an inmate of the New York Foundling Asylum, was well, except an eczema of the scalp, until the night of April 3, 1882, when she was attacked with vomiting and diarrhoea. She was feverish and drowsy, and at 2 P.M. on the 4th the scarlatinous efflorescence appeared upon her neck, body, and lower extremities; tongue coated; pharynx red; temperature (axillary) 103°; pulse 160. The symptoms and aspect indicated a grave form of the malady, and the usual sustaining treatment was ordered. On April 5th the temperature was 102°, pulse 144, tongue less coated, eruption fading, less stupor, no albumen in urine. April 6th, morning temperature 102°, pulse 160; passed a restless night; stools thin and too frequent; has grayish patches in the throat: P.M. temperature 103.2°, pulse 150. April 7th, the diarrhoea continues, and she has a copious muco-purulent discharge from the nostrils; P.M. temperature 103.6°, pulse 160. April 10th, the temperature has continued at about 103°; the patient is very sick, with a constant foul-smelling discharge from the nostrils; breath very offensive; temperature 103.5°, pulse about 180. April 12th, general appearance a little better, but the posterior surface of the fauces is completely covered by a thick pseudo-membrane; had four loose stools last night; temperature and pulse the same as at last record; a dark, offensive, and jagged coating over the fauces, and a dark, foul discharge from the nostrils, as before; examination of the chest negative. April 14th, is much prostrated; temperature 104.5°, pulse rapid and weak; respiration noisy, diminished resonance over lower two-thirds of left side of chest; ulcers upon the mouth and tongue; fauces red and ulcerated. April 17th, pulse 150, temperature 100.5°; general appearance somewhat better, but the diarrhoea continues, and patches of a diphtheritic character have appeared upon the lips; moist râles in left side of chest. The symptoms continued nearly the same until April 23d, when she died. A dull percussion sound and distinct bronchial respiration were observed in the left scapular region during the last days of her life.

Autopsy nine hours after death by the curator, Dr. W. P. Northrup: Body well nourished; the tissues have a jaundiced hue; lips sore; on turning the head to one side pus runs from the left ear and dirty muco-pus from the mouth. Brain normal; on opening the petrous portion of the left temporal bone the middle ear is found full of pus, which communicated freely with the external ear through a perforated membrana tympani; the Eustachian tube cannot be traced in the sloughy tissue, and a passage filled with pus extends from the ear to the fauces; opposite the greater cornua of the hyoid bone are two deep ulcers, each having about the diameter of a ten-cent piece, with sloughy and offensive base and sides; the left ulcer communicates by a ragged and wide sinus with a dark and sloughy cavity of about four drachms capacity; this cavity is located in the neck under the angle of the jaw, apparently occupying the site of a disintegrated gland, and it opens upon the surface of the fauces. The surface of the larynx has a dusky, dirty appearance, sprinkled with little cheesy-looking spots, and covered by a dirty, foul-appearing liquid, as if some of the ichorous pus had escaped into it from the neck; about one and a half inches below the vocal chords there is an unmistakable pseudo-membrane; below this, near the bifurcation, the trachea has a bright-red color, as if a pseudo-membrane had been peeled from it, leaving the surface raw. The detachment of a pseudo-membrane from this part, if it did occur, must have been ante-mortem, for the organ had been carefully handled in making the autopsy. Between the apex of the left lung and the median line the tissues of the neck, dissected upward, are found indurated, yellow, and giving an offensive odor, showing that the cervical cellulitis had extended downward farther than usual. The bronchial glands have undergone hyperplasia, being enlarged and hard. The right lung is normal; about one-half of the left lower lobe is consolidated, and when cut is found to be gangrenous and offensive. The liver is apparently somewhat enlarged; spleen normal in size; gastric mucous membrane has a congested appearance and is covered with mucus; mesenteric glands enlarged, pale, and firm; Peyer's patches swollen and pale; at lower end of ileum some pigmentation of these glands; in large intestine the solitary glands are enlarged, and a few of them pigmented; kidneys pale, cortex thickened, and markings indistinct. Microscopical Examination.—In the pia mater perhaps a little increase of cells; meninges of brain otherwise normal. The trachea shows well-marked diphtheritic inflammation; it contains a film of pseudo-membrane; evidences of inflammation occur also upon the laryngeal surface, though less marked than in the trachea. The solidified portion of the lung exhibits the ordinary lesions of broncho-pneumonia, with some interstitial change. In the kidneys we find parenchymatous nephritis, with some cell-growth in the Malpighian bodies.

