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decline of the chicken-pox, about the thirteenth day, when the vaccine pustule began to be developed.*
In the following the two diseases co-existed:
Illustration XXXVI.-Ring has recorded several instances of chicken-pox appearing a few days after vaccination, and not at all interfering with the progress of the cow-pox. Thus of one case he remarks:-"Fresh pustules appeared in succession during the formation of the cow-pock pustule; totally refuting the fallacious theory that two morbid actions at the same time are incompatible."+
Illustration XXXVII.-In the Medical Gazette' (vol. ii. p. 633), a case is recorded of chicken-pox contemporaneous with cow-pox. The vesicles of the chicken-pox were very numerous and characteristic, and appeared on the eighth day of the cow-pox; the former disease having been communicated by the infant's brother, who had caught it at school.
L. Rubeola and Pertussis.-Illustration XXXVIII.-Dr. Bateman mentions a case in which the hooping-cough, of six weeks' standing, was suspended by the occurrence of measles, but returned on the decline of the latter.
Illustration XXXIX.-In a Report of the Dispensary for Children in London in 1819, several cases of children are mentioned, in whom well-marked measles appeared while they were under the complete influence of hooping-cough of three weeks' standing. In three or four days the measles disappeared, leaving the patients in the same state as regards the hooping-cough.§
Illustration XL.-Dr. Williams saw three cases in which hoopingcough and measles co-existed, all of which proved fatal.||
M. Variola, Rubeolu, and Pertussis.-Illustration XLI. Ring mentions upwards of a dozen cases in which the small-pox, the measles, and the hooping-cough, all three co-existed, and all three ran their course together. ¶
N. Scarlatina and Rubeola.-The co-existence of these two diseases is probably not an uncommon occurrence.
Illustration XLII.-In an account of the diseases prevalent at Paris in 1800, we are told that scarlatina was frequently observed complicated with measles, and that such cases were always of extreme severity.**
Illustration XLIII.-During the year 1833, in which many cases of both measles and scarlet fever were admitted into the Hôpital des
Mr. Washbourne: Medical and Physical Journal, vol. ix. p. 370. 1803.
+ Diseases of London, p. 91. § London Medical Repository, vol. xiii. p. 90. 1820. On Morbid Poisons, vol. i. p. 303.
Treatise on the Cow-pox, pp. 107, 267, 1029.
** Recueil Périodique de la Soc. de Méd., tome viii. p. 359. 1800.
Enfans Malades, at Paris, numerous instances were observed by M. Guersent, in which the two diseases co-existed.*
It is not so generally known as perhaps it ought to be, that an affection partaking of the characters of both measles and scarlet fever is of very frequent occurrence upon the Continent, and is not uncommon in our own country. It is characterized by an eruption appearing about the end of the third day, at first resembling that of measles, and subsequently that of scarlet fever, by a combination of the morbillous coryza with scarlatinous angina, and by a subsequent desquamation of the cuticle, in the form of fine branny scales. This is the disease spoken of by German writers under the terms Rötheln and Rubeola. Under the latter name it was accurately described by Hildenbrand.† The rubeola, then, of German writers is not the same disease as we in England call rubeola. Before the time of Sauvages and Cullen, the term morbilli was always applied to the measles even in this country, and the substitution of rubeola by those nosologists has created no small confusion. Other designations have been applied to this German rubeola or rötheln, such as morbilli scarlatinosi, scarlatina morbillosa, scarlatina hybrida, bastard measles, bastard scarlatina, &c., all of which plainly indicate that the disease is very different from English measles. Much difference of opinion exists as to the precise nature of this affection, and observations are still wanting in order to form an accurate decision. Partaking of the characters of both measles and scarlet fever, and occurring, as it generally does, during contemporaneous epidemics of these two affections-and more especially during the transition period, when an epidemic of the one is immediately followed by an epidemic of the other-it has naturally been considered by many as a hybrid disease; and seeing that we can now no longer deny the possibility of something approaching to a hybrid between any two of the exanthemata, this view is perhaps the more probable. On the other hand, it must be allowed that arguments of no small weight have been adduced to prove that rötheln is a specific disease distinct from both measles and scarlet fever. The principal of these are the following: 1. It is said that we may have epidemics of röthen alone, without either measles or scarlet fever; and 2. It is alleged that previous attacks of either true measles or scarlet fever confer no immunity from rötheln, while in one case I find that an attack of rötheln was followed in four months by simple scarlet fever. For further information upon this interesting subject I must refer to the work of Hildenbrand already quoted, to the article Rubeola in Dr. Copland's Dictionary of Practical Medicine,' and to two papers giving an account of epidemics of the disease in this country-one by Dr. Robert Paterson, of Leith,§ and the other by Dr. George Balfour, of Cramond.
