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Full text of ' 3~ m Columbia ©ntt>e«ftp (College of $fj?stnans anb burgeons Digitized by the Internet Archive in 2014 The Journal o Cutaneous Diseases John T. D.; Edward B. D.; William T. D.; Martin F. D.; Milton B. D.; James Nevins Hyde, M.

D.; George T. D.; Francis J. Stelwagon, M. D.; Grover W. MacKee, M.D., New York Editor including syphilis Under the Editorial Direction of Volume XXVIII 1910 THE GRAFTON PRESS 105 West 40th Street New York Copyright, 1910, By The Grafton Press THE JOURNAL OF CUTANEOUS DISEASES VOL. XXVIII JANUARY, 1910 NO.

1 SEVEN CASES OF DERMATITIS EXFOLIATIVA WITH A FATAL ENDING IN FIVE. Edward Wigglesworth Professor of Dermatology, Harvard University. DURING the last five years a number of cases of generalized dermatitis exfoliativa have been treated and studied in the Ward for Skin Diseases of the Massachusetts General Hospital. As the records of some of these cases are fairly complete, and as it is important in my opinion that a large number of fully reported cases of this obscure and much discussed affection should be collected in order to obtain more light ultimately, I have con- sidered it worth while to describe, as they 'stand upon my records, the following cases. If it is true that the}' cannot claim to settle many of the mooted points, I think it is equally true that they offer a slight contribution to some of the questions at issue. In 1902, at the meeting of the American Dermatological As- sociation, the writer presented a communication entitled ' Four Forms of Generalized Exfoliative Dermatitis.' While not agree- ing witli the complicated sub-divisions of the French, it was con- sidered that these four forms had claims to be considered separately.

These forms were each illustrated bv a typical example. The first form was the recurrent desquamative scarlatiniform dermatitis, which has been described especially by the French.

It was admitted that this form may occur from the ingestion of drugs, although it is clearly shown that no such association exists in a number of the cases, as will be further emphasized later. This form seems to be quite clearly cut, and not to afford examples which merge into the other types. The second form, illustrated by a typical case, was what has been described as dermatitis exfoliativa (Wilson), 'dermatite ex- foliative generalisee.' It was remarked that the boundary line be- tween this form and some of the others was not very clearly defined. 2 ORIGINAL COMMUNICATIONS. The third form was that which occurs as a sequel to psoriasis, eczema, lichen planus, or is caused by the administration of a drug internally, such as quinine, belladonna, etc., or by the action of an external agent such as mercury.

The last form was the pure pityriasis rubra of the Hebra type, of which a typical example was cited. My experience since this short paper was written has tended to show me more and more how much these types that I have al- luded to, as well as the more complicated sub-divisions of Brocq and others, run into one another, as is well illustrated by several of the cases that follow: Case 1. The patient was a man of fifty-seven, born in New York.

He entered the hospital on April 10, 1905. His family his- tory was negative, and he had had no previous illness with the ex- ception of pneumonia ten years ago. Nine months ago his present affection began with itching on his back. The skin at this point soon became red, and scaling. This had gradually spread until two months ago when the scaling and redness became general over the whole body. On entrance to the hospital he was in a condition of general erythema, and pro- fuse scaling.

The scales were of medium size,* attached at one edge. The natural folds of the skin were everywhere exaggerated. There was much infiltration of the lower half of the fore-arm and the hand, with thick scales, and numerous fissures.

There was a similar condition on the palms and the soles. The lymphatic glands were enlarged, especially those of the groin, which could be distinctly seen with the naked eye. The mucous membrane of the mouth was thickened, of pearly color, and thrown into folds corresponding to the teeth. A smear of blood taken showed an increase of eosino- philes. During the next four months the patient's condition re- mained about the same, with the exception that there was some slight scaling, and much relief was obtained from treatment, espe- cially from the use of starch baths. In this case there was a marked tendency to chilliness, and the patient required his room to be kept at a very high temperature.

