depending upon the fancy which comes to the individual, when the desire or thought of producing the lesion arises. The lesions may be erythematous, vesicular, or ulcerative, depending upon the application made, either with acids, strong alkalies, heat, friction, or any traumatic agency. The lesions may assume any form, circular or otherwise; they usually appear suddenly, any time when the patient would be alone and not disturbed. The lesions appear on the parts of the body easily reached by the hands, new ones constantly appearing, or the old ones continued by irritation. These lesions have an artificial look and do not resemble any ordinary cutaneous disease. Close observation of the lesion and also taking into consideration the general health of the patient, especially as regards the nervous system (for most of these cases are found among the hysterical), will usually clear the diagnosis. Impetigo contagiosa is an acute inflammatory disease, markedly contagious, as the name implies, composed of small vesicles or vesico-pustules, which in a few days dry up, forming thick, yellowish crusts, very superficial, with no inflammatory area of redness about the lesion, and no induration, located generally upon the face. Occasionally these individual lesions may coalesce and form ringlike or irregular gyrate figThis condition might be mistaken for a pustular eczema, or possibly ringworm; of the former, it occurs in more of a patch, and not so distinctly ringed, also, the redness and infiltration are more marked; then almost invariably one is sure to find individual scattered lesions of impetigo elsewhere.

ures.

In ringworm, one would find a less acute disease, fine scales in place of the crusts, the border of minute vesicles, and the impetiginous lesions decidedly more acute and inflammatory. Lupus erythematosus in its later stages sometimes assumes a somewhat ringed condition; the disease begins as a scaling inflamed patch of a reddish or violaceous color, extending peripherally, and of slow growth, occurs generally upon the face and scalp, yet may be found upon any part of the body. It is usually observed in the adult, seldom in childhood. As the disease extends, the center of the patch tends to heal, leaving a depressed, atrophied scar, with the border raised, sharply outlined and covered with scales, gray or yellowish in color.

Lupus erythematosus is often confused with eczema, or seborrhoic eczema. With the former it is more acute, and has a sharply defined border; with the latter, the border may be sharply defined, but the greasy and more abundant scales, with seborrhoea of scalp plainly visible, would give the differential points. There are occasionally lesions in lichen planus, which may be in the form of rings, with only one or two rings being present, but sometimes the rings are numerous and form a striking feature of the case. The rings are small and are made up of flat, purplish, striated papules of lichen planus. This flat papule with gray striations is characteristic of lichen planus and can be mistaken for nothing else, and really resembles no other disease.

There is one disease, erythema multiforme, very acute and inflammatory in character, of dark red macules, papules or tubercles occurring singly or in patches of various size and shape. The particular form which interests us is called erythema annulare, because it is a distinct ring, formed by vesicles, or vesicopapules, always extending from the periphery, the center being purplish or pink in color and the border a deep red; these rings may increase in size, coalescing with adjacent rings, and we have the irregular rings or erythema gyratum; again, it may not be one single ring, but several, the new forming on the outside of the old. Thus we get different degrees of color, pink, red and purple, from without in. This form is spoken of as an erythema iris. The diagnosis of erythema multiforme is most likely to be confounded with urticaria, but lesions of this latter disease come and go acutely, are extremely itchy, are not so dark a red in color, do not form the rings spoken of above, and are more general in their distribution over the body. Erythema multiforme is usually limited to location, as the hands, forearms and legs, less frequently on the body.

In conclusion, the ringed eruptions most commonly met with are: ringworm, pityriasis rosea, psoriasis, syphilis, seborrhoic eczema, and erythema multiforme. The general practitioner in the course of his daily round of work is confronted with an eruption on the skin, markedly ringed in appearance; the thought immediately occurs to him, it must be ringworm, for ringworm

is in decided rings. That is true, but all ringed eruptions are not ringworm.

The location, duration, age of the patient, general appearance of the lesion, with a thorough examination of the entire body of the patient, will generally clear the diagnosis; for often, when there is doubt as to what disease one has before him, one or more typical lesions (not necessarily ringed) of some one disease may be found, which will give the key to the situation and clear the mind of doubt. As the silvery scales of psoriasis, or the greasy scales and general scaling of the scalp denotes seborrhoea, the peculiar wrinkled, yellowish center of pityriasis rosea ring, the congested, inflamed, violaceous rings of erythema multiforme, or the irregular, infiltrated, raw-ham colored rings with accompanying scars of syphilis, all have their individual peculiar marks, and studying them as a whole with the process of elimination a correct diagnosis can be made, and thus intelligent treatment instituted with, I hope, a happy termination both for the patient and the physician.

DISCUSSION.

