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bullæ, of rather larger size, rounded, filled with transparent serosity and without an areola of inflammation. This areola does not become established until two or three days after, at the period of desiccation and cure of the bullæ.

I am aware the difference is not of much importance; but it may be interesting to those who pay much attention to diseases of the skin, and who would be perfectly cognizant of their anatomical characters to recognize it.

Discrete chicken pox, is always a slight disease which scarcely affects the health of the children. When it is confluent it is accompanied by more or less intense fever which does not fail to diminish in proportion as the eruption disappears. The duration of chicken pox is from eight to fifteen days at most, and it only leaves behind slight traces on the surface of the skin.

Chicken pox presents itself under the epidemic form, as much in the course of epidemics of small pox as in the opposite circumstances. Thus, I have observed, at the Necker Hospital, an epidemic of chicken pox, at a time when there was no epidemic of small pox. The disease, confined in the wards for children, seized each of them successively and remained several months, for fresh children were admitted every day into the focus of infection, and did not fail to catch it. commenced at the period when the slight epidemic of measles, the history of which will be given further on, ceased.

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It may be transmitted by the inoculation of the serous humourdemes of the vesicles, and although the experiments which I have performed" do not confirm this opinion, they are not sufficiently numerous to invalidate the assertion of Willan, who declares that he has succeeded in its inoculation.

Chicken pox may produce small pox, and the latter may give birth to chicken pox (Rayer).

The diagnosis of chicken pox is not difficult. In fact, there is no cutaneous disease which presents the characteristic of chicken pox, scattered and isolated vesicles. It resembles pemphigus, when it appears in a primary manner as a small bulla not surrounded by an inflammatory circle; but the bullæ of pemphigus are always larger and more numerous than the bullæ of chicken pox. Besides, it does a not prevent in a general manner the character of the bullous eruption just alluded to; on the same patient well-characterized vesicles are met with, which is not the case in pemphigus.

The treatment of chicken pox is very simple; the children should be protected from the cold and emollient diaphoretic drinks administered, without consideration as to the termination of the disease, which cannot be uncertain.

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Scarlatina is a contagious, eruptive fever, characterized by the presence of a special exanthem under the form of red patches diffused over the skin and on the mucous membrane of the pharynx.

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CAUSES.

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Scarlatina is much more frequent than small pox in the first years of existence. No examples of it have ever been observed in the newlyborn. It is scarcely observed until towards the end of the first year; but its maximum of frequency appears to be between five and ten This period passed, it becomes more and more rare. equally remarked amongst boys as amongst girls. It is an epidemic disease, especially in schools and in hospitals for children. It sometimes becomes developed sporadically. Scarlatina is contagious and is : transmitted indirectly by the air, or in a more direct manner by contact, by the medium of linen and clothing which have been used by infected subjects, or lastly, by a lancet charged with blood taken from an active scarlatinous patch. Stoll, MM. Mandt and Miquel stated'Amboise have at least declared this.

The necessary and absolute cause of scarlatina is the presence, in the interior of the organism, of a specific agent, of unknown nature, inappreciable, except by its results, and which has been termed the scarlatinous virus. It is this which is always reproduced in a form identical with itself, in the evolution of the same disease having the human body for its location and the skin for the place of development. Scarlatina oritur a miasmate exteriore quod in aere volitat, aut contagione et contactu suscipitur. It is thus that the illustrious Borsieri expressed himself, and we have nothing that can set aside these judicious words, confirmed by the observations of all ages. Scarlatina shows itself under several forms, which should be described under the terms of regular, irregular, and malignant.

SYMPTOMS.

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The symptoms of regular scarlatina differ in the various stages the disease; in the stage of incubation, invasion, eruption, and desquamation.

The young child submitted to the morbid influence which should ultimately lead to scarlatina resists the action of the virus for a

greater or less period. Several days elapse during which, in the midst of apparent health, the virus germinates in the economy, a variable time, differently estimated by authors, and which appears to me to vary between three and ten days. It is the stage of incubation of scarlatina. The fever then appears and indicates the invasion of the symptoms. It is accompanied by depression, or by considerable agitation and fretfulness; the breast of the mother or of the nurse is an object of disgust or of anger; drinks are swallowed with avidity, and one is at a loss what to do in order to calm the irritable child and make it sleep. Efforts of vomiting are repeated at intervals, sometimes vomiting takes place; the stools are either suppressed or deficient.

The tongue is white, dotted with red spots, the mouth warm; at the end of some hours, the pharynx and the tonsils become red and appear painful, for the children refuse to drink; angina may then be suspected, when the eruption appears it dissipates the doubts of the practitioner.

Sometimes the nervous agitation is most violent, and at the same time that the fever of invasion appears, an attack of convulsions commences the series of symptoms.

At the end of twelve, twenty-four, or forty-eight hours at most, the eruption appears and is first observed on the neck, then on the face and on the rest of the body.

Small red dots more or less numerous appear here and there, become multiplied and coalesce in enlarging so as to form patches of variable size with irregular edges, serrated, without being raised above the skin, and the colour of which momentarily disappears under the finger and returns as soon as the pressure has ceased. These patches are at first isolated, then become multiplied, coalesce, and become confluent, covering nearly the entire surface of the body with a scarlet tint.

The redness of this exanthem is always very decided; it often approaches the colour of raspberry juice, or of ripe mulberries, and it varies at different periods of the day. According to the observations of M. Rayer, it is of a deeper colour in the evening than in the morning at sunrise.

