Case III. Girl, LL, age twenty-two years. This patient had been drinking water from a well in which later a dead animal was found.

On the twenty-seventh day of October she was taken suddenly ill with what she called the grippe. She had a severe chill, followed by fever, and pains in the back, legs and arms. Two days later, when I saw her, she was deeply jaundiced and the liver and spleen were both below the ribs and both tender. She complained at this time of anorexia, pain in the head and limbs, and constipation. The temperature was 102. These symptoms continued for seven days, when the temperature reached normal and all the other symptoms disappeared except the jaundice, which continued three weeks longer. The patient regained her health and strength slowly and was not able to resume her mill work for five weeks. Widal's reaction was negative also in this case.

DISCUSSION.

DR. J. M. GILE, HANOVER.

The discussion of this paper was to have been opened by Dr. Smith, but as he was called away, he asked me to take his place.

I shall comment very briefly upon some cases which I suppose to be of the same diagnosis as that given for the cases reported.

I should think eight or ten years ago, a group of boys from Dartmouth College, in the engineering department, had been making a survey of a somewhat lengthy piece of road, and had been living either in farmers' houses along the way, or living outside, drinking water from brooks that they came across, living practically a camping life. After about a week or two of this life, the fellows of this group began to drop back to Hanover on account of being sick, and I think there were perhaps three or four out of that

group of eight or ten who came back in that way with fever, increased pulse marked, usually deep jaundice, and in some with abdominal pain and tenderness, and others not, as I remember it. I am simply giving you this report from memory. A while after that, cases began to break out in the college, the same thing, and among students who had not been living under the same conditions as this first group. In all, there were some twelve or fifteen cases that ran through the course, although I should say with rather less average severity than has been described in the paper read. I should assume that they did not seem like cases of ordinary abstracted jaundice. I should assume we might place them under this head.

So far as I can see, the great point in diagnosis between simple jaundice and acute infectious jaundice, such as has been described, would depend on two points: temperature and increased rate of pulse, your abstracted jaundice ordinarily giving you a normal or oftentimes subnormal temperature, and a slow pulse, whereas in these cases there is an increased temperature and increased rate of pulse, and at times, and perhaps always, the definite symptoms of soreness and pain.

DR. A. W. MITCHELL, EPPING.

I will not attempt to discuss the paper, but I will add just my remembrance about the history of this condition. I think just a year ago this month I had a family in an adjoining town, with three cases which I would diagnose as acute infectious jaundice. The patients had suffered with the grippe a little while before. The conditions about the place were apparently good. The mother first developed the condition and before she was out of bed the husband and daughter the parents being about 55 years of age, and the daughter 25-developed symptoms of it. The cases were typical of this condition and were very similar. It was the only instance where I have ever seen this acute infectious jaundice in more than one case in a family.

ECZEMA AND ALLIED CONDITIONS.

DANIEL R. CHASE, M. D., ORFORD.

When asked by the secretary to prepare a paper for this meeting, I promised to do so, but was in doubt for a subject until it occurred to me that the skin was lightly considered and many physicians were content to call all chronic diseases of the skin “eczema” and the more acute forms of dermatitis they oftentimes let go without attempting a diagnosis, simply treating the condition in a general sort of way.

The subject of skin diseases in general is a vast one, and I shall merely endeavor to bring out some of the more salient points of eczema and some of the commoner conditions which may be difficult to differentiate.

Eczema is distinctly a protean disease as the following definition from Stelwagon shows: "an acute, subacute, or chronic inflammatory disease, characterized in the beginning by the appearance of erythema, papules, vesicles, or pustules, or a combination of these lesions, with a variable amount of infiltration and thickening terminating either in discharge with the formation of crusts, in absorption, or in desquamation, and accompanied by more or less intense. itching and a feeling of heat or burning."

This condition is one of the diseases of the skin of most frequent occurrence. Statistics show that it forms from twenty to forty per cent. of dermatological cases reported; acne is a more common affection than eczema, but as many subjects of acne never deem it necessary to submit to

treatment, the records of such cases do not figure in above statistics.

By as much as inflammation is the commonest accident of other organs of the body, by so much is its enveloping organ subject to the same pathological process.

The classical signs of inflammation, heat, redness, pain and swelling are present in every eczema though modified by the anatomical peculiarities of the part affected. The surface involved in typical eczema always shows some rise in temperature, being very slight in chronic, but more marked in acute, cases. Redness varying in shade from the bright red of the acute case, to the dull red of the chronic form, is also true of the eczematous skin. Pain here is represented by a sensation of itching, which may vary from a slight annoyance to an almost intolerable dis.tress. The fact that itching rather than pain accompanies inflammatory disorders of the skin is due largely to the fact that the skin is exposed to the air, and its increase in bulk is not opposed by contiguous surfaces. The moderate edema with slight infiltration, so common in acute eczematous attacks, may, in chronic cases, become more pronounced and even excessive.

In addition to the above a very characteristic symptom is the serous discharge which is present during at least a part of the course of most eczemas, and a valuable differential, in that it stiffens and stains linen.

Clinically, several types of eczema can be recognized which require separate description. It should not be forgotten, however, that in a majority of cases two or more types are seen, either in succession or simultaneously, but it is usual for one type to predominate, either throughout the course of the disease or for certain periods.

Eczema Erythematosum. This type of the disease is most common on the face, especially in individuals exposed to wind and weather or to direct heat, but it may appear on any part of the body. It begins usually as a diffuse,

ill-defined area of redness, occasionally irregularly outlined hyperemic macules or patches; these latter may coalesce and its features become more pronounced. Swelling is variable; at times in face cases so severe as to close the eyes, especially in acute forms. In the more subacute the edema is not so marked but there is more infiltration and thickening of the skin. Itching is usually excessive, though at times burning or a sensation of heat is more pronounced. The color varies from a bright to a dull or purplish red, oftentimes irregularly distributed, producing a mottled appearance. The area involved is harsh and dry, and after a few days is usually covered by a more or less fine desquamation. There is no discharge unless as usually happens, the type changes to a moist form. In places where folds of skin come in contact the epiderm may be destroyed by maceration and friction and leave a raw oozing surface.

This type may pursue an acute course and heal promptly, or more frequently it merges into some other type, papular, vesicular, pustular or mixed, and becomes more or less chronic, both in intensity and progress. The exfoliation may become so marked a symptom as to be classed by itself, eczema squamosum.

It is usually aggravated by exposure to heat, cold, wind or any condition which favors congestion of the part.

Eczema Papulosum is characterized by the appearance of greater or less numbers of papules, which are acuminate, pin-head size or larger, colored in various shades of red to a dark lurid shade, and are usually seated upon a reddened and thickened base. They are generally discrete, though often closely crowded, and are accompanied by an intense form of itching as shown by scratch marks and blood crusts on the apices of individual lesions. Existing papules may persist for weeks, or may disappear and be replaced by others.

They may coalesce to form irregular, thickened, elevated,