al. The causes of skin diseases may be divided into congenital, predisposing and direct. There is a number of skin diseases, of which the etiology is not known and they are treated empirically and symptomatically. Examples of congenital disorders are syphilis, abnormal deficiency of normal physiological functions, such as the secretions of lubricating glands, resulting in ichthyosis, furthermore deformities like nevi, hirsuties, etc. Predisposing tendencies are hereditary or acquired. Hereditary, in tuberculosis of the skin, or in other inherited variations of the general condition, which does not permit a successful resistance to injuring influences. An acquired predisposition is found in any lowered vitality, whether due to malnutrition, excessive or insufficient food, faulty hygiene, defective elimination or external traumatism. Direct causes may be internal or external. Internally produced are all affections due to disturbances of the nervous system, to toxemias and to general microbic infections. An external or local action on the skin is exerted by physical and chemical means and by parasites either vegetable, animal or microbic.

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Before taking up the individual management of the most common skin diseases in children, it will be well first to discuss some general principles governing the care of the skin in children. Hygiene has a strong bearing on its condition. gard to cleansing the skin, harmful extremes are found plentifully. There is no need to speak of the fact that quite a number of eruptions are directly due to dirt. The accumulated dirt acts upon the skin mechanically, chemically, causing dermatitis, eczema, and by favoring secondary infections, impetigo, furunclosis and others. Insufficient drying of the infants and infrequent changing of napkins is a common source of intertrigo. Profuse sweating especially if allowed to remain on the skin for some time causes dermatitis, and miliaria or prickly heat. The tendency of carrying the use of water too far is just as injurious to some skins. Hebra, the nestor of dermatology, used to say that he saw more skin troubles in people who were active bathers, than in those who went to the other extreme. Especially in the tender skin of children frequent washing and consequent continuous removal of the necessary fat will make the skin dry and irritable. The question of soap is important. Some soaps, heralded by patent medicine firms as universal cures for skin diseases are used extensively by the public and even recommended by physicians. They do

more harm than good, their composition being unknown and their purity doubtful. Only pure soaps, unadulterated by perfumes and chemicals should be employed. Even plain water is at times irritating and should be softened by the addition of bran, oatmeal, or an alkaline. There is no doubt that a faulty metabolism makes the skin susceptible to the action of local irritants. The regulation of the diet is therefore an important item. Breast-fed children suffer frequently from overfeeding and from irregular feeding. The usual fault with mother's milk is that it is too rich, though at other times the child is starving from insufficient nourishment. Regular and not too close intervals between feeding should be insisted upon, to give the stomach a chance to digest the food, and night feeding should be omitted as soon as feasible. In obstinate chronic cases weaning and the adaption of a proper artificial food may be found necessary. In older children we often find the mistake that they are allowed to partake of everything that comes on the table for the adults. It is remarkable to see them fed on sausage, cheese and pickles so often without any harm. It is self-evident that a thorough inquiry in this matter and insistence on easily assimilated food is essen. tial to the cure of any and every skin disease. The nervous condition of children influences the course of skin diseases to a great extent. An infant needs rest and sleep during the major part of the day and the night. Too much handling and petting by the over-anxious mother makes it peevish and irritable and is liable to frustrate all efforts of the physician. We see children get well at a hospital, when they show no benefit under the same treatment at home. As to the administration of drugs, a good general principle is to do too little rather than too much. The natural tendency of the skin is to recover if given a chance and if protected from harm. Internal drugs find very little employment for any direct action on the skin and are only used as adjuvants if needed for correction of some internal complication. Opiates should be eschewed as much as possible. Abundance of fresh air, a clean well ventilated home and at times a change of climate prove of benefit.

The scope of this paper is too small to permit anything of a complete review of most of the important skin affections in childhood. Only some, therefore. that come continually to the care of the general practitioner will be taken up, and practical points in their etiology, diagnosis and treatment discussed.