This eruption is usually diffused over all the body. It may, however, only cover one portion of it; the skin is sometimes at the same time covered with some papulæ, but more frequently with colourless and opaque vesicles, which constitute miliary scarlatina.

At the same time that the eruption occupies the skin, an eruption of the same, but much more serious nature, is developed in the mouth and pharynx. The mucous membrane of these parts is dotted, sometimes covered with flakes of lymph, or thin false membranes; the tongue is swollen, red, and quite deprived of epithelium at the edges; this constitutes scarlatina anginosa.

The skin is dry, very hot, and its temperature is slightly increased. M. Roger has observed it from 100° to 102° Fah. The fever remains as intense as in the first stage, and the pulse is always very quick and agitated.

At the end of two or three days the eruption begins to pale, and it gradually disappears at the same time as the miliary eruption dries and scales off. Then desquamation commences which lasts from six to ten days. It is sometimes very slight, but usually it leads to the renewal of the whole of the epidermis which is detached in the form of large flakes; whereas in measles, as we shall see, it is only a fine desquamation, termed furfuraceous.

Regular scarlatina appears under the form just described, and generally terminates favourably, when the children are at home and properly attended to. But in the hospitals for children, scarlatina, even when regular, is followed by serious complications which are very serious and cause the death of half the children attacked.

Scarlatina is said to be irregular when the symptoms of invasion are wanting or are but slightly marked, when the eruption is very pale, or very deep, black, hæmorrhagic; when no angina exists, or lastly, which is much more rare, when the eruption is entirely wanting.

There are cases in which the scarlatina is accompanied by convulsive and comatose phenomena from the commencement of the disease, and others where the scarlatinous angina is tranformed into laryngopharyngeal diphtheritis or into sphacelus of the mouth, which constitutes malignant scarlatina.

Scarlatina may be complicated by inflammation of the glands of the neck, described under the term of scarlatinous bubo; and on this subject we may remark that M. Mondière has seen a young child die from asphyxia in consequence of this inflammation. It is often complicated by broncho-pneumonia, by enteritis, and lastly by anasarca, in consequence of the disturbance of the cutaneous perspiration, and of the anatomical change in the kidneys known under the name of Bright's disease. This last complication is a very serious one; it may disappear at the end of some weeks, but when it is of long duration, it invariably causes death.

It is said that scarlatina may appear several times in the same individual. Examples of this are very rare, and for my part I have never met with one which could support the truth of the above

observation.

[The following case is related by Dr. Mauthner (Erster Jahres-Bericht über die wissenchaftlichen, &c. 1851; p. 24). It occurred in a girl seven years of age, who for two years and a half had been brought up as a foundling by the mistress of a boarding house, and until now had remained quite well. Four days ago she came from school as pale as a corpse, became very hot and had pain of the neck; during

the night delirium supervened. At home a cataplasm was applied to the neck and a purgative given. As she got worse, however, she was brought to the hospital on the 20th of October, and was immediately received into the clinical department. The patient seemed strong and well developed for her years, had brown hair, was quite unconscious and delirious; the breath was very offensive; the balls of the eyes rolled outwards, their whites finely and brightly injected, and the cheeks were circumscribedly reddened. The mouth was half open, the lips and gums brown and dry, the teeth dull and brownish, the tongue very red, the tonsils and papillæ of the tongue greatly swollen, the breathing short, and a hacking loose cough was present. On the left side, from above downwards, the sound on percussion was dull, and the respiration bronchial with mucous rattle. There was nothing abnormal as respected the abdomen, the skin was cool, the fingers and toes were blue and cold, the pulse was small, rather hard, 100.

After the attention of the students had been directed to the important fact that the child had become ill without any premonitions, that she had probably brought the malady from school, and that a simple pneumonia does not prove fatal in four days, it was decided that the anginose conditions, the colour and state of the tongue, appeared to indicate scarlatina perniciosa to be the right diagnosis. The disease ran a course of a month and the patient recovered. No exanthem made its appearance, but about the seventeenth day desquamation of the skin ensued and continued for more than a week; ischuria also occurred.-P.H.B.]

DIAGNOSIS.

The diagnosis of scarlatina is difficult at the commencement of the fever of invasion, for then the first symptoms resemble those of other eruptive fevers. It is only after twenty-four or thirty-six hours that it is probable to foresee the evil which is about to appear when the disease of the throat sets in, and soon after, the eruption, under the form of bright red patches, with or without accompanying miliary eruptions. Thus then, fever, affection of the throat, redness of the pharynx, diffused eruption of deep colour, are the diagnostic points of scarlatina, whereas in measles, with fever, there is coryza, lachrymation, bronchial cough, and afterwards a rosy eruption composed of small irregular patches, more or less elevated, discrete or confluent. In small pox, the fever and vomitings are first observed, then the characteristic pustules, and lastly, if there is angina and bronchitis, it is consecutive to the eruption, while quite the contrary is the case in the two exanthemata just alluded to.

PROGNOSIS.

The prognosis of scarlatina is less unfavourable in the city, and when it is developed in children of the middle classes than when it attacks the patients of the hospitals for children. The same holds good in all the diseases of children, and to believe on this head the statistical tables, compiled in hospitals dedicated to children,~^ would be assuming a very false idea of their seriousness.

Scarlatina is a very fatal eruptive fever in children at the breast;

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