The above case has been related at length, not only because it shows how severe and destructive the inflammation of the throat, extending into the tissues of the neck, sometimes is, but because four other complications or sequelæ were also present—to wit, otitis media, diphtheria, nephritis, and pneumonia. We see from the above case how formidable a disease scarlet fever sometimes is when attended by the inflammations to which it so frequently gives rise, for a child older and stronger than this, if thus affected, would necessarily have perished with the best possible treatment.

In localities where diphtheria is endemic, as in New York City and Paris, scarlet fever is often complicated by a pseudo-membranous inflammation of the fauces and air-passages. In severe cases of scarlet fever the Schneiderian as well as the faucial surface is covered with it, so that it can be readily seen on inspecting the anterior nares. Occasionally, the pseudo-membrane appears upon the laryngeal and tracheal surfaces, as in the case which I have related above and in others presently to be related, causing dangerous embarrassment of respiration. This complication sometimes begins almost at the commencement of scarlet fever, but in most instances it does not occur before the third or fourth day, and it sometimes does not appear till in the declining stage of the fever. When it begins, it intensifies the febrile movement and produces general aggravation of symptoms.

The common opinion is, that whenever a pseudo-membrane occurs upon the inflamed mucous surface in scarlatina true diphtheria has supervened; but there are those who hold that scarlet fever itself, when the inflammations which attend it are severe, may give rise to pseudo-membranes, so that what seems to be diphtheritic is but an element in the primary disease. My convictions are strong that when pseudo-membranes occur on any of the inflamed mucous surfaces in scarlet fever, true diphtheria has, with few exceptions, supervened if the patient live in a locality where diphtheria is prevalent. That scarlet fever may occur in an individual along with another acute infectious malady is shown by abundant cases. It often occurs with varicella, and J. Herzog relates the following case, in which measles and scarlet fever coexisted:² A boy aged eight years had measles, with the usual catarrhal symptoms, and on the fourth day, as the temperature was returning to the normal, it rose again suddenly, and the scarlatinal rash and sore throat appeared. In due time these subsided, and desquamation occurred. I have seen a similar case in consultation during the current year, so that there is nothing improbable in the theory that scarlet fever may coexist with other infectious maladies; and it is admitted that diphtheria, like erysipelas, may complicate the most diverse constitutional diseases. Moreover, when a child with pertussis, measles, typhoid fever, or tuberculosis suddenly develops a high fever with the occurrence of a pseudo-membranous inflammation upon the fauces or air-passages, all admit that diphtheria has supervened, since such inflammation is not an element in any form or type of either of these diseases; and I see no reason in the nature of the disease why scarlet fever should not be equally liable to this complication.

² Berl klin. Woch., 1882, No. 7.

The elaborate treatise by Sanné of Paris on diphtheria contains a chapter entitled "Secondary Diphtheria." In it the author says, what all who are familiar with diphtheria will agree to, that secondary diphtheria does not differ in nature from the primary form, and that it exhibits a tendency "to occupy the organs which are themselves the seat of the more pronounced local determinations of the primitive malady.... Diphtheria is seen in the course or sequel of numerous diseases. Some appear to have a special proclivity for engendering diphtheria; these are specific maladies: measles, scarlet fever, pertussis." I have tabulated as follows Sanné's statistics of secondary diphtheria:

Diphtheria complicating measles, 100 cases, 83 deaths, 15 cures, 2 doubtful.

