exhaustion. Less commonly it pursues a chronic course and terminates in recovery. Excised bits of muscle present a light color, and appear as if watered and swollen, while microscopic examination discloses granular turbidity, fatty degeneration, vitreous degeneration, and vacuolation in the muscle-fibers, together with hyperplasia of the interstitial connective tissue. The brain, the spinal cord, and the peripheral nerves are unaltered. In treatment warm baths, massage, salicylic acid, and sodium salicylate, as well as faradization of the muscles, have been employed. MYOTONIA. Myotonia is known also as Thomsen's disease, and is generally an hereditary affection. In isolated instances it has been observed to develop in the sequence of fright and over-exertion. The disease has not rarely been seen in the newborn, while in other instances the earliest symptoms have not appeared until childhood, and occasionally not before the twentieth year. The essential feature of the disease consists in the circumstance that the muscles after every contraction remain for some time in a state of tonic, painless contraction, so that an intended movement is prevented or is executed most incompletely. Should the patient desire to stand up and to walk, elevation of the body is effected only with great difficulty and slowness, while often the patient falls and rolls to and fro upon the ground, and only after some time does walking become possible. If an object be grasped, it cannot at once be released, as, for instance, in taking the hand of the physician. The muscles of the face and the tongue are not rarely involved, and then the speech becomes drawling and halting. Even the ocular muscles may be affected. The disorder generally begins in the lower extremities and gradually extends upward. The sphincters of the bladder and the rectum remain uninvolved. The affected muscles generally become increased in size, but are nevertheless impaired in function. Occasionally they exhibit fascicular contraction. The muscles at times are also tender on pressure. The myotonic reaction is a notable feature. If the muscles are stimulated with a strong galvanic or faradic current, the muscular contractions persist for from twenty to thirty seconds beyond the stimulation. On stimulation with a number of opening faradie currents, however, short and lightning-like muscular contractions take place. On stimulation with the galvanic current, contractions are obtained only on closure. If one pole of the galvanic current is placed in the palm of the hand, and the other upon the nape of the neck, rhythmic muscular waves will soon be observed in the flexors of the fingers, passing from the kathode to the anode. Quantitative alterations in electric irritability are not known to occur. Electric stimula of the related motor nerves also discloses no quantitative changes. The nerves likewise exhibit no qualitative alteration, except that on labile application of the galvanic current tonic contractions appear in the related muscles and persist for as long as ten minutes afterward. The mechanical like the electric irritability of the muscles also induces a persistence of the contraction. The tendon-reflexes are at times unaltered, at other times exaggerated, and at still other times enfeebled. Cutaneous sensibility is unaltered, although some patients complain of paresthesia. The disorder generally persists throughout life; only rarely has recovery been observed. The symptoms are usually aggravated by cold, while the movements. are more readily executed after repeated attempts. The brain, the spinal cord, and the peripheral nerves have been found unaltered on postmortem examination, while increased width, granular clouding, vitreous degeneration, vacuolation, increase in the muscle-nuclei, and degeneration, together with empty sarcolemmasheaths, with slight hyperplasia of the interstitial connective tissue, have been demonstrated in the muscle-fibers. Myotonia is not dangerous to life, but is a most troublesome disorder, preventing patients from the pursuit of their occupations and rendering them incapable of military service. Subjective relief is occasionally afforded by means of massage and tepid baths. MYASTHENIA. Myasthenia consists in an undue readiness of fatigue on the part of the muscles. If the patient raises his arms aloft several times, progressive weakness becomes manifest, and the arms appear for a time incapable of movement, as if paralyzed. A like condition occurs also in the legs. Even the muscles of speech and of deglutition become exhausted rapidly, and eating is attended with the danger that a bolus of food may become impacted and cause death by suffocation. The muscles of the eyelids also readily become exhausted; the eyelids close and cannot be opened. Profound involvement of the bulbar nerves gives rise to a condition closely resembling chronic bulbar paralysis, except that the muscles recover within a short time and occasionally manifest their functional activity. If the muscles be stimulated electrically, they likewise soon become exhausted, and no longer respond. Nothing of a definite nature is known with regard to the etiology of this rare disease, although of late the possibility of auto-intoxication has been considered. The treatment should be directed to invigorating the body by means of a nutritious diet and of rest. In addition, preparations of arsenic, cinchona, and iron have been recommended. PART VII. DISEASES OF THE SKIN. I. INFLAMMATIONS OF THE SKIN (DERMATITIDES). ERYTHEMATOUS INFLAMMATIONS OF THE SKIN (ERYTHEMATOUS DERMATITIDES). URTICARIA (NETTLE-RASH; HIVES). Symptoms and Diagnosis.