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 anesthetic.

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

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 a very livid 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.

A

I have seen more or less extensive erythematous eruptions in uræmia, in septic conditions (whitlows, suppurating wounds, etc.), in acute rheumatism, and in tonsillitis. 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 fœces.

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 oedema 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.

eruption depends on some personal peculiarity on the part of the patient himself, and Besnier goes so far as to say that without this predisposition the rash will not develop. Brocq and Besnier, who did probably more than anyone else to define this disorder, regard it as a mild form of pityriasis rubra, but this opinion is not shared by many English dermatologists, as it differs from that disease in not causing a constant exfoliation of cuticle. Crocker considers it more allied to the toxin erythemata.

Finally, there remains erythema exudativum multiforme, a disease of an erythematous type characterised by extreme polymorphism. In consequence of this feature, it has been split up into many sub-divisions and varieties, of which erythema papulation, erythema tuberculatum, erythema circinatum, erythema gyratum, erythema iris, erythema bullosum, and herpes iris, are the best known. It is, however, common to find two or more of these varieties present at the same time. Herpes iris, however, is usually met with by itself, and not intermingled with the other skin lesions of erythema multiforme. There is often slight feverishness and malaise before the eruption of multiform erythema appears, if it occurs idiopathically; but if it occurs in the course of some general disease, as e.g., acute rheumatism, these symptoms may be absent. All these eruptions show a great tendency to be symmetrical on the limbs. They start most frequently on the backs of the hands and on the dorsum of the foot, and they spread from these regions up the arms and legs. Quite rarely the trunk may be first affected. Fresh lesions may continue to appear whilst the older areas of eruption are disappearing, and the average duration is from two to six weeks. Relapses may follow, and in some cases are frequent. I have found myself, in taking the history of cases of herpes iris, that there has generally been a previous attack, and in some cases patients have always ascribed the attack to the same cause-being overworked and overstrained, or having mental worry. The eruptions of erythema multiforme cause, as a rule, very little itching and smarting of the skin, even when the eruption is very extensive, or when bullæ are present.

Herpes iris, though in many cases running a very mild course, may sometimes be much more severe in type. The disease may not only invade the backs of the hands, wrists, elbows, and knees-its usual situations-but the palms of the hands and soles of the feet may be affected, and the mucous membrane of the mouth and lips may also share in the attack. In the case of a woman that I saw in April, 1897, the disease began in the ordinary way on the backs of the hands, but crops of eruption appeared later on on the palms of the hands, on the upper arms, and on the mucous membrane of the lips and palate. The woman became very ill, with a temperature of 103 degrees for several days, and only slowly recovered. In the severe forms of this disease a considerable hæmaturia has been recorded.

In this place I may briefly mention another well-known erythematous eruption-erythema nodosum-which has a very characteristic appearance when well marked on the legs. When, however, one "node," or, perhaps, two only are present, the diagnosis is not so easy, and I have seen these cases diagnosed as "periostitis," acute infective, or syphilitic more than once. Sometimes the extensor surfaces of the forearms may be affected as well as the front of the legs. This affection, as is well known, is very closely related to rheumatism, and S. Mackenzie, as a result of an examination of 108 cases, concluded that it is frequently, if not generally, an expression of rheumatism. A few other observers, however, deny its rheumatic relationship, and it is doubtful if the salicylates in any way cut short the eruption. I have treated many cases both with and without salicylates internally, and one set of cases did as well as the other.

Peliosis rheumatica has many close relationships to erythema multiforme, and resembles in its course that eruption, except that its lesions are purple from the first or actually hæmorrhagic. They, therefore, do not fade on pressure. The spots usually appear in largest numbers around the joints, which are very generally swollen and tender. Sometimes a very similar purpuric eruption is associated with intestinal hæmorrhage, as it was in the case of a young girl I saw in London many years ago, which terminated fatally.