speaking, rather beneficial than injurious, particularly when it occurs towards the termination of the eruption; we are, therefore, to refrain from interfering with it, especially in robust and plethoric subjects, unless it be attended by prominent symptoms of gastro-intestinal disease.

During convalescence, the utmost care should be taken to guard the patient from the influence of cold and damp. Even during the warm season, he should not be allowed to go out of doors, excepting in the middle of the day, and in dry weather. His diet should be light, nourishing, and unirritating; every species of stimulating drink should be avoided. The use of the warm or tepid bath daily, will always be advantageous.

It is said that when any cutaneous disease occurs after measles, the internal organs are seldom liable to become affected; and that, even when some internal disorder has already existed, it has disappeared on the occurrence of a spontaneous eruption upon the skin. We should, therefore, be cautious in interfering with vesicles, pustules, boils, and the like, when they occur subsequent to an attack of measles.

Various diseases may remain or occur upon the decline of the eruption, which require great attention, as they are often exceedingly troublesome, and attended with even greater danger than the original malady. They are usually bronchial or pulmonic inflammation, and, occasionally, inflammation, either acute or subacute, of the intestinal canal. In general these sequelae may be entirely prevented, or rendered more manageable when they do occur, by a proper treatment of the exanthem from its commencement. When they present themselves, they must be treated in accordance with their character, extent, and violence, and the condition of the patient's strength.

2. Scarlet Fever.-Scarlatina.

Scarlatina, in its mildest and most simple form, is a febrile exanthem, characterized by a diffused efflorescence upon the surface of the body of a bright scarlet color, which appears usually on the second day after the occurrence of the fever, and terminates in a desquamation of the cuticle, at the end of about five days. Most commonly, it is attended by a severe affection of the throat, or of some one or other of the internal organs, by which the symptoms and progress of the disease are very considerably modified; an attack which, when regular and uncomplicated, scarcely demands the interference of the physician, becomes converted into the most unmanageable and destructive of any to which children are liable.

In consequence of the various modifications under which it presents itself in the same, or in different epidemics, scarlatina has been divided by practical writers into several varieties. Those most commonly recognized are the scarlatina simplex; the scarlatina anginosa; and the scarlatina maligna. The last of these denominations is particularly objectionable. The term malignant is, to say the least of it, indefinite; while from its former, and even now very common application, it is extremely apt to lead to erroneous views, in regard to the nature and proper treatment of the affections it is employed to

designate. To the above varieties, some writers add a fourth, in which, from exposure to the contagion of scarlatina, the throat alone becomes affected, without any eruption occurring upon the skin. This, however, cannot, with strict propriety, be considered as scarlet fever.

The malignant form of scarlatina has, with an approach to greater clearness and precision, been divided by Armstrong into three varieties: the highly inflammatory, the highly congestive, and the irregular congestive.

We propose to consider the disease under two divisions only:-1st. The inflammatory, including the simple and anginose varieties of Willan, and the highly inflammatory of Armstrong. 2d. The congestive.

To distinguish the different modifications of inflammatory scarlatina and the consequent variations of treatment that is demanded, we shall describe it as it occurs: 1st. Under the form of simple excitement; 2d. Attended with inflammation of the fauces; and 3d. With inflammation of one or more of the internal organs.

The disease seldom manifests itself until from about the third to the fifth day subsequent to exposure.

In its mildest form it is usually ushered in without much rigor, or disturbance of the stomach. There is always present more or less pain, or uneasy sensation in the head, with restlessness, and lassitude, paleness of the face, and a weak pulse. These symptoms may continue from one to three days, when they are succeeded by a general febrile reaction.

It is usually on the second day after the occurrence of the febrile excitement, that the efflorescence upon the skin begins to show itself, first about the face and neck, in innumerable red points, which, within the space of twenty-four hours, are to be seen over the whole surface of the body. As the points multiply, they coalesce into small irregular patches; by the third day, the eruption presents a diffuse and continuous efflorescence over the limbs, and around the fingers, giving to the skin a color somewhat similar to that of the shell of a boiled lobster.