On the 28th of November it was noted that the liver was pal- pable two inches below the costal border, and the spleen also was palpable three and a half inches below the costal border. At this time there began to be bleeding from the mucous membrane of the nose and mouth, and a certain amount of purpura appeared on the lower legs, checks, and forehead. There was a rise of temperature, SEVEN CASES OF DERMATITIS EXFOLIATIVA. 3 and the patient began to grow weaker.

On the 22nd of December the redness of the skin had entirely disappeared and the exfoliation was very much less. Many parts of the body were entirely free from scaling for a short time, and then the scaling would recur. The character of the scaling had also changed from moderately thick, to very thin, branny scales. The patient was much emaciated, but there were no signs of atrophy. The urine was normal. The patient complained much of pain in and about the but- tocks.

There was some blood in the sputum. The irregular tem- perature, for which no cause could be found on physical examina- tion, continued. After gradually failing, the patient died on December 26. Autopsy, 5f hours post-mortem. Anatomical Diagxosis: Dermatitis exfoliativa. Purulent bronchitis with few small abscesses of the lower lobe of the left lung.

Chronic pleuritis. Fatty degeneration of the myocardium. Slight dilatation of the heart.

Chronic hyperplasia of the spleen. The body of a man fifty-seven years of age, 169 cm. Long, well developed, emaciated. Head not examined.

The incision is restricted to a twelve inch cut in the abdom- inal wall, and is so made. Tru^k: The skin of the face, trunk, and extremities gener- ally is more or less covered with thin grayish-white, dry scales and flakes of superficial epidermis. In many places there are small irregular, superficial losses of the skin with red bases. Over the anterior aspect of the thighs the skin presents rather large, brown- ish-red scaling patches.

On the posterior surfaces of the left thigh and a little above the popliteal space there is a loss of substance of the skin, measuring five by three centimetres. On section the subcutaneous fat is very slight in amount, and the muscles are rather thin and pale. Peritoneal Cavity: Is free from fluid, and the peritoneum is smooth, and shining.

The appendix is not remarkable. Pleural Cavities: Free from fluid. The lungs are bound down by fibrous adhesions.

The bronchial lymphatic glands are enlarged, dark red, and pigmented. There is a small piece of tissue in the position of the thymus gland, which resembles somewhat the tissue of that organ. A piece is taken off and microscopically examined. ORIGINAL COMMUNICATIONS. The trachea, and bronchi are not remarkable, except that the bronchi leading to the lower lobe of the left lung show a reddened mucosa, and contain a considerable amount of yellow pus. The pleura of the right lung in places shows fibrous thickening, and the upper lobe on section presents no areas of consolidation. The sub- stance of the lower lobe of the lower part in relation with the bronchi, shows two or three small collections of yellow pus.

Heart: Weight, 285 grams. Pericardium is not remarkable. On section the myocardium is flabby, and of a pale brownish-yellow color, mottled in places with small brownish-yellow areas. The left ventricular wall measures 1 mm. The right ventricular wall, 3 mm. The mitral valve circumference, 10.5; aortic, 7.5; tricuspid, 12.5 cm. The valves are not remarkable.

The cavities are slightly enlarged. The coronary arteries are free and smooth. The aorta is fairly smooth. Liver: 1500 grams. On section the tissue is firm, pale, and homogeneous in appearance. No stones in the gall bladder. The bile ducts are free.

Pancreas: On section is not remarkable. Spleen: 600 grams.

The upper lobe of the organ is firmly bound to the diaphragm by fibrous adhesions. The capsule shows fibrous thickening in places.

On section the tissue is firm, and quite red in color with visible follicles, and rather prominent trabeculae. Adrenals: Not remarkable. Kidneys: Combined weight, 280 grams. The capsules strip leaving a smooth surface showing foetal lobulation. On section the tissue is firm, very pale with reddened markings. The cortex measures 5 mm.

Ureters: Free. The bladder, prostate, and seminal vesicles on section arc not remarkable.

