or hands, from which they spread to the axillas, and finally traveled extensively over the body. Of the ten cases treated in the Lakeside Hospital, the following present sufficient variety to serve for the present:

to see the case.

The walls easily bacteriologic ex-again a

Case I. Male, aged 25, a member of the Fifth Regiment, O. V. I., was admitted into Lakeside Hospital, Sept. 10, 1898, with enteric fever. The second day after admission an unusual eruption was noticed and I was asked There were found on the right hypochondrium two blebs,. kindney-shaped, two centimeters in length by one in breadth, with flaccid walls and containing a clear fluid. ruptured and the fluid was collected for amination. The following day there was amount of fluid collected in the flaccid blebs, and they had extended fully a centimeter at the periphery. A lesion was then observed, for the first time, on the left thigh, which presented a denuded surface about the size of a dime. The epidermis had evidently been rubbed off by the bedclothing, leaving a raw surface. There was no redness surrounding the lesions, neither was pain or itching complained of.

small

The blebs were irrigated with a saturated solution of boric acid, and compresses of the same were applied. The lesions extended to about five cm. in their long diameter, became covered with pie-crust scales, and gradually healed.

Case II. C. E., private, aged 30, Fifth Regiment, O. V. I., entered Lakeside Hospital, Sept. 14, 1898, presenting a bullous eruption which had already begun to subside. The patient was a fine specimen of physical development, and aside from hemorrhoids, for which he entered, enjoyed good health. He had previously served in the British Army in India, and twelve years ago, had a venereal sore, which was not followed by any secondary or later manifestations of syphilis. The present eruption first made its appearance after his regiment had been stationed in Tampa, Florida, six weeks. The weather was very hot-106° Fahr. in the shade. The patient took frequent salt baths, but next the skin wore flannel which was not changed at night, and was frequently worn a fortnight without being washed.

The patient thinks he contracted the disease from a comrade who had a few vesicles on his face. The morning following the use of his comrade's towel, he noticed a blister the size of the little finger-nail on the right side of the mouth. It extended at the margin until it attained the size of a twentyfive-cent piece, when it ruptured. Nine or ten hours later a second blister appeared within a short distance of the first, and the following day about ten similar lesions broke out on various parts of the face, especially marked on the chin and region of the beard. In the course of three or four days the eruption appeared in the axillas. Here it was confluent, there being thirty or forty blisters which merged, forming extensive denuded weeping surfaces. The disease then spread to the arms, trunk, and finally the scalp and thighs.

The palms and soles were free, but the clefts and tips of the fingers were favorite positions. The eruption never extended below the knees. The mucous membranes were not implicated. The patient said the blebs ruptured almost every day and partly refilled, noticeably at the margin. During the course of the disease the patient enjoyed good health and there was but slight discomfort experienced, except when extensive areas became involved. During his seven years in India the patient had never seen the disease, but noticed many of the colored people of Florida afflicted with what appeared to be a mild form of the same trouble.

When he entered the hospital only a few typical lesions remained, but a slight pigmentation and faint reddish areas, thickly scattered over the trunk and other parts of the body, showed the distribution of the eruption.

Case III. D. B., private, Fifth Regiment, O. V. I., aged nineteen, had in common with many others of his regiment, been troubled with an eruption of variously-sized bullas. While in Florida they had appeared on different parts of the body, but since his return to Cleveland the bullas had been of smaller size and were gradually becoming less plentiful. When seen (see plate I.) the blebs had ruptured and the areas thus involved were covered with friable crusts, through which oozed serum, sometimes tinged with blood. In this case also the areas previously involved could be made out. At the same Clinic, three children, from a public nursery, also presented themselves, and the striking similarity was remarked upon. Cultures were made from each; three of indubitable Impetigo Contagiosa, and one of what has been described Pemphigus Contagiosus. The plate shows the eruption late in its course, when it is identical clinically as well as culturally, as will be shown, with Impetigo.

Case IV. M. R., aged 26, private, Fifth Regiment, O. V. I., was admitted to Lakeside Hospital with enteric fever, Sept. 15, 1898. Three days after admission a half-dime-sized erythematous patch was observed on the back of the right hand. In a few hours a serous exudate elevated the epidermis to a slight extent, and the periphery continued to extend. The following day it had attained the size of a twenty-five-cent piece, the roof of the bleb flaccid and wrinkled, was elevated about 5 μ and contained a clear fluid. Twelve hours later the contents were seen to be slightly turbid, in radiating lines, with a suggestion of a yellowish tint. The following morning the bleb had ruptured, and the appearance was as indicated in plate 2. Five days later a second bleb appeared on the right thigh. This ruptured from contact with the bed-clothing very early in its course. The lesion on the back of the hand partly refilled once or twice, but, after being flushed with a bichlorid of mercury solution and packed with boric acid, it disappeared in a few days. I am indebted to Dr. J. F. Kelly for the colored sketches of these two cases, and to Dr. G. W. Crile, brigade surgeon, for the photograph, which was taken on board the "Yale."

