that come away with the cuticle during desquamation. Although this form, called scarlatina miliaris, being the result of exudation from the capillary vessels, shows an intensely inflamed state of the skin, its course is usually mild and its issue favorable; because the morbid poison comes readily to the surface.

15. SCARLATINA SINE EXANTHEMATE.

There are also mild cases of scarlet-fever, when little or no rash appears, and the throat is very little affected. These are the result of a particularly mild character of the epidemy, together with a peculiar condition of the skin, the desquamation of which shows that the poison went to the surface without producing the usual state of inflammation, or the rash peculiar to the disease. This form, called scarlatina sine exanthemate, is extremely rare.

16. THE MALIGNANT FORMS OF SCARLET-FEVER

are caused by the character of the epidemy, but, perhaps, more frequently by the weak and sickly constitution of the patient and the external circumstances affecting it. Thus, persons of scrofulous habit, being naturally of a low organization, without much power of resistance, are much more liable to experience the destructive effects of scarlatina than those whose organism possesses sufficient energy to resist the action of the morbid poison, and to expel it before it can do any serious harm inside the body.

17. SUDDEN INVASION OF THE NERVOUS CENTRES.

Of the different forms of scarlatina maligna the most dangerous is the sudden invasion of the nervous system, particularly the brain, the cerebellum and the spine, by which the patient's life is sometimes extinguished in a few hours. In other cases the symptoms deepen more gradually, and death ensues on the third, fifth or seventh day.

18. AFFECTION OF THE BRAIN.

When the brain is affected, the patient suddenly complains of violent headache, vomits repeatedly, loses his eye-sight, has furious delirium, or coma (a state of sleep from which it is difficult to rouse the patient); his pupils dilate; the pulse becomes small, intermits; sometimes the skin becomes cold; there is dyspnœa (difficulty of breathing), fainting, paralysis, convulsions, and finally death; or, sometimes, the paroxysm passes suddenly by with bleeding from the nose or with a profuse perspiration.

19. AFFECTION OF THE CEREBELLUM AND SPINE.

In affections of the cerebellum and spinal marrow, the patient complains of violent pain in the back of the head and neck, in the spine, and frequently in the whole body. These also frequently terminate with the destruction of life.

20. During all these invasions of the nervous centres there is little or no rash, and what appears is of a pale, livid hue.

21. PUTRID SYMPTOMS.

Next to those most dangerous forms—most dangerous, because the organic power (the vis medicatrix naturæ), from which the restoration of health must be expected, and without which no physician can remove the slightest symptom of disease, becomes partly paralyzed from the beginning—putrid symptoms present a good deal of danger, although they give the organism and the physician more time to act.

22. CONDITION OF THE THROAT, AND OTHER INTERNAL ORGANS.

The condition of the throat requires the most constant attention. From a highly inflamed state, it often passes into a foul and sloughy condition; the breath of the patient becomes extremely fetid; the nostrils, the parotid and submaxillary glands swell enormously, so that swallowing and breathing become very difficult. There is an acrid discharge from the nose; the gangrenous matter affects the alimentary canal, causing pain in the stomach, the bowels, the kidneys and the bladder; a smarting diarrhœa with excoriation of the anus, and inflammatory symptoms of the vulva. Also the bronchia, lungs, pleura and pericardium become affected, as sneezing, cough (the so-called scarlet-cough) and the pain across the chest and in the region of the heart indicate.

23. OTHER BAD SYMPTOMS.

These symptoms may present themselves with the rash standing out; but most frequently they occur when there is little or no eruption, or when it fades, becomes livid, or disappears altogether. A sudden disappearance of the rash, before the sixth day, commonly increases the typhoid symptoms, and must be considered a bad omen. Also the invasion of the larynx, which is happily of rare occurrence, is commonly fatal.

24. DESTRUCTION OF THE ORGAN OF HEARING.

When the glands pass into a sloughing state, the parts connected with them are frequently damaged. Thus the ulceration of the parotid gland often causes deafness, by the gangrenous matter communicating to the eustachian tube and the inner ear, where it destroys the membrane of the drum and the little bones belonging thereto, or by closing up the tube. When the discharge from the outer ear is observed, the destruction has already taken place, and it is too late to obviate the injury.

25. OTHER SEQUELS, DROPSY, &C.

Beside the ulceration of glands and deafness, some of the sequels of scarlatina are white swelling of one or more of the joints, usually the knee, chronic inflammation of the eyes and eyelids, and partial paralysis. These chiefly occur in scrofulous subjects. Dropsy, which I have mentioned before, is one of the sequels that frequently prove fatal.

26. THE CONTAGION OF SCARLATINA VERY ACTIVE.

The contagion of scarlatina is very active, and adheres for a long time to the sick-room, bedding, clothes and furniture. The best means to destroy it, is plenty of air. It is difficult to say when the contagion is over, as much depends on the season of the year and the care with which the house is aired. Physicians and visitors at the sick-room are very apt to carry it about, unless they be exceedingly careful in changing their clothes and washing themselves, hair and all, before entering other rooms inhabited by persons who had not had the disorder before. It is astonishing how easily such persons are taken by it; and it even sometimes happens that such as have gone through it, take it again in after years. I am authorized by experience, that the idea as if patients under water-treatment, or even such as take a cold bath every morning, were inaccessible to the contagion, is erroneous. I have had patients under treatment for chronic diseases, who had had scarlatina several years before, and neither this nor the water-cure protected them from taking it again. With some of them, however, the throat only became affected and no desquamation took place, whilst the character of the complaint with the rest was rather mild. I have been astonished to read that in a meeting of a medical society of this country, which took place a very short time ago, some members could have raised the question whether scarlatina was really contagious. I admit that the profession in general has not made great progress in the cure of the complaint, but it does not require great study and long experience to know that scarlet-fever is contagious!

27. The form of the disorder in one patient does not imply the necessity of another who caught it from him having it in the same form. A person can take the contagion from one who dies of malignant