Diphtheria complicating scarlet fever, 43 cases, 22 deaths, 17 cures, 4 doubtful.

Diphtheria complicating pertussis, 20 cases, 12 deaths, 6 cures, 2 doubtful.

Diphtheria complicating typhoid fever, 8 cases, 8 deaths.

Diphtheria complicating tuberculosis, 19 cases, 19 deaths.

Sanné's statistics relating to the seat of scarlatinous diphtheria are as follows:

Fauces alone attacked, 15 cases.

Fauces with larynx attacked, 4 cases.

Fauces with nasal fossa attacked, 8 cases.

Fauces with larynx and nasal fossa attacked, 4 cases.

Fauces with larynx and bronchi attacked, 1 case.

Fauces with nasal fossa and lips attacked, 1 case.

Fauces with lips and skin attacked, 1 case.

Fauces unaffected, 3 cases.

Diphtheria generalized, 2 cases.

Larynx only affected, 2 cases.

Nasal fossa affected, 1 case.

The opinion of so good an observer as Sanné, that when in scarlet fever, pseudo-membranous exudation appears upon the mucous surfaces which are the seat of scarlatinous inflammation, diphtheria has supervened, and not a croupous form of scarlatinous phlegmasia, carries with it great weight. That it was diphtheria in four instances in my practice I had sufficient proof, for this disease became dissociated from scarlet fever, and extended to other members of these families as idiopathic diphtheria.

Nevertheless, one of the most difficult problems which we have to deal with in certain cases is to distinguish diphtheritic from non-diphtheritic inflammation; and I see no reason why the scarlatinous inflammation when intense may not be sometimes membranous; and those no doubt err who ignore this, and consider every inflammation attended by a pellicular exudation diphtheritic. We know that in some cases of dysentery a fibrinous exudation occurs upon the surface of the colon; that in croupous pneumonia fibrin exudes into the bronchioles and alveoli of the lungs; and that physicians in localities where there is no diphtheria meet, though at long intervals, cases which they designate croupous pharyngitis and laryngitis; and it seems to me that the intense inflammation of anginose scarlatina probably sometimes produces the same exudation. Moreover, it is very difficult to distinguish in the swollen fauces between a membranous exudation and ulceration or superficial gangrene so common in malignant scarlet fever. The grayish-white surface, jagged and foul, may be the one or the other, an exudation or a sphacelus, and in certain instances it is impossible to discriminate between the two conditions at the bedside.

Diphtheria complicating scarlet fever sometimes begins nearly simultaneously with the latter. Henoch states that exceptionally he has observed suspicious patches upon the fauces before the appearance of the scarlatinous eruption upon the skin; and he adds: "I have had repeated opportunities of observing this unusual beginning. In such cases we must ask ourselves whether the first affection was really connected with the second, or whether the former was a true primary diphtheria, rapidly followed by scarlatina. This opinion is favored by the fact that I have only observed such cases in the hospital, in which infection with various forms of contagion can scarcely be avoided."

But usually it is not till the third or fourth day of scarlet fever that this complication begins. The patient has been progressing favorably with the scarlet fever, till on a certain day a marked aggravation of symptoms occurs. A higher temperature, more pungent heat, and the physiognomy of a more serious malady are present. On inspecting the fauces to discover the cause we observe a pellicle forming over the tonsils and perhaps other portions of the faucial surface. Often the entire aspect of the case changes by the occurrence of this complication, a mild case of scarlet fever becoming grave and fatal in consequence. Thus in a case which I saw with Dr. Hardy of New York the membranous inflammation of diphtheria, commencing upon the fauces on the third day of scarlet fever, extended to the Schneiderian membrane, and thence along the left lachrymal sac to the eyelids, producing redness and swelling along the side of the nose and upon the cheek like that of erysipelas. A thick diphtheritic pellicle occurred upon the under surface of each eyelid on the left side, with great tumefaction of both lids, gangrene of the cornea, and destruction of the eye. The case soon ended fatally.

