These observations do not dispose of the idea of an assessor being employed; they only show that a doctor in the case is not the man to act as such assessor. In cases, for instance, involving examination of the conduct or procedure of medical men or institutions, a coroner occasionally summons an outside professional witness, to whom questions may be addressed which would be ineffective if put to the person immediately concerned. An outside witness so called serves the purpose of an assessor, as he is a witness for the court, although, in the legal sense of the word, an assessor does not give evidence.

Without discussing at length the question of Dr. Freyberger's appointment as pathologist, it may be stated that in Birmingham the practice of the coroner is to assume that a medical man reporting a case is capable of making a post mortem examination if required; and that in cases involving a criminal charge two medical witnesses are summoned.

SOME REMARKS ON

SCARLATINIFORM

ERUPTIONS.*

THE DIAGNOSIS OF

AND ERYTHEMATOUS

BY A. DOUGLAS HEATH, M.D., M.R.C.P.,

Casualty Assistant Physician, General Hospital, Birmingham.

AN apology is usually given by the reader of any paper before this society for the subject chosen by him, and, as such is the custom, it would be well for me to adhere to it.

In the search for a subject, we are often lead to attach a false importance to matter which, though of interest to ourselves, possesses small attractions for others. It is a knowledge of this fact that has led me to draw up a few descriptions of common rashes, in the hope that a useful comparison of experiences may be brought out in the discussion to follow this paper.

No problems in diagnosis are much more difficult than some of the scarlatiniform and erythematous eruptions, and yet a mistake in diagnosis may be attended with very unpleasant results both to the patient, his friends, and his medical adviser. The rashes of the exanthemata are for the most part ably described in numerous medical works, and sharplydefined distinctions drawn between them, and yet what a number of atypical cases we meet with in practice which do not conform to our carefully-learned types.

Some eruptions also-German measles, for instance-are very quickly developed and equally quickly fade away, and if not seen in all stages are exceedingly difficult to recognise. It is also most important when a rash breaks out in a patient in hospital, or in a child at school, that the nature of the rash should be made out as quickly as possible; otherwise, infection of others may be quickly brought about. Many large institutions now promptly isolate any doubtful eruption, and await events until a positive diagnosis can be made.

*Paper read before the Midland Medical Society.

There is no doubt that very mild scarlet fever and epidemic roseola are sometimes extremely alike, and time only will decide the diagnosis. I have known instances where several medical men have all held different opinions as to a particular rash, and have known men of great experience call an epidemic scarlet fever, where others of equal eminence have diagnosed roseola. It seems, therefore, to me that I shall make my future remarks on other eruptions more clear if I draw your attention at first to the rashes of the exanthemata with which we are now most concerned-scarlet fever, German measles, and ordinary measles.

The rash of scarlet fever is of a very bright brick-red colour, and appears first on the front of the chest, neck and upper arms. The eruption spreads downwards, and is fully developed in about two days. Either at the end of that time or a day or two later it begins to fade--first in those regions where it first appeared and has generally completely disappeared at the end of six or seven days. The rest of scarlet fever is made up of two elements-(a) very closely-set minute red papules, and (b) an erythematous blush surrounding them. I have sometimes seen the rash much more papular than is usually the case. As a rule, the typical punctiform eruption does not occur on the face. If it does, the forehead and temples only show it. The face is intensely flushed, especially on the cheeks, but the region around the mouth is left quite pale. Over the flushed surface of the face is soon developed a fine powder-like desquamation looking something like the bloom on a peach. This appearance is most suggestive of scarlet fever. Desquamation, which is usually well marked at the end of seven days, first begins on the face, neck, and chest, and is usually not general until the end of the second week.

66

It is on the trunk, limbs and neck that the most characteristic desquamation occurs. Here the fine flakes of epidermis are thrown off in thin lamella, which have a worm-eaten or pin-hole" appearance, due to the mechanical friction on the summit of the papule, which forms the centre of each little portion of the eruption. This desquamation is most easily seen in a mild case where the eruption has been most

distinctly papular. One can then see about the eighth to the tenth day small groups of fading papules capped with a fine scale scattered here and there over the trunk. In young infants desquamation is usually poorly marked, and the same remark holds good for persons with very thick, greasy skins. Although the above description applies to average cases of scarlet fever, groups of cases every now and then occur in surgical wards with scarcely any temperature and fairly welldefined rashes. There is no doubt that these cases are infectious, patients in neighbouring beds being often attacked, whereas others at a distance in the same ward often escape.

I have seen many instances of scarlatiniform eruptions in surgical wards and in burn cases, and it has been sometimes exceedingly difficult to come to a diagnosis, as the patients often show extremely few constitutional symptoms, and the rashes are often curiously irregular.

The eruption of German Measles, or Epidemic Roseola, apears first on the face in the form of scattered pinkish-red spots or macules, darker in the centre than at the periphery. The rash spreads very rapidly, and will often reach the feet in twenty-four hours. Sometimes the rash shows considerable hyperæmia, when it closely resembles measles; at other times it is almost entirely scarlatiniform. It is well to remember this variability of epidemic roseola, and an examination will sometimes show both types of eruption in the same patient. Sometimes the eruption will not spread over the whole body, or the trunk and limbs only may be involved, and the face left untouched by the eruption. Forchheimer describes small dark-red papules on the soft palate appearing simultaneously with the rash, but only lasting from twelve to fourteen hours. Most observers have not noted their appearThe spots of German measles may remain separate or they may coalesce to form irregular erythematous areas. On the face they usually quickly fade without coalescing, but on the limbs and trunk they often run together to produce a typical scarlatiniform eruption. There may be no desquamation whatever, or it may be furfuraceous. It usually lasts for a very short time-two to three days at the most-and leaves the skin perfectly normal.

ance.

In Measles the eruption appears first on the temples, at the hairy margin of the forehead, behind the ears, and at the upper part of the neck. The papules are at first usually small, but they soon increase in size, and become more distinctly raised. Later still they become more purple in colour, are often more or less grouped, and may be crescentic in shape. The eruption spreads downwards on to the trunk and limbs, and reaches its maximum on the third day. The face is often very much flushed, besides showing the eruption proper, and the region around the mouth is very frequently thickly covered with papules. The rash fades first in the regions where it first appeared.

I have not made any mention of the character of the tongue, throat, glandular enlargement, or temperature in these rashes, as I am confining this paper purely to the characteristics of the rashes themselves. For the sake of brevity, also, I have not dwelt on the hæmorrhagic form of scarlet fever or measles, or on the rare severe form of German measles such as that reported by Dr. Cheadle in 1879.

Some authorities describe under the name infective or epidemic roseola a very mild disease, generally met with in summer, in which a roseola appears suddenly on the neck, limbs, and trunk, without any prodermal symptoms or glandular enlargement. Others regard these cases as a very mild form of German measles.

Passing on now to skin diseases themselves—though certain of the erythematous eruptions seem hardly worthy of being classed as diseases, being purely the result of hyperæmia--we come to erythema from friction, from heat, from certain rays of light, from cold, and from various irritants such as mustard and turpentine, and from nervous causes. Of these, the only two I propose to notice now briefly are erythema pernio or chilblain-which may pass outside ordinary congestion and become a true inflammation-and dermatitis from the effects of certain rays of light.

We are all of us familiar with ordinary chilblains of the hands, feet, and ears in winter. We see some patients, and even some families, in whom they occur year after year, but