Aside from the ten cases at Lakeside Hospital, I had, through the courtesy of Dr. J. S. Windisch and Dr. C. D. Noble, medical officers of the Fifth Regiment, an opportunity to study the eruption in five other cases. Dr. Windisch related a striking instance of local infection in a case observed while the command was in Florida, in which there appeared a small bleb on the side of the face which ruptured, the contents running down the cheek; the following day several small erythematous points were observed following the line of direct exposure and they developed into bullas within a day or two thereafter.

Payne has observed that Impetigo Contagiosa is frequently associated with or follows other suppurative diseases, such as conjunctivitis, otorrhea, purulent rhinitis, ulcerative stomatitis, as well as suppurating wounds and scratches.

Manson32 in his work on tropical diseases describes the affection as being very commonly met with in South China during hot weather, and sometimes the number affected almost warrants its being called an epidemic. He also observes that European children are more prone to the affection than are the natives, which was verified during the past summer in Florida, the native population having a mild endemic form, while the Northern troops developed the more active or bullous form of the disease.

Similar cases have been reported in this country by Elliot33 and Allen34. Crocker35 presented a case, which he called Impetigo Contagiosa, before the Clinical Society of London, and spoke of it as a rare form of Impetigo which had only during the last two years been recognized in England.

Pathology. The following report was received from the pathologic laboratory of Lakeside Hospital.

Bacteriologic examinations were made from ten cases, including eight of Impetigo Contagiosa and one of the bullous forms described in cases I to IV, observation No. 3. All possible precautions were taken to avoid contamination, the cultures being taken from the moist surface beneath the crusts in the Impetigo cases, and from the interior of the bullas, both from the apparently serous exudate and from the purulent exudate in specimen Nos. 1 and 2. The cultures in all cases showed the ordinary pyrogenic staphylococci unmixed with other organisms. In three cases of Impetigo, the staphylococcus albus was found in pure culture, in four cases the staphylococcus aureus, and in two cases staphylococcus aureus and albus together. The cultures from serum. and pus alike in observation No. 4 showed pure cultures of the s. aureus. All cultures of the s. albus, save one, showed a growth on agar and a liquefaction of gelatin somewhat slower than the stock cultures of s. albus growing at the same time on media of identical composition, and in all probability were the staphylococcus epidermis albus, a constant inhabitant of the skin. The other observation showed growth in all respects like the stock culture of albus.

Unfortunately cultures were made from only one case of bullous eruption, which was due to the premature rupture of the blebs and the zeal displayed by the nurses in treating the lesions. Crocker also obtained pure cultures of the staphylococcus pyogenes aureus (loc. cit.)

Etiology. There can be no doubt that Impetigo is caused by some local agency, but thus far neither the microscope nor cultural tests have succeeded in finding a special organism for the disease. Both Elliot's and Allen's cases followed vaccination, but this is not uncommon in all clinical forms of Impetigo. Further, Elliot's case occurred in February, hence heat could not beaccounted an etiologic factor. It must be admitted, however, that the bullous form of Impetigo is more common in hot countries, and the experience of the surgeons of the Fifth Ohio Regiment during the past summer seems to fully substantiate this claim.

Other conditions which may or may not be dependent on excessive heat in the unacclimated, doubtless are also potent factors in its causation. Thus uncleanliness, impure drinking water, ill-prepared and unwholesome food, malaria, and other depressing influences of camp life may have contributed in supplying the soil necessary to this special form of eruption. On returning to Cleveland, where cooler weather and better hygienic conditions obtained, the disease assumed the more ordinary form of Impetigo, and finally, within a month or two, wholly disappeared.

Diagnosis. The importance of recognizing this clinical form of Impetigo is apparent when we consider the grave diseases with which it is most liable to be confounded. This is ably pointed out in the admirable article by Elliot, to which reference has previously been made. The disease has undoubtedly been most frequently mistaken for Pemphigus, to which, in some instances, it bears a close resemblance. Pemphigus is a grave disease, not infrequently recurring from time to time, accompanied by marked constitutional disturbances, and in many cases terminating in death, while the bullous form of Impetigo, as has been shown, is due to a local contagium confined to the superficial strata of the epidermis, never interfering with the general health, and terminating in recovery. The bullas in Pemphigus Vulgaris appear in successive crops, do not extend so rapidly at the periphery, are usually more tense and less prone to rupture, and are not so clearly autoinoculable.

Erythema Multiforme Bullosum would be less liable to be mistaken for