The diphtheritic inflammation sometimes extends to the larynx and trachea, producing hoarseness and more or less obstruction to respiration. A thin film or flakes of fibrinous exudation, rendering the respiration noisy, developed on the laryngeal or tracheal surface, is, I think, not infrequent in diphtheria complicating scarlet fever, but the rapid development of a thick and firm pseudo-membrane, so as to imperil the life of the patient from the stenosis in the air-passages, has been much less frequent in my practice than it is in primary diphtheria and in diphtheria complicating measles or pertussis. The following were cases of this severe complication occurring in a recent epidemic in the New York Foundling Asylum. In these cases the respiration was noisy, but the obstruction to breathing seemed to be due to infiltration and swelling around the aperture of the glottis, rather than to diphtheritic croup, which the autopsies showed to be present.

Case 2.—A child aged three and a half years, who previously had symptoms of mild catarrhal croup, with moderate redness of the fauces, sickened with scarlet fever on Oct. 1, 1882, the rash being profuse and soon covering nearly the entire body. The axillary temperature was 103°, pulse 140; slight stridor in breathing and some cough; fauces very red, but free from membrane. Oct. 2d, restless, sleeping but little; has vomited four times. Oct. 3d, temp. 103.5°, pulse 120; fauces much swollen; still vomiting; rash abundant. 4 P.M., temp. 104.3°, pulse 128; tongue clean; some discharge from nares; urine not albuminous, but its quantity diminished. Oct. 4th, aspect that of very severe sickness; profuse discharge from nostrils; fauces of a deep red color, and a diphtheritic pellicle over tonsils and uvula; tumefaction along the sides of the neck; temp. 104°, pulse 140; breathing moderately stridulous; urine is passed more freely than yesterday; evening temp. 105°. Oct. 6th, croupy symptoms more marked; tonsils and uvula greatly swollen, so that the fauces are almost occluded; temp. 103.5°; breathing difficult, but apparently sufficient oxygen is received; profuse nasal discharge, and other symptoms as before. About 1.30 P.M. he was raised to take some milk, and suddenly became asphyxiated. His face was dusky, his eyes protruded, and he voided urine and feces. Dr. Swift, who attended the child, and to whom I am indebted for this history, immediately performed tracheotomy, which gave temporary relief by the expulsion of a considerable quantity of pseudo-membrane through the opening. On the following day the respiration again became obstructed at some point below the canula, so that it could not be removed; the features grew livid, and death occurred in convulsions twenty-six hours after the tracheotomy.

The autopsy was made by Dr. W. P. Northrup, curator of the asylum, who found the pharynx covered by a membrane which was traced to the posterior nares; larynx, trachea, and bronchial tubes as far as the third divisions also covered with membrane; portions of the tracheal surface denuded, and the mucous membrane underneath of a bright red color and smooth; tonsils sloughy and fetid; mucous membrane of smaller bronchial tubes very red and covered with viscid mucus and pus; a portion of the left lung, extending from the root posteriorly to the surface, gangrenous, discolored, and honeycombed; two or three intensely hyperæmic spots, as large as a bean, in left lung; right lung congested, but not consolidated; slight catarrh of stomach; circumscribed areas of congestion in intestines; solitary glands of intestines swollen, and some of them ulcerated; spleen of normal size, rather pale; liver congested and somewhat enlarged.