DR. MARK S. BRADLEY (Hartford): There is one skin disease prone to occur in ring-like configuration besides those given by Dr. Gold in his interesting paper; and, although somewhat rare, it is common enough to be given consideration. I refer to dermatitis herpetiformis. The eruption of this disease may be preceded by constitutional disturbances. Its onset in some cases is sudden; but in other cases, several days, or even weeks, may elapse before the eruption develops. When fully developed, it may cover almost the entire surface of the body. The severity of disease is as variable as its location. Some cases are slight; some are severe. Itching is usually a constant and most troublesome factor. The eruption tends to group formation, and is papular, vesicular, bulbous, pustular, erythematous, or mixed. It is the erythematous type that shows the ring formation in nearly every case. In fact, it closely resembles a generalized erythema multiforme.

The most striking case of ringed eruption that I have ever seen (if I may be excused for being personal) was in a man who walked into my office one day last winter. He had a well-marked case of psoriasis of long standing, which covered his legs, his arms, and his body. The eruption was typical enough, except on his abdomen, which was large and protuberant. The umbilicus was surrounded by a circle about four inches in diameter, solid with the eruption. Around the circle was a ring

of healthy skin about an inch and a half broad; and just external to that was a ring of the eruption about two inches broad. The abdomen looked like a typical target in a shooting-gallery, the umbilicus acting the part of the bull's-eye.

Another point that should be emphasized is the number of times that syphilitic eruptions are mentioned in this paper. In the differential diagnosis of ringed eruptions in skin disease, we must bear in mind that syphilis is the greatest of imitators.

DR. RALPH A. MCDONNELL (New Haven): Mr. President and Gentlemen-I have always been of the opinion that the interest of a discussion lay in honest criticism, freely offered; in divergent views, openly expressed; or in the corroboration of doubtful points by added testimony. There can be no interesting discussion, except by a humorist, of such a proposition as the statement that two and two make four; and I shall not waste my breath nor the time of the assemblage by telling you what an incontrovertibly excellent paper Dr. Gold has written, because you know that already.

I shall, however, express my surprise at the general attitude of the profession toward skin diseases. Many good diagnosticians in general practice look with something akin to suspicion, not infrequently mixed with personal resentment, upon any patient who presents himself with a skin disease. The physician who utilizes the latest diagnostic aids, like the sphygmomanometer, the blood-count, the complement-fixation test, and the scientific examination of the urine, to clear up the etiology of such an utterly uninteresting complaint as chronic headache, will dismiss with a glance and a prescription for resinol ointment almost any skin case, having made no real effort to get to the bottom of it. Every Sherlock Holmes knows that one of the best ways in which to hide a thing is to put it in plain sight; because it is a human characteristic to dive after the unfathomable and to soar after the infinite, neglecting the things that are at hand.

Pathological processes of the most varied description may be watched in the human skin. Almost every lesion known to the microscopist presents itself here errors of nutrition and circulatory disturbances; and the products of the activity of a wide variety of chemical, actinic and microbic irritants. The very thoughts of the owner show in his skin. Shades of color, arrangement of outline, sequence of development, and parts affected are all indications of value. In connection with these, a profound consideration of the patient as a whole will help the physician to understand a skin case and make him feel like a real doctor, which he knows that he is not when he peeks at a sample of skin and prescribes cuticura.

I congratulate Dr. Gold on having written an admirably instructive paper.

The Feeding of Sick Infants.

CHARLES A. GOODRICH, M.D., HARTFORD.

The object of this paper is to emphasize certain clinical observations concerning the feeding of sick infants, rather than to dwell upon the science of their nutritional needs.

When an infant is ill it is the common practice to prescribe for its temporary diet, provided it be artificially fed, a cereal decoction, albumen water, a sugar solution, or whey, and inasmuch as the selection and composition of these various substitutes influence in no small measure the progress of its recovery, it may not be amiss to say a few words here concerning these articles.

For a long time it has been well recognized that the decoctions of cereals, replacing for the time being the ordinary diet, in many of the digestive disorders were productive of beneficial results, and hence in those maladies in which milk is temporarily prohibitive, as, for instance, in the acute enteric infections, barley water, rice water, etc., have been extensively used. In looking over the formulas commonly followed for making these cereal waters, one cannot help being impressed with the small food value of the daily nourishment prescribed. Thus such strengths as two teaspoonfuls of barley or a tablespoonful of rice to the pint of water are frequently recorded. While in many instances this may be all that the disordered economy can assimilate, on the other hand, there are many more cases in which this diet is not only much weaker than can be given, but what is of more importance, one which will result in most unfortunate ultimate results. The importance of considering the maintenance of body structure in addition to treating the immediate symptoms, cannot be too strongly emphasized. Take, for example, a case of summer diarrhoea; while in the beginning a weak cereal water is indicated, in many infants the flour can be increased even to a much higher proportion than is ordinarily employed. Having