The stomach on section presents no lesions. No ulcers of the lower end of the ileum. The retro-peritoneal lymphatic glands generally are enlarged, dark red in color, and are firm. In the skin, in many places, there are large areas showing complicated tattoo markings. Bacteriological Report. Cultures on blood serum. Heart: not taken owing to incision.

Liver: slight growth of colon-like bacilli. Spleen: no growth. Microscopical Examination. Thymus: Islands of thymus tissue are present in which the pathological elements are numerous. SEVEN CASES OF DERMATITIS EXFOLIATIVA. 5 Lymph node: The sinuses are well shown by being filled with blood. The seminal vesicles are not remarkable.

Liver: Some widening of the capillaries in the central portion of the lobules. Spleex: General diffuse increase in the interstitial connec- tive tissue which is also infiltrated with small cells.

The outline and the follicles are indistinct on account of in- crease in their interstitial tissue. A few follicles are lar z IN- MI1I.K ■j H U Day of E.KTEXT OF ERUPTIOX z - 0 Small Large M AB1 Disease L 7,040 27 11.5 2.5 57.5 7.5 0 1th day Moderate.

10.400 16.15 10 1.15 69.22 3.13.34 15th day Moderate. 10.160 24.8 4.8.4 68 2 0 6th day Moderate. 7.800 24 11.11.55 55 9.33 0 15th day Scant. 7,100 23.8 11.9 2.38 54.35 7.14.5 5th day Scant. 10.600 25 3.5 1 64.5 6 0 4th day Profuse. 10.00U 23 9.5 62.5 5 0 6th day Profuse, multiform erythema 8^ 6.000 20 5.33.88 71.11 2 2 1.44 5th day Moderate.

6,700 23.8 11.9.47 61 2^38.47 6th day Moderate. 7.000 41.38 3.51 1.37 51.69.68 1.37 7th day Profuse. 7.100 40 11 1 45 3 0 Moderately profuse. 11.100 22 4.5 1 62.5 10 0 4th day Profuse. 9.900 27.5 1 62.5 2 0 VerY profuse, recurrent. 5.700 29.37 8.12.62 55 6.25.62 Profuse. 8.300 14.01 7.91.41 73 4.16.41 5th day Moderate.

9.000 32.2 4.34.43 54.34 7.82.87 5th day Profuse. 10.000 44.44 9.61 1.92 38.59 5.44 0 5th day Moderate. 8.200 37.05 8.82 1.2 47.05 5.88 0 7 th day Moderate.

6.300 30 10.5 56 2.5 0 6th day Moderate. 6,500 28.8 5.67.56 59.65 5.67 0 6th day Quite moderate. 8.245 27.71 7.95 1.01 58.12 4.9.22 * From Clinical Laboratory of St. Agnes Hospital. Johx Albert Kolmer, M. 72 ORIGINAL COMMUNICATIONS.

BLOOD EXAMINATIONS.* Table II. June 12, 1909. ■ >us to Lymphocytes - o 2 9 g i D c £ u r s >w y •J Small Large Tit ANSI TION, S a 2 — e. S =- 1° Mast Cells SrLClAL CLLLb 1. 7,000 28 2 1 63. 9 54.54 2.72 0 0 2.

8.600 20 7 59.76 69.25 2.5 0 0 8,000 37 62 56.25 1.87 - 1 0 4.... 10.000 25 fj.i 8 54!85 64.1.87 0 0 5.

10 34 1.37 55.16 7.58 1 37 0 6. 8,800 35 66 8 66 4.66 46.66 4.66 0 0 7. 5,400 28 63 5 23.47 64.28 2.38 0 0 8.

8,000 40 86 4 16.83 51.66 1.66 83 0 9. 8,000 31 79 1 76.58 64.7 1.16 0 0 10. 6.700 38 46 3 16.66 57.06.66 0 0 11.

8,000 26 25 5 62 1.87 64.39 1.87 0 0 12. 8.000 21 82 10 45 1.81 64.56.45 9 0 13. 6,200 25 5 83 1.66 64.17 3.33 0 0 14. 7,*00 31 81 6 84 1.13 59.65.56 0 0 15. 8,100 28 88 10 24.88 55.55 3.11 1 33 0 16. 7,500 25 24 3 93.56 64.6 5.11 56 0 17. 6,000 25 26 8 42.52 63.17 2.1 52 0 18.

