The article of J. J. Weaver furnishes the most conclusive evidence. His experience was as follows: Some months prior to Dukes' publi cation, he noted in the Southport Borough Infectious Disease Hospital in which he was medical superintendent, in a number of scarlet fever cases, recurrences with a new eruption and fever. In 20 cases of scarlet fever 6 such recurrences were noted in three months. He reported 14 hospital cases in his experience with their temperature charts. These charts are of especial interest because they are in cases in which the "Fourth Disease" either preceded or followed scarlet fever.
The clinical picture of Weaver agreed in the main with that of Dukes. He called attention to the regular fine, punetiform character of the eruption and noted that in his cases the rash appeared first on the face and, contrary to scarlet fever, involved the skin surrounding the mouth. Certain rather negative features he considers characteristic of the disease, little or no fever, little or no disturbance of the pulse, very slight pharyngitis and practically no general symptoms. There was no strawberry tongue, and the incubation was nine to twenty-one days. The mildness of the symptoms of course suggests rubella but neither coryza nor cough was observed, and the swelling of the cervical lymph-nodes was less marked and not so constant as in rubella and lastly, in his cases there was no marked desquamation but a simple scaly separation of short duration.
The existence of the "Fourth Disease" as a separate clinical entity can only be determined by a series of unprejudiced observations but one can state that there exist mild epidemics suggestive of scarlet fever which attack children who have already had scarlet fever and rubella and it does not protect the patient from a subsequent attack of either scarlet fever or rubella.
All of us who have to do with the acute exanthemata either in the hospital or in private practice have doubtless seen such cases as Dukes and Weaver have described. I myself have repeatedly seen such cases
but unfortunately have not made such observations as would serve to clear up definitely this question. It must be noted, however, that the observations of Dukes and Weaver, however convincing they may be, do not suffice to solve the interesting and important question. When we search the literature of rubella we find much which in my opinion goes to show that Dukes is on the right track and that his opinions will be verified.
It is remarkable that Dukes, before he published his important studies, did not search the foreign literature for there he would have found much enlightenment upon this subject. In 1SS5 Nil Filatow, in an article in Russian, raised this question and, in 1896, in his lectures on the infectious diseases of children outlines in a special chapter a separate disease similar to the one which Dukes described. Naturally he did not include under the heading "rubella scarlatinosa" those eases of rubella in which in addition to the typical spots there is an erythem atous eruption. According to Filatow, rubella scarlatinosa is "a sepa rate acute infectious and contagious disease, which is characterized by a scarlatiniform eruption but which may be separated from scarlet fever by the mild course and especially by the difference in the con tagiousness.
In my opinion megalerythema epidemicum or erythema infecti osum (or the fifth disease, as the latest French writers would call it) which has been a matter of discussion in the German literature since 1900, has nothing to do with the "Fourth Disease " The disease des cribed by Trommer in 1901 as scarlatinois, and that which Pospischil called scarlatinoid have no bearing on the question of the existence of the fourth disease.