Upon the body the efflorescence is seldom continuous, but is distributed in diffused irregular patches; the scarlet hue being most vivid about the flexures of the joints, and around the loins. The efflorescence is often accompanied with a perceptible roughness of the skin, which is most evident upon the extremities, and front of the body, giving a sensation as if the surface was covered with granules. This is caused by an enlargement of the cutaneous papillæ.

Where the redness of the skin is most intense, and particularly, when the patient has been subjected to a heating regimen, small miliary vesicles occasionally appear upon different parts, more generally upon the trunk. About the fourth or fifth day of the efflorescence, an eruption of semi-globular vesicles, filled with a thin pearlcolored serum, is occasionally observed about the forehead, neck, chest, shoulders, and extremities. They vary in size, and succeed one another without determinate order.

The efflorescence is not confined to the surface, but extends over the mucous membrane of the mouth and fauces, and even of the nostrils, and is occasionally visible upon the adnata of the eyes. The papilla of the tongue, also, are considerably elongated, and project their scarlet points through the white coat with which the surface of the tongue is covered.

On the fourth day, the eruption is usually at its height; and on the fifth, begins to decline by interstices, leaving the small patches as at first; on the sixth it is very indistinct, and is generally entirely gone before the termination of the seventh day; a desquamation of the entire cuticle then takes place, which often occupies many days before it is completed.

Early in the stage of excitement, there is most generally some degree of soreness, or a sense of fulness in the throat, and the voice is not quite so clear and sonorous as ordinary.

The skin, from the excessive injection of its blood vessels, becomes morbidly sensible, dry, and hot. Its temperature seldom, however, exceeds 103 degrees of Fahrenheit. The lips are of a vivid red; the face is flushed and somewhat tumid, and the tongue is covered upon. its centre with a white mucus, but is red around the edges. The pulse is, in general, increased in strength and quickness, but seldom rises above 100 or 110 in the minute. The thirst is seldom very urgent; the appetite is lost, and the bowels are costive; when evacuations are obtained, they are frequently of a much darker hue than natural. The febrile symptoms slightly remit towards morning, but gradually increase during the course of the day, and attain their greatest intensity in the evening, when some degree of delirium is often present.

The stage of excitement seldom continues longer than from four to five days, when it gradually subsides; the pulse becoming slower and softer, and the skin cooler and more relaxed.

The foregoing description is that of the most usual form of simple scarlet fever; which seldom continues longer than fourteen days, and is occasionally of shorter duration. Its termination is very generally favorable; the first stage being attended with but a slight degree of visceral congestion, the second being marked with general, but short and moderate excitement, which is succeeded by no serious collapse.

In its course, however, either suddenly or by degrees, symptoms of a more decidedly inflammatory character may become developed, and the throat being now more deeply affected, the case assumes the anginose form of scarlatina.

Scarlatina anginosa commences nearly in the 'same manner as the simple form. It is generally ushered in, however, by a greater degree of chilliness, headache, and restlessness. There is a sense of greater oppression at the præcordium, with prostration of the voluntary powers, nausea, retching or vomiting. The eruption upon the skin generally appears within the first three days, and about the same period the fauces become red and swollen, and the patient complains of a stiffness in the neck and jaws, and a fulness and soreness of the throat, particularly in speaking or swallowing. The pulse is quicker than in the preceding form; there is also greater thirst, and more uneasiness

of the head; the tongue is drier and redder at its edges, and the beat of the surface is more elevated, ranging from 106° to 108° or 112°. The discharges from the bowels are darker, and of a more bilious. appearance. The evening exacerbations are more intense, and more often attended with delirium, during which the patient, if alone, or in the dark, talks much to himself.

The efflorescence does not pervade so generally the surface of the body, in the anginose as in the simple form; but usually occurs in scattered patches on the chest and arms. In some cases, it is confined to the back of the hands and wrists; it sometimes entirely disappears on the second day, and partially reappears at uncertain periods. When the eruption is slight, or speedily disappears, it is often not suc ceeded by desquamation. In other instances, however, desquamation continues often to the end of the third week, or even longer; large portions of the cuticle occasionally separating, particularly from the hands and feet.