Case 3.—Katie, aged six and a third years, was returned to the asylum on Nov. 18th. Three days later (Nov. 21st) she had sore throat, reddened fauces, coated tongue, and a faint rash upon the neck, chest, and arms; eyes injected; temperature 102°. In the afternoon temperature 103°; eruption still faint. Nov. 22d, temperature 103.5°; an eruption on chest, abdomen, arms, and legs in patches. Evening, temperature 104°; voice clear. Nov. 23d, temperature 103.5°; tongue red; fauces deeply reddened, but without any visible pseudo-membrane; eruption of a scarlatinous appearance over the back and abdomen; on the extremities dusky, livid patches. P.M., temperature 104°; is slightly delirious; eruption abundant. Nov. 24th, temperature 103.5°; eruption well out on abdomen; it is the same as yesterday upon the extremities, except perhaps a little more dusky; still no pseudo-membrane to be seen upon the fauces; is restless and delirious. P.M., during the day has been very restless, suffering from dyspnoea; no croupy voice nor croupy cough, though the dyspnoea continues, and a pseudo-membrane is now visible over the tonsils and adjacent faucial surface; eruption dusky; skin cool; pulse very frequent and feeble. From this time she sank steadily, and died at 11.30 P.M. During her sickness her urine seemed to be diminished, but it was not properly examined.

Autopsy Nov. 25th by Dr. W. P. Northrup, curator: Points of redness, apparently a hemorrhagic eruption, over the face, shoulders, and parts of the trunk; a few of the same on the extremities; no pseudo-membrane visible in nostrils or in buccal cavity; brain not examined. Naso-pharynx covered by a thick fibro-purulent membrane. Larynx contains a well-marked pseudo-membrane, but not continuous. Trachea covered by a pseudo-membrane, continuous over most of its surface, but in places broken and flaky. Where it is detached the mucous membrane is seen underneath, dusky and deeply injected. At the root of the lungs the pseudo-membrane can be traced along the tubes about an inch in all directions. Lungs oedematous, with deep congestion in places, but apparently no pneumonia; about two drachms of clear, straw-colored fluid in pericardium; a few stringy decolorized clots in the cavities of the heart; left ventricle contracted. The heart-fibres, carefully examined, microscopically, in the laboratory, are found to be normal, not having undergone granular or fatty degeneration. Liver normal in size; pale-yellow areas upon the superior surface, either from anæmia or fatty deposition. Kidneys of usual size, capsule not adherent; pyramids congested; cortex pale; markings distinct. Spleen enlarged about one-third; consistence normal. Stomach and intestines not examined.

Case 4.—Scarlet fever complicated by diphtheria, nephritis, and broncho-pneumonia. (History by house physician, Dr. Swift.) Phoebe, aged three and a quarter years, was delicate, but in her usual health till Oct. 29, 1882, when she became languid and vomited several times, and her tongue was coated. Oct. 30th, occasional vomiting; fauces reddened; tongue coated. Oct. 31st, remains languid; fauces deeply reddened; a faint scarlatinous eruption over back, wrists, and feet; temperature 100.5°. P.M., eruption of scarlet fever well out over the surface; tongue cleaner. Nov. 1st, rash over entire body; temperature 100.2°. Nov. 2d, fauces deep-red; tonsils and uvula swollen; diarrhoea and vomiting. Nov. 3d, temperature 102.5°; the eruption, which has been bright red, is now more dusky. Nov. 5th, temperature 104.5°; dusky-red color of the eruption; skin beginning to desquamate in places; urine normal; a discharge from nostrils. Nov. 6th, temperature 103.5°; eruption still present, but skin of abdomen and back desquamating; has otorrhoea on both sides; fauces deeply hyperæmic, but no pseudo-membrane visible upon them. Nov. 7th, temperature 103°; respiration and cough have a slight croupy character; other symptoms as yesterday. Nov. 8th, temperature 101°. A careful inspection of the fauces shows that it contains no pseudo-membrane; nostrils discharging a dark-brownish liquid; examination of urine negative. Nov. 11th, eruption, which appears to have been hemorrhagic in points, is fading and the desquamation is less. Nov. 14th, nostrils still discharging; glands of neck swollen. Nov. 16th, temperature 103°; sp. gr. of urine 1010, no casts, nor albumen; the chest seems clear; less discharge from nostrils; fauces clean and but slightly inflamed. Nov. 17th, 18th, temperature 103.5°; vomits; lungs healthy, but breathes with considerable effort, though without stridor; urine diminished; its sp. gr. 1020, albuminous, contains blood-corpuscles and granular casts. Nov. 19th, is very pallid; temperature 104°; very restless; vomits; urine diminished; bowels freely open. Nov. 20th, respiration still embarrassed; subcrepitant râles over the entire chest and percussion resonance not clear; temperature 102.5°. Nov. 21st, physical signs the same; temperature 103.5°; respiration 80. Nov. 22d, urgent dyspnoea; dulness on percussion over top of right lung and over lower part of left lung; is delirious; no perspiration; urine scanty; bowels freely open. From this date the dyspnoea became more urgent, and death occurred at 4 P.M. on the 23d.