* Gazette des Hôpitaux, vol. viii. p. 34. 1834.
+ Institutiones Practico-medicæ, vol. iv. p. 414. 1833.
O. Typhus and Scarlet Fever.-I am not aware of any instance in which the eruptions of the true typhus and of scarlet fever have coexisted in the same individual. It is, however, by no means unusual for patients admitted into the London Fever Hospital with either typhus or scarlet fever, to contract the other affection before their discharge. I have notes of four cases in which patients admitted with typhus took scarlet fever subsequently-one on the fourteenth day of the primary convalescence, a second on the tenth, a third about the seventeenth, and a fourth about the seventh. Again, I have notes of five cases, in which patients admitted with scarlet fever contracted typhus. In one case there appeared to be an interval of five weeks between the two diseases; in two other cases, a fortnight intervened; in a fourth, ten days; and in a fifth, only three or four days. This last case deserves more especial mention.
Illustration XLIV.—A boy, aged four years and a half, was admitted into the London Fever Hospital with all the usual symptoms of scarlet fever, including well-marked eruption and sore throat. On the fourth day, the rash was well out, but from this date it continued to fade, and on the eighth day the boy was convalescent. Three or four days later, the febrile symptoms returned, and on the fourteenth day from the first commencement of the scarlet fever, a typhus rash made its appearance. Ten days later, he had anasarca, lumbar pain, and scanty urine, containing albumen. The anasarca and albuminous urine continued for about a week, after which the patient recovered.
This patient, then, would appear to have gone through an attack of typhus, before the system had thrown off the scarlet fever poison.
P. Scarlatina and Typhoid or Pythogenic Fever.-No cases have hitherto been published showing the possibility of these two diseases co-existing. In the London Fever Hospital it is far from rare for a patient labouring under the one disease to be exposed to the contagion of the other, and many instances have occurred in which a patient admitted with the one has taken the other while in the hospital. This remark applies more especially to scarlet fever supervening upon pythogenic. This, indeed, is not to be wondered at when we remember that although pythogenic fever may under certain circumstances be communicated from the sick to the healthy, it is very rarely so, and is probably never contagious in the ordinary acceptation of that term. During a period of ten years I have been able to find the notes of only one case, in which a patient admitted with scarlet fever contracted pythogenic fever while in hospital. In this case the pythogenic fever supervened during convalescence, on the 26th day from the date of commencement of the scarlet fever, and on the thirteenth day after admission into hospital. Moreover, it is to be remembered in reference to such cases, that a delicate scarlet tint of the skin sometimes precedes for two or three days the eruption of the rose spots of pythogenic fever, and may cause the disease at first to simulate scarlet fever. Dr. W. Jenner has recorded an instance, in
which such a case was sent into the Fever Hospital with a certificate from a physician of eminence, that the disease was scarlet fever. After a few days, the scarlet rash disappeared, and was followed by rose spots. The etiology of such cases deserves closer investigation than it has yet received. It is not impossible that some of them at all events may be examples of the co-existence of the two exanthemata, and in Dr. Jenner's own case it is to be noted that sore throat was a prominent symptom, while diarrhoea and epistaxis (both symptoms of pythogenic fever) existed during the presence of the scarlet rash.
