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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 appear

The 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

the usual thing is for each chilblain to have a more or less short existence. It may either get well—the redness disappearing—or it may rupture and slowly heal. In other cases, however, persistent hard nodules of congested skin may be left which last for months. In certain situations these nodes may be very inconvenient. I was consulted by a lady some months ago for one of these nodules on the end of the nose, which had been present for six months; and I remember seeing a young lawyer who had to give up bicycle riding in winter, as he developed a large chilblain in the same situation for several winters in succession.

The erythema from the chemical rays of light and the X-rays is familiar to all workers on lupus and rodent ulcer, and, as Finsen pointed out, is liable to be followed by a very longcontinued pigmentation. Rarely one meets with individuals whose skins are extremely sensitive to sunlight, or, rather, to the violet rays in sunlight. I have recently seen a lady who can never, even in winter, go into the sunlight without an erythematous eruption of a severe type appearing on the face.

Local erythematous eruptions, due to irritation, are often seen about the thighs and buttocks of children, and they are also subject to transitory patchy erythema from teething, worms, and other causes.

Scarlatiniform erythema, closely resembling the rash of scarlet fever, is fairly often seen after certain drugs, as copaiba, antipyrin, belladonna, chloral hydrate and quinine, and a mild form of erythema is often noticed during the administration of ether as an anæsthetic.

Everyone has probably seen several instances of copaiba rashes, which are often of an intensely red colour, and may become confluent. Enemata may also be followed by brilliant scarlatiniform eruptions, which may be patchy or may completely cover the body. Sometimes a few urticarial lesions are also present, and, if so, the recognition of the eruption is more easy. These eruptions do not seem to depend on the kind of enema given, although they appear to be more common after soap and water than after other forms of enemata. The erythematous areas in these enema rashes

a very livid

have a great tendency to appear simultaneously in several situations, and begin on the limbs, as a rule, more frequently than on the trunk. They are sometimes accompanied by a great sense of heat in the skin, but the thermometer, placed under the tongue, indicates no rise in temperature. In scarlet fever, on the other hand, pungent heat in the skin always means a fairly high temperature. Enema rashes are generally thought to be due to the absorption of some toxic substance from the bowel.

Scarlatiniform eruptions may also be met with in diphtheria, typhoid fever, and influenza. I saw eruption of this kind at the Birmingham Fever Hospital some years ago. A young girl, with membrane on the throat and genitals, before antitoxin serum had been given, had a very bright scarlet eruption all over the body, except on the face and neck. The upper limits of the eruption on the lower part of the neck were quite sharply defined, and considerable desquamation followed.

Antitoxin serum is very prone to cause eruptions in diphtheria patients. According to Dr. Arthur Stanley,* in five hundred cases of diphtheria, these eruptions followed the injection of the serum in one-fourth of the cases. The period of onset of the rash was usually in the second week after the giving of the serum. The rashes were generally erythematous in type, and were sometimes prolonged.

I have seen more or less extensive erythematous eruptions in uramia, in septic conditions (whitlows, suppurating wounds, etc.), in acute rheumatism, and in tonsillitis. A scarlatiniform eruption in tonsillitis, especially if on the chest, is particularly difficult to distinguish from scarlet fever. I have seen two or three such eruptions, and there can be little doubt, I think, that such cases are more common than they are thought to be. I have also seen an instance of a morbilliform eruption in malignant endocarditis, and late in typhoid fever. Crocker has seen erythematous eruptions in sewer-gas poisoning, with an ulcerated throat, and in a case with an artificial anus. He has also noticed a morbilliform

* British Medical Journal, Feb. 15, 1902.

eruption with infection of the mucous membrane, apparently due to a patient having a mass of retained fæces.

A rarer form of eruption is erythema scarlatiniforme or recurrent desquamative scarlatiniform erythema, in which, along with a moderately high temperature (101 or 102 degs.), a bright scarlatiniform eruption spreads rapidly over the body, often becoming universal in twenty-four hours. Sometimes small areas of ædema may also be noted, or this feature may be very marked. Desquamation, it is important to note often starts about the fourth or fifth day, or may be delayed. It is usually very free, much more so than in scarlet fever, and the hair and nails may sometimes be shed. The disease shows a great tendency to relapse, but the first attack is generally the most acute. Some patients have had a large number of attacks-seven, ten, or more. Tilbury Fox had a patient who had a hundred or more, and various complicating disorders have been observed. It is probable that some imagined instances of scarlet fever occurring four or five times in the same patient have really been instances of this disease. The eruption may be distinguished from scarlet fever with extreme difficulty in the first few days, and in case of doubt isolation is advisable. A previous history of similar attacks would be strongly in favour of erythema scarlatiniforme.

Desquamation, as indicated before, is a valuable aid in diagnosis, as it is seldom well marked in scarlet fever before the tenth day, but may be very early (fourth or fifth day) in scarlatiniform erythema. The desquamation is also more long-continued in scarlatiniform erythema, and epidermic casts of the hands and feet may be thrown off, and the hair and nails may even be shed in severe cases. It is not contagious, which also often helps to distinguish it from scarlet fever, German measles, and measles. The causes of this very interesting eruption are numerous. Instances have been recorded after certain foods, particularly shell-fish. Elliot* recorded a case where the rash developed at each menstrual period, an enlarged and prolapsed ovary being the exciting cause. It is probable that in the majority of cases the

*New York Medical Journal, 1890.

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