When the febrile symptoms begin to abate within the first four or five days, the tonsils and fauces are seldom covered with membranous exudations; there is merely an increased secretion of tenacious mucus, some of which often adheres to the fauces; and the constant efforts made by the patient to expel this, increase his sufferings. But, when there is a longer continuance or higher grade of febrile excitement, small patches of a grayish hue are observed upon the tonsils and fauces, which are often mistaken for sloughs; but by gargling the throat of the patient, the exudation may frequently be removed, when the mucous membrane beneath will be found entire. The exudation is renewed from time to time, and frequently extends into the lateral parts of the pharynx and oesophagus, but seldom into the larynx or trachea. As the fever declines, which is frequently about the eighth day, the patches of exudation separate, and leave the fauces somewhat redder than natural, but free from ulceration.

Occasionally, instead of so favorable a termination, symptoms of a much more alarming character arise in the progress of the disease. The patches in the throat acquire a darker color, and the secretions from the fauces and nostrils become highly offensive, causing considerable fetor of the breath; painful indurations of the glands of the neck ensue, and the patient is troubled with griping pains of the abdomen, with tenesmus, or diarrhoea. In some cases, a state of collapse quickly ensues, and terminates promptly in death.

A common accompaniment of scarlatina anginosa is an inflammatory intumescence of the submaxillary glands, which in general presents itself the day subsequent to that upon which the swelling occurs in the pharynx. The swelling of the glands is painful to the touch, and sometimes tense and red. From the glands, the inflammation in many cases soon extends to the surrounding cellular tissue, often producing considerable tumefaction, reaching around the front of the throat from ear to ear, and preventing the jaw from being opened wider than to permit merely the tip of the patient's tongue to be protruded. Ordinarily, the swelling results from an oedematous condition of the cellular tissue of the throat, and quickly disappears as the

inflammation of the glands diminishes. Occasionally, however, suppuration takes place, commencing either in the glands or in the cellular membrane, and an abscess occurs, which is always a very unfavorable result. The inflammation sometimes attacks the skin, when suppuration takes place still more readily.

In other cases, during the stage of excitement, symptoms of cerebral disease manifest themselves, and the patient dies comatose, about the end of the second week. Not unfrequently, also, there occur slight pain, tenderness, and tumefaction at some part of the abdomen, with increased frequency of the pulse and respiration. The pain and tenderness of the abdomen quickly increase in intensity, and are at length attended with vomiting, eructation, general restlessness, and a tympanitic condition of the abdomen.

At the end of six, seven, or eight days, the pain and tenderness. diminish or disappear; the pulse grows more rapid and feeble; the respiration more anxious, and the vomiting more urgent. Cold, clammy sweats, and universal collapse now speedily ensue, and are the immediate precursors of death.

There is in general a much greater tendency to inflammations of the serous membranes of the brain or of the thoracic or abdominal regions, than of the substance of the organs.

Not unfrequently, the anginose form of scarlatina is attended with a very intense degree of febrile excitement. The inflammation of the throat runs very quickly into a gangrenous condition; and there is often severe cerebral excitement, a redness of the eyes, intolerance of light, and a throbbing pain of the head, with tinnitus aurium, watchfulness, confusion of mind, and delirium. To these symptoms there may succeed a state of stupor, occasionally interrupted by loud screams, or by fits of violence or of fretfulness.

In other cases of scarlatina, symptoms of severe abdominal inflammation ensue; considerable pain, increased upon pressure, with tension, fulness, and heat of the abdomen; short, quick, anxious respiration; very quick, contracted pulse; considerable irritability of the stomach, and either a costive state of the bowels or diarrhoea.

In other cases, again, neither the head nor abdomen seems so decidedly affected; the greatest uneasiness being referred to the respiratory organs-the trachea, bronchi, pleura, or lungs. Whatever may be the organ or organs affected, the stage of excitement is of short duration, and is succeeded by a greater or less degree of collapse; the heat of the surface being diminished, the energies of the system depressed; the pulse becoming weaker and more quick; the skin relaxed; the tongue fouler; the respiration more laborious; finally, the patient is attacked with convulsions, violent vomiting, or symptoms of suffocation, according to the organ principally affected, which are quickly followed by death.

The anginose form of scarlatina, and that accompanied with acute or subacute inflammation of the central organs, differ only in the seat,. and the greater or less violence of the attendant affections.

One of the most frequent of the sequelae of scarlatina is an oedematous condition of the eyelids, face, and lower extremities. Frequently,.