diverse, dermatoses are brought about factitiously; medical literature contains many illustrations of it. Under its varied forms, however, this disease, as for convenience sake we may call it, has certain common characteristics.

To enumerate these these characteristics briefly, it may be said, first, that it is generally an anomaly in its appearance, its locality and the course it runs. It either resembles no disease of an ordinary sort or is a defective dissembler. Seen early while fresh it has an artificial look. Scratch marks can still be seen; an irritant liquid applied freely by an unskilled hand will gravitate to the dependent portion and produce a characteristic intensity of reaction in that part of the lesion. The color may be suggestive, such as the yellow stain of nitric acid about the lesion, or on the fingers or clothing, possibly; the smell of carbolic acid may be retained; if an erythema, it may have a sharply-defined or angular outline. While these features may be overlooked, especially if not anticipated, as they are ordinarily not likely to be, they may be marked enough to arrest attention.

It appears on a part that is accessible— on the anterior part of the body, on the front of the limbs, on the left side by preference, as people are commonly righthanded. They will never be found on the back, out of sight and reach, for that involves having an accomplice, which, except in the case of true malingerers, will not occur; the disease is very individual, and both for convenience and from a desire to observe their handiwork, the site of the lesions is accessible and visible to the subject.

Lesions appear suddenly and often during the night, when the subject is likely to be unobserved. Mystery attends their recurrence. These are features that

appeal to the emotional or hysterical subject.

A motive may be found or suggest itself for malingering, for avoiding duties or for exciting curiosity, interest or sympathy. It is wisdom not to inquire. into this at least directly; it is bad form to press an inquiry in such a way as to force a patient to admit deception, for a physician is not a judicial magistrate, and his point of approach and view is different. The motive, however, may be of the slightest, as in the case of one young woman who resorted to her exanthem on the slightest pretext, such as avoiding a trip to New York with her mother.

These cases are often very puzzling of diagnosis, but the anomalous appearance, the site and the freakish course are frequently suggestive enough. Gottheil's case, to which I have referred, with ovoid bullæ for a time, then linear bands about the legs, again excoriations, coming in crops over night, for a period of months, is a good illustration of the disease.

A case of my own, in many ways extraordinary, will serve as an example and illustration to picture this subject.

The celebration of All Hallowe'en by a carnival a couple of years ago in Albany was attended with a great deal of license and rudeness, prominent attention to which appeared in the daily papers and was the subject of general comment and conversation. Among other things was the thrusting into people's faces of certain feather brushes, often dirty ones, and the chance of blood poisoning thereby was freely commented on. A young woman living in the country nearby sus tained a trifling abrasion on the left arm at the wrist from one of these. Three or four days after the family physician was called to see her, and found at or near the site of this abrasion a lesion the size of a

silver half dollar, somewhat deeply inflamed, the surface being of a dark leather color or like parchment, with an areola of redness. In five days a similar lesion developed near and above it; then others. followed at intervals of a few or several days. They took a course up the arm, over the outer condyle to the shoulder; then the procession turned, and lesions appeared successively along the inner side of the arm and parallel with the upward series in linear order. Most of these lesions were of the size of a dollar, individually separate, deep and very long in healing, with destruction of tissue and the production of keloidal scar, red and nodular; all of them were of considerable intensity, and close enough together to effect involvement of the tissues in a band two or three inches wide from the starting point to the shoulder and back to the wrist again.

The process extended over a period of about three months, the intervals between the formation of new lesions varying. Moderate malaise attended. A surgeon seen in consultation confirmed the diagnosis of gangrene from blood poisoning, naturally suggested by the apparent connection with the feather duster. Repeated cultures from the lesions were made with negative results.

An interval of a few weeks followed the arrival of the recurring lesions at the starting point at the wrist; then near the old starting point a fresh lesion on healthy skin posterior to the first one appeared on the same arm, and a fresh series set itself in operation. It took a similar course up the arm to the first series and again proceeded to the shoulder. By this time the tissue of the limb was pretty well involved, at least all but the posterior portion of it, so instead of traveling back down the arm as before, the course taken

was across the top of the shoulder to the chest, and successive lesions appeared down the left chest, over the breast outside the nipple on to the abdomen and to the waist line. At this time I saw her.

She was a healthy-looking, intelligent and well-developed girl of 20, living at home, having finished school a year or two, with no material abnormality in personal or family history, save an epileptic brother. She volunteered no suggestions regarding the lesions and talked little about her condition. Her family relations were pleasant; a sister had been confined two weeks prior to her last outbreak, and she had to take care of the baby at night after the nurse left.

The older of the more recent lesions were irregular patches, with abrupt margin as if punched out down to the papillary layer, and having a granulating base. Between them there was congestive dermatitis. They had been kept under treatment continuously from the first with bichloride packs, and at times with iodiform, with nothing, however, which could have contributed to their persistent production. The lesions were painful, evidently, but no urgent objection was made. to manipulation about them.