-Urticaria is characterized by the formation of wheals or pomphi, which are often attended with intolerable itching. The wheals occur especially upon the face and the trunk, and less commonly upon the extremities. At times but a few disseminated wheals are present, while at other times the body is densely covered with them, so that often adjacent wheals coalesce (urticaria conferta) and form at the same time irregular bands (gyrate urticaria). The wheals vary in size from that of a lentil to that of the palm of a hand, and even beyond. The designation giant urticaria also is applied to wheals of unusually large size. The wheals are at times uniformly red in color, while at other times they are pale at the center, and only the elevated border is red (urticaria porcellanca). In rare instances vesicles or blebs form upon the wheals (miliary, vesicular, or bullous urticaria). Occasionally wheals occur also upon the mucous membranes, as, for instance, that of the cheeks, the pharynx, the larynx, and the bronchi. The duration of the individual wheals is extremely variable. Not rarely they disappear within a short time, while new wheals appear at other points upon the skin. Occasionally the disorder is confined to the local alterations in the skin, and it disappears in the course of a few hours-ephemeral or evanescent urticaria. In other instances it begins with chilliness and fever, or fever soon develops after the appearance of the wheals-nettle-fever, febris urticata ; but recovery generally takes place in the course of a few days. There is, further, a chronic variety of urticaria―urticati 164 catio, chronic urticaria, urticaria perstans-the disease persisting for months or years, or even throughout the whole of life, less commonly without intermission, but rather in constantly repeated recurrences. The patients are greatly distressed by the intense itching by day, and particularly by night, and they are gradually reduced to a state of alarming exhaustion. A chronic variety of urticaria has been designated pigmented urticaria, beginning in the first months of life, persisting to the tenth year, and attended with the presence of reddish or brownish, slightly elevated pigment-areas upon the skin, instead of wheals. Anatomic Alterations.-The anatomic alterations in the skin must be studied during life, as the manifestations largely disappear after death. If a wheal be punctured and be compressed from the side, a small amount of clear fluid is expressed, and the wheal collapses. The histologic alterations in the skin have been studied especially in wheals induced artificially in animals. Dilatation of the blood-vessels and the lymphatics of the cutis was found, although the blood-vessels may be compressed, narrowed, and emptied, in consequence of edema of the cutis. Colorless blood-corpuscles and mast-cells had accumulated upon the outer aspect of the vessels. The cutis was edematous, and occasionally swelling could be demonstrated also in the lowermost epithelial cells of the epidermis. Etiology.-Urticaria is most commonly of toxic origin, while mechanical and nervous influences are less commonly operative. Toxic causes occasionally exert their influence from without directly upon the skin, and it is well known that contact with the stinging nettle, Rhus toxicodendron, and certain caterpillars, the external application of carbolic acid and of poultices may give rise to urticaria, as well as the bite of a number of insects (flea, mosquito, bedbug) or of the leech. In other instances toxic substances reach the skin only through the intermediation of the blood-vessels and the lymphatics. Urticaria is therefore not an uncommon manifestation in connection with gastric and intestinal catarrh, as well as with jaundice. Some individuals are always attacked with urticaria after the ingestion of certain articles of food (strawberries, lobster, crabs, cheese, oysters) or of certain drugs (quinin, salicylic acid, antipyrin, balsamics, potassium iodid, etc.). Urticaria occurs not rarely after puncture of echinococcous or ovarian cysts, obviously because in the act of puncture some of the cystic fluid has found its way into the abdominal cavity and by absorption has gained entrance into the general circulation. Urticaria occurs occasionally also in association with intestinal worms. In this connection the cases should be considered that develop after infectious diseases (relapsing fever, typhoid fever, scarlet fever, measles, pulmonary tuberculosis) and after diseases attended with profound disturbances in metabolism (diabetes, nephritis, carcinoma). The mechanical causes for urticaria include those that induce active scratching of the skin. In the presence of cutaneous parasites, the mechanical effect is often superadded to the toxic effect. Itching diseases of the skin (prurigo, pruritus) also are generally followed by urticaria. Urticaria develops in some individuals when the skin has been exposed to the action of the wind. In some persons, particularly neurotic and hysterical individuals, the skin is so sensitive that urticaria can be induced in any desired design by means of a hard body-factitious or dermographic urticaria. Especially neurotic influences can be readily discovered in some cases of urticaria. The affection occurs frequently in association with hysteria, occasionally with neuralgia, and it may develop also after fright and joy, or through reflex influences in connection with dentition and uterine disorders. Urticaria has been designated an angioneurosis of the skin. Prognosis. Although urticaria is not a dangerous disorder, it may in its chronic form become extremely troublesome, and drive the patient almost to distraction. Treatment.-The prophylaxis should be directed to the avoidance of food and drugs that experience has shown to be capable of inducing urticaria. Causal treatment should be directed to the removal of causative conditions (destruction of insects, relief of gastro-intestinal catarrh, etc.). Symptomatically, inunctions of carbolized ointment (1:10) or affusions of a solution of carbolic acid (5.0: 100), or the local application of lotions containing lemon-juice, vinegar, or cologne-water, may be recommended. Internally, salol (salol, 1.0-15 grains; saccharin, 0.02— grain; 1 powder every two hours) may be administered. Occasionally successful results have been obtained from the employment of potassium iodid, quinin, carbolic acid, arsenic, atropin, potassium bromid, or pilocarpin. The use of tepid baths also appears worthy of recommendation. The patients should wear soft and warm underclothing, and avoid thick feather-beds. NODOSE ERYTHEMA. Symptoms and Diagnosis.-Nodose erythema begins not rarely in the manner of an acute infectious disease, with chill and fever. The patient feels extremely languid, and presents enlargement of the spleen. At the same time or in a short while articular pains appear, most commonly at the knee and the ankle. The joints are swollen, and the overlying skin often is reddened. The attention of the patient is generally directed to the skin by the burning and prickling sensations. There form red nodules, |