Affections of Congenital Origin.-These may be present at birth or develop shortly afterwards and may be due to an infection or injury during fetal life, or to an abnormal development of the skin and its appendages. Hereditary syphilis is most common and important among them. The mortality of syphilitic children is great and the development of the survivors usually stunted. A child may be born apparently healthy and with no signs of the disease at first, but may develop them during the next four to six weeks. When syphilis is apparent at birth, it is usually characterized by bullous eruptions, most frequent on the palms and the soles, and is at times mistaken for pemphigus neonatorum. When appearing later the child may suffer from the typical snuffles, hoarseness of the cry due to laryngeal inflammation and skin eruptions of an erythematous, vesicular or pustular character. A prophylactic treatment of the pregnant mother may result in the birth of a healthy child. The treat ment of the child itself is carried out with mercury internally in the form of calomel or the gray powder or externally with inunctions with the blue ointment spread on flannel bandages and kept tied around the abdomen. Salvarsan in small doses seems to be well tolerated and to get quick results. As the mother is already infected, whether showing any signs of syphilis or not, and her milk is the best nourishment for the infant, breast feeding should be given the preference.

Of the congenital conditions, nevi or birth-marks are often matters of great anxiety to the parents. The vascular nevus or portwine mark may be situated in the subcutaneous tissue only or in the deeper tissues also. It may be small at first and either retrograde spontaneously or increase to considerable size. If stationary it is better left alone, until the child is one year or older. If growing, operative measures are imperative. The most satisfactory method is freezing with the carbonic acid gas snow. The pain is slight and transient and no scars, worth of any consideration, are left, if care is taken not to apply the snow too long and over too big an area at one time. While it may take considerable time and repeated applications to effect a cure, the above mentioned advantages and the good final result recommend this treatment. Another affection of congenital origin is ichthyosis, characterized by dryness and harshness of the skin, gradually leading to serious local and general complications. In a milder form, as xeroderma, it is rather common and makes the child predisposed

to dermatitis and eczema at the slightest provocation. The indications for treatment are the improvement of the general health and an endeavor to increase the secretion of fats by internal administration of fatty foods, cod-liver and olive oil and by keeping the skin supple and soft with frequent oilings.

Local infections with parasites are numerous in childhood. Of animal parasites the acarus scabiei, causing the itch, is common, especially in charity and dispensary practice, though well-to-do families do not escape. The soft skin of children reacts rapidly to the irritation from the itch-mite with inflammation, vesiculation and pustulation, which obscures the parasites and its burrows. The diagnosis must frequently depend on other features. The distribution differs from that in adults, by not only occurring on the hands and feet, but also on the head and the face. Severe itching, getting worse at night, and the presence of a similar trouble in other members of the household are suggestive. The object of the treatment is to destroy the acarus and relieve the diseased condition of the skin. It must not be forgotten, that the skin of children will not stand the strenuous applications used in adults. The most effective method is a daily bath with free use of soap and inunctions with weak ointments of sulphur (2-5 per cent) or balsam of Peru.

Other affected members of the family must be attended to at the same time.

Of vegetable parasites affecting the skin. of children the trichophyton fungus, causing ringworm is mostly met with, though not as common here as in Europe. The treatment with the X-rays, which do not destroy the fungus directly, but eliminate it by a thorough epilation of the hair, has reduced the time of a cure from years to months. It has the disadvantage that it is not always available, needs special experience and great accuracy of the dosage, to get the desired result and avoid injury to the patient.

A number of skin diseases are caused by the local action of micro-organisms. Nonpathogenic and pathogenic germs are continually present in small numbers on the healthy skin. In conditions of lowered resistance the latter multiply and produce inflammatory reactions. Among them are the staphylococci, streptococci, the tubercle and acne bacilli. Until recently the staphylococci were alone held responsible for all pus-infections. But recent investigations have shown that the streptococcus shares in their production. Impetigo contagiosa is a very common condition especially among

the poor and the ill-cared for. It assumes a great variety of clinical aspects and is at times taken for eczema and even for pemphigus. The typical primary lesion, a superficial flaccid vesicle or bleb, and later on the straw-colored, laminated crust, looking as if stuck on in the centre, are distinctive features. The treatment is simple and consists of a thorough removal of the crusts with free use of soap and water followed by the application of a mild parasiticide (2-5 per cent ammoniated mercury ointment). I have seen cases getting worse all the time because diagnosed as eczema and the rule of avoiding water and soap in this condition, when acute, applied to its treatment.