Autopsy by Dr. W. P. Northrup, curator: Body well nourished; slight oedema of both legs; swelling at angles of jaws, most marked on left side. Vessels of brain moderately injected; otherwise appearance normal. Cicatrizing ulcers on both sides of fauces; a diphtheritic pseudo-membrane on septum of nose, larynx normal. Trachea, upper half apparently normal; a thin film of pseudo-membrane extends from just above the bifurcation upward to nearly the middle of trachea. About an ounce of fluid in each pleural cavity; on the right side a few loose flakes of fibrin floating in the serum, and consolidation of lung at apex; collapse in one or two places. Left side, recent adhesions over whole of posterior surface and base; surface of lower lobe dark, and when it is detached strings of fibrin adhere to it, and it is consolidated. The cut surface shows marked oedema, injection, increase of mucus in bronchi, and disseminated miliary tubercles in every part; no tubercles in the pleura, and none elsewhere in the body except in the left lung; tubercles in the lower lobe larger and more thickly grouped than in the upper lobe. Decolorized clots in heart, extending from ventricles into auricles of both sides. The capacity of the ventricles seems normal. Liver and spleen, normal. Kidneys rather large; capsules not adherent; superficial veins injected. The cut surface shows congested pyramids and pale cortex; markings indistinct and irregular; about four ounces of clear straw-colored fluid in abdominal cavity, and the solitary follicles of large intestines show pigmentation; two simple intussusceptions, each three-fourths inch in length, in small intestines.

Coryza frequently commences at or about the time of the pharyngitis. The inflammation of the Schneiderian membrane is continuous posteriorly with that of the fauces, and is announced by redness and swelling, inability to breathe freely through the nostrils, and an irritating ichorous discharge. Simple coryza in itself involves little danger, though it is an unpleasant complication, and in the nursing infant it may interfere with sucking. Diphtheritic coryza, on the other hand, which is frequently present when diphtheria complicates scarlet fever, involves danger, since it is apt to cause ulcerations, hemorrhages, and septic poisoning. When the local symptoms are unusually severe and the discharge abundant, it is probable that inflammation has in some cases extended to the antrum of Highmore.

Inflammation of the middle ear is another unpleasant and not infrequent complication. It is attributed to extension of the catarrh from the pharynx along the Eustachian tube to the tympanum. In a considerable proportion of cases of otitis media this tube is occluded by the infiltration and swelling of its mucous membrane, so that the muco-pus escapes with difficulty or is retained. Hence severe earache, an increase of the febrile movement, and outward bulging of the membrana tympani occur. Sometimes headache or other cerebral symptoms arise, probably from the fact that the meningeal artery, which supplies the meninges, is connected by anastomosing branches with the tympanum. In one of the cases related above it will be recollected that the ulceration and abscess extended from the fauces to the middle ear, the entire Eustachian tube having disappeared in the ulcerative process.

Frequently, the otitis escapes detection, its symptoms being masked or obscured by the general disease, until the membrana tympani is perforated and otorrhoea begins; but by careful examination the nature of the complication can usually be ascertained before the ear is injured to this extent, for a patient too young to speak will often press with the fingers against the painful ear or lie with the ear pressed upon the pillow, evidently having an increase of suffering if placed in any other position. One old enough to speak and in proper mental condition makes known the earache as soon as it occurs.