On the other hand, instances of scarlet fever supervening upon pythogenic have been by no means rare, and are not open to the same fallacy as I have pointed out may be applicable when the sequence of events is reversed. I have notes of nine such cases, and in four at least of these the eruptions of the two diseases were present at one and the same time. With regard to one of the cases, my notes are very imperfect, and I am unable to state at what period of the pythogenic fever the scarlet fever supervened. In the second and third cases the scarlet fever appeared in the third week of convalescence, and five weeks after admission, and in one of these cases the scarlet fever was followed by enlargement of the submaxillary glands, general dropsy, and albuminuria, and during the persistence of these symptoms, about the thirtieth day from the supervention of the scarlet fever, wellmarked variola showed itself. In a fourth case, the scarlet fever supervened nine days after admission, and on the twenty-first day of the primary fever. It was followed by glandular swellings and discharge from the ears, and proved fatal. No mention is made of rose spots after the appearance of the scarlet rash, but diarrhoea, which had been a prominent symptom before, still continued. In a fifth case, scarlet fever appeared six days after admission, and on the sixteenth day of the primary fever. Rose spots were noted three days before the appearance of the scarlet rash, and it is not impossible but that they existed afterwards. In all of these cases, as well as in those about to be mentioned, the usual symptoms of scarlatina, in addition to the rash, were present. In the four following cases, the eruptions of pythogenic and scarlet fever existed simultaneously.
Illustration XLV.—A girl, aged fourteen and a half, was admitted, Oct. 20th, 1856, with all the usual symptoms of pythogenic fever, including headache, sickness, diarrhoea, &c., having been ill five days before admission. On the ninth day eight or nine rose spots made their appearance, and for six days similar spots continued to come out in successive crops. On the thirteenth day six fresh ones were noted. On the fourteenth day, eight days after admission, a scarlet rash appeared all over the body, which on the subsequent day had assumed all the characters of perfect scarlatina. No fresh spots were noted after the fourteenth day, but on the sixteenth one or two of the old ones still remained, surrounded by the scarlet rash. Simultaneous with the appearance of the rash there were increased rapidity of pulse,
* Medical Times, vol. xxii. p. 277. 1850.
sore throat, and the characteristic tongue of scarlet fever. In the same ward there were many cases of scarlet fever. The patient recovered.
Illustration XLVI.-A policeman, aged twenty-three, was admitted from a house from which several other cases of pythogenic fever had come, on July 26th, 1857, having been ill four days. His symptoms were vertigo, quick pulse, tympanitic abdomen, gurgling in the iliac fossa, and watery diarrhoea. On the fifth day rose spots began to appear, and on the eighth upwards of four hundred were counted on the anterior aspect of the body. On the seventeenth day the spots still continued numerous. On the twentieth there was great aggravation of the febrile symptoms; the rose spots had nearly all disappeared, but a few still remained, and there was in addition a scarlet rash, having all the characters of that of scarlatina. The throat was sore and the fauces very red. The diarrhoea still persisted. This rash disappeared after a few days, and the patient recovered.
Illustration XLVII.-A policeman, aged twenty-three, was admitted November 9th, 1857, having been ill for three weeks with wellmarked symptoms of pythogenic fever, including red, glazed, and fissured tongue, tympanitic abdomen, urgent watery diarrhoea, and rose spots. These rose spots on admission were so numerous as in some places to run into one another. Eight days after admission the rose spots, which for some days before had been increasing in number, still continued abundant, and the diarrhoea persisted. There was, in addition, a general scarlet rash, identical with that of scarlet fever, a strawberry-red tongue, with large papillæ, sore throat, and injected fauces. Two days later the rose spots still continued in great numbers, and the scarlet rash persisted. Two days after this the scarlet rash was fading, but the rose spots continued out for a few days longer. A week after the disappearance of the scarlet rash there was copious desquamation. The patient made a good recovery.
Illustration XLVIII.-A boy, aged fourteen, was admitted, August 25th, 1858, from a house in which there had been other cases of pythogenic fever. He had the symptoms of pythogenic fever in a mild form, and with no very well-marked abdominal symptoms. Rose spots made their appearance on the thirteenth day, in sparing numbers, and continued coming out in successive crops. On the twenty-second day there were still some rose spots, and also a general scarlet rash having all the general characters of that of scarlet fever. The tongue was moist, with thick white fur and large red papillæ; the throat sore; the tonsils enlarged and red, and coated with a white membraniform deposit. On the same day the pulse had risen from 72 to 132, and the temperature under the tongue from 99° to 104° Fahr. After three or four days both the eruptions disappeared. On the twenty-fifth day the tonsils were so large as almost to meet, and the tongue was clean, red, and of a strawberry aspect. On the twenty-seventh day desquamation commenced. Convalescence was delayed by tedious swellings