Of skin diseases of a toxic origin urticaria may be mentioned. It also occurs from local irritation or as a pure neurosis, but the internal cause is usual. The lesions or wheals, usually blanched in adults from the compression of the capillaries, may be distinctly red from the start in children. Their size varies up to that of a hen's egg and larger, the latter due to fusion or extension. They are extremely itchy and as a rule transient, but by outcropping continually the disease becomes chronic. The acute attacks are mostly due to the ingestion of certain foods, especially shellfish and some fruits. In chronic cases it may be impossible to detect the harmful food, still the fact that if such a child is fed on perfectly plain food it gets well, speaks for the error in the diet.

Among the affections of which the etiology is not known eczema comes first in importance. In spite of the fact that it is the most common and frequent skin trouble and that every physician has seen and treated a great many cases, it is approached every time with doubts and apprehensions. It is no surprise that at the last meeting of the American Dermatologicl Association some experienced men pronounced it practically incurable with our present means. Its study is of the greatest interest because of its common occurrence, the obscurity of its causes, its troublesome nature and the difficulty of its management. Infants seem especially liable to it. It is not hereditary and children are not born with it. Dentition has been accused as a cause, but the eczema may appear before the teeth do. Gastro-intestinal disturbances will aggravate it, but do not cause it. If it is due to microbes, then a predisposition of the skin to their invasion and action must be present, otherwise every child would suffer from eczema. The subject of eczema is too large to cover it in this paper and only some points shall be taken up which are of help

in its management. in its management. The regulation of the diet has already been mentioned. Constipation is a frequent complication and must be corrected. When anemia is present, codliver oil and iron are indicated. Local treatment is always of the first importance. Remember that the eczematous skin is extremely sensitive and that even plain water and the air do harm. Protection from any possible irritation is therefore the key to success. Only the mildest applications should be employed and kept on the diseased parts continually. They should only be changed once or twice in twenty-four hours to avoid exposure to the air and interference with the new forming epidermis. If an ointment is used it must be spread on thickly on a mask or on bandages, to prevent it from drying too soon, and oil should be put on from the outside repeatedly. Before renewing the dressing the dry old ointment, scales and crusts must be gently removed with sweet oil. At times even the purest ointment base, like vaseline or lanolin are not tolerated and in these cases I have found a liniment of olive oil and lime water of decided benefit. It does not show lack of knowledge to make frequent changes in the applications, if not doing well, but wisdom. Scratching, if permitted, will defeat all efforts and must be prevented by every means. If necessary the hands must be tied out of reach of the affected parts. If these few points are kept in mind, the simplest remedies may be followed by results and seemingly the most hopeless case may take a quick turn for the better. 520 Brandeis Theatre Building.

VINCENT'S ANGINA.

JAMES S. GOETZ, M. D., Omaha, Neb.

One of the most frequent occurrences in the routine practice of medicine is inflammation of the mouth; indeed there is hardly a disease which is not complicated at some time or other with sore gums, tongue or throat, due to bacterial invasion of the weakened mucous membrane. Often the symptoms produced are severe, and very often in low types of the specific infections, absorption of poisonous material from the mouth, materially adds to the severity of the disease, and often affects adversely the prognosis.

The bacteriology of the mouth, like that of the nose and orbital cavities, has been pretty well worked out. Of course, of first importance is the Klebs-Loeffler bacillus, while of scarcely less importance are the

pneumococcus, the staphylo and streptococcus and the bacillus of Friedlander, "soor" fungus (oidium albicans) and the organism of Vincent, are not to go unmentioned, and it is this last named organism, often neglected with which this paper has to do.