The career of the lesions as exhibited in their graded series of evolution from those which first appeared a few weeks before to those of recent appearance was that of various stages of healing dermatitis of severe character. The picture which they presented was fantastic as a whole and bizarre, as can readily be conceived. The chief interest centered in the more recently-produced lesions. Some were oval in shape, an inch or two in diameter, others were of an inverted Vshape, being broadened at the base. They all had the manifest peculiarity of having the greatest intensity of activity at the

base; that is, being on the trunk at the more dependent portion of the lesion. When one's attention became attracted to this it was seen to be a characteristic of all the series to show intenser action at the lower portion. It was such as might be expected to follow the rather free application to the skin of a camel's-hair brush filled with liquid irritant of semicaustic quality, which, flowing over the surface, settled more abundantly and spread out over the bottom of the area of application, producing thereby a deeper action and trauma. With some this was more marked than with others. They were similar to what might follow dichlor acetic acid, or perhaps formalde

hyde or some other severely irritant liquid applied in the manner suggested; they were without stain or suggestion of odor, and did not show the congestion and eschar of carbolic-acid burns.

The anomalous and unusual appearance of the picture of the entire mass of lesion and this peculiarity of individual lesions coming, after a study of them, determined to my mind the diagnosis. One can hardly imagine any unassisted affection of the skin pursuing such a course and attended with such phenomena. The skin is subject to much variation from the classic and ordinary in the results upon it of pathological processes, but there is some approach to order in it.

Dr. Robert Koch.-Dr. Koch, whose portrait we publish, is making an extended tour in the United States, where he is being warmly welcomed by the members of the medical profession. Professor Koch's discovery of the tubercle bacillus was made about 20 years ago, and since then, as a direct result of the new pathology, more lives have been saved thereby than by all other medical discoveries combined. In the city of New York alone the deaths from consumption in 1881 numbered 6123, while in 1901 there were only 6049 deaths and hundreds of thousands of increase in our population. The same conditions are found in every city of the civilized world. Thus the men of science bestow immeasurable benefits upon the human race and receive scant recognition from those who are the direct beneficiaries.

The physicians honor and revere Dr. Koch, and in time the public at large will

Physical Diagnosis.-J. H. Tryndale, Lincoln, Neb. (Journal A. M. A., February 15), contends that the diagnosis of tuberculous invasion of the lungs is as much dependent on auscultatory skill as ever, though the general symptoms of lassitude, anæmia and emaciation, unaccounted for by other disease conditions, and the percussion resonance are also of importance. Auscultation, according to the simplified method, recognizes only "tonality" and "pitch" as representing the sounds heard in inspiration and expiration. The mechanical movements are represented by "rhythm" and "tempo," making in all only four terms as against twenty-seven in the old nomenclature. The two fundamental tones perceived in the lung are the pulmonary and the bronchial, or, in other words, the vesicular

and the tubular. Pitch is a relative term, tracheal breathing being the standard. Three degrees each of raised or lowered pitch are sufficient for diagnosis. Rhythm is the regular recurrence of inspiration, pause and expiration, and the change from a continued to an interrupted rhythm marks one of the earliest beginnings of a pathologic change in the lung. The "tempo" is only the speed of the rhythm; râles and rhonchi simply indicate transudation or secretion, and give no clue to the pathologic condition. Percussion recognizes resonance only, and four degrees

of resonance-excessive or deficient-are ample to describe existing conditions. Inspection takes account only of anatomic sufficiency of the thorax; judge only by an abnormally narrow or an abnormally wide one, and by a few deep inspirations ascertain the physiologic sufficiency. Keep in mind that a narrow chest may be capable of unlooked-for expansion, and vice versa. Palpation is only useful for ascertaining the amplitude of the diaph

ragmatic excursions; lateral, not anteroposterior expansion is the gauge of sufficient respiration. Five general maxims are stated: 1. Raised pitch in auscultation with reduced resonance denotes condensation. 2. Lowered pitch with exaggerated resonance denotes expansion. 3. Both expansion and condensation tend to loss of elasticity. Temporary loss is a phase of healing process, permanent loss is a terminal condition. 4. Degree of percussion resonance establishes the value of auscultatory respiration pitch. 5. Areas or foci of infection or inflammation, or both, shown by auscultation and confirmed or not by percussion, exist either beneath the locality examined or are the result of mechanical hindrance to respiration. Tyndale asks how many practitioners ever discover or take heed to

diaphragmatic pleural adhesions, which are the cause, he says, of diminished respiration in the upper lobes of the lung in the majority of cases where it is credited to infiltration. This, he says, is the most neglected field in medicine, and the one in which the most slipshod diagnoses are made the results and treatment of pleuritic adhesions and their mechanical effects. They call for removal whenever found, and liberation of the imprisoned lung (by hypodermic injection of sodium. cinnamate) should always precede the immunization with watery extract of tunow firmly-established vaccine therapy by bercle bacilli. The sequence of symptoms in consumption is given by Tyndale as follows: 1. Permanently accelerated pulse associated with one or more of the general symptoms, lassitude, anæmia and emaciation. 2. Permanent change of

rhythm, associated with lassitude, anæmia

and emaciation, singly or combined. 3. Changes in pitch, heard permanently over a given area. Percussion must confirm the find by deficient resonance, and the diagnosis is complete. 4. 4. Permanent change of tonality from the pulmonary to the bronchial, from diffused to concentrated tubular breathing. These are the principal features to be looked for; the presence of râles is to be noted as merely incidental.

Higher Entrance Requirements at Three More Colleges.-Dr. Samuel W. Lambert, dean of the College of Physicians and Surgeons, the Medical Department of Columbia University, informs us that the faculty has raised the entrance requirements, beginning September, 1909, to two full years of study in an approved college or scientific school, which course must have included instruction in physics, chemistry and biology.

Dr. J. N. Simpson, dean of the College