Vincent's or Plaut's angina is a membranous inflammation in the mouth due to an organism known as the B. fusiformis. These bacilli are long, slender rods with pointed ends, having a slight bulging in the center. They may be slightly curved, and are often accompanied by atypical short rods, and long S-shaped thread-like bodies with pointed ends. They are easily stained and are Gram negative. They are probably slightly motile. Accompanying this bacillus is a spirochete, very motile, differing from each other very markedly in the number of their windings and in thickness. They also are Gram negative, but do not stain as readily as the bacillus fusiformis. Invasion of the mouth with this organism causes the characteristic clinical condition known as Vincent's angina. The description of the condition as given in the text-books is very meager. In fact it is a difficult task to find any satisfactory description of the disease anywhere. In view of the fact that it is of very frequent occurrence, is very easy of diagnosis bacteriologically. but presents marked difficulties clinically, it is surprising that more attention has not been given to it, especially by men who see it so often. Conditions such as diphtheria, lacunar tonsillitis and the mucous membranous lesions of syphilis, are common enough, and are usually the diseases that are looked for when the patient complains of sore throat or mouth. It is surprising what a lack of knowledge there is of this other clinical condition, invasion of the mouth with the organism of Vincient, and how frequently it will be found if properly looked for.

In my experience, the disease presents itself etiologically in two ways either as a primary invasion of the mouth, forming a distinct clinical condition, or as a secondary invasion on some already existing ulcero-membranous lesion. Primary invasion of the mouth is favored by all condi. tions which favor any infection, such as lack of cleanliness of the mouth, insufficient care of teeth and gums, decayed teeth, etc. It is not so generally known that secondary infection may occur in almost any variety of ulcerative sore throat or mouth. It is not uncommon to find mixed with a smear from a Klebs-Loeffler infection the organism of Vincent's an

gina. Ulcerative conditions as a result of chronic lead or phosphorus poisoning are also favorable soil for the growth of the organism in question, while above all others, the development of whitish patches on the base of ulcerations, the result of overdosing with mercury, are very frequently the result of infection with the organism of Vincent, and it is very often that these sores are mistaken for mucous patches, and the mercury continued, when they will quickly disappear as soon as the mercury is stopped, and proper treatment used.

The acute infectious fevers, when accompanied by a sore mouth, also appear to favor the growth of the B. fusiformis, as does also any low cachectic condition, so that it is not an infrequent finding in children suffering with rachitis or scurvy.

The mode of invasion in the primary infection takes place in two ways: either the tonsil is first infected, a membrane developing and spreading off the tonsil on to the soft palate and uvula, or the gum back of the last molar is the point of invasion, the membrane spreading along the lines of the gums and off on to the cheek. Usually only one side is affected, but it is not infrequent to see both tonsils or jaws invaded. A whitish or greenish membrane forms. It is firmly attached, lasts a variable length of time, sloughs and leaves an ulcerated surface, which may become reinfected, and thus the condition persist for a long time. When the jaw is invaded, the membrane back of the tooth disappears early, and usually leaves a deep ulcer with a necrotic base.

The symptoms of the disease are extremely variable, varying from hardly any disturbance at all to very severe constitutional manifestations. The tonsillar infection is the most severe. It frequently starts suddenly with a chill, fever, sore throat, glandular swelling and general constitutional symptoms such as are found in ordinary tonsillitis. It is usually of short duration, a week to ten days, but is very liable to recurrence. That form starting on the gums is not nearly so severe as far as the constitutional symptoms go, but is very persistent, and in some cases may spread irregularly along the entire alveolar margin, causing an irregular ulceration in places and patches of a dirty greenish membrane in others. The cheek about the angle of the jaw is also commonly involved, the mouth becomes fetid and mastication a very difficult process. I am convinced that many cases of pyorrhea alveo