8.800 28 07 S 04 1.21 62.8 4.87 0 0 5,600 33 15 4 57.57 58.85 2.28 57 0 6,100 31 23 33.55 58.33 1.55 0 0 Average 7,470 29.03 6.63 1.12 59.99 2.56.37 * From the Clinical Laboratory of St. Agnes Hospital. John Albert Kolmer, M. SUMMARY OF BLOOD EXAMINATIONS.

Date Leucocytes Lymphocytes Small Large Transi- tionals Polymor- phonu- clears Eosino- I philes Mast Cells. June 8 8 245 27.7 7.95 1.01 58.12 4.9.22 7 470 29.03 6.63 1.12 59.99 2.56.37 Two examinations were made in each case. Due care was exercised in avoiding digestive leucocytosis. Wright's stain was used throughout. In each case two smears were examined in every instance. One must examine the tables and not the averages to appreciate the blood changes. Examination will show: 1.

That a moderate leucocytosis was present in most cases dur- ing the acme of the disease. That the eosinophilia was well marked in the larger number of cases at the height of the eruption. Both the leucocytosis and eosinophilia subsided with improve- ment of the symptoms. That the other leucocytic elements show no particular changes. Rise Of Nations Rules.xml File. 73 The urine was examined on several occasions by Dr. The results are seen in the accompanying table. URINE EXAMINATIONS.* June 7, 8, 9, 1909.

B 1 z Color and Sedimext tals: few epithelial cells and granular material. Lemon and cloudy 1.020 acid -r 57 34 Negative. Pale yellow, clear 1.012 acid 17 6 Negative. Amber, cloudy 1,032 alk. + - Triple phosphates; amorphous de- posits: no ca-ts. Dark amber, cloudy 1.025 acid + 21.33 Negative: no casts.

Pale lemon, cloudy 1.013 alk. Amorphous phosphates. Amber, cloudy 1,022 alk. Triple phosphates; bacteria: amor- phous deposits.

Yellow, cloudy 1.024 alk. Amorphous phosphates: bacteria; epithelium. Yellow, clear 1,015 alk. 24.78 Negative.

Pale lemon, clear 1.010 alk. 30.98 Few epithelial cells. Amber, clear 1,030 alk. Triple and amorphous phosphates; calcium carbonate.

Yellow, cloudy 1.030 alk. Triple phosphates. Amber, clear 1.022 alk.

Triple phosphates: calcium phos- 20. Brown, cloudy UK, alk.

Lemon, cloudy 1.022 alk. No casts: triple phosphates; bacteria. Amber, clear. 1.026 acid Negative. Light yellow, cloudy 1,025 acid Negative.

*From Clinical Laboratory of St. Agnes Hospital. Johx Albert Kolmer, If. D- It will be observed that albuminuria was present in three cases. A more recent contributor to this subject, Dr. Rawles, of Huntertown, Indiana, has also noted albuminuria in several of his patients. This condition is probably analogous with the albumi- nuria which not infrequently accompanies scabies.

Nicholas and Jambon found albumin in the urine sixteen times in one hundred cases of scabies. Microscopic Examination of Lesions. A vesico-pustule on an urticarial base was excised for microscopic study.

Description of a section stained with polychrome methylene-blue and orange: Over the region of the vesico-pustule there is seen under low power a circumscribed elevation of the epidermis. The horny layer is repre- sented by merely one or two layers of corneous strands. The 74 ORIGINAL COMMUNICATIONS. Stratum granulosum is absent.

Two layers of fusiform rete cells with reddish cell bodies and bluish nuclei extend from the lateral portion of the roof of the vesicle towards the middle, but are lost over the central area. No vertical cleavage is present in the centre suggestive of a puncture by a parasite, nor is any parasitic appen- dage noted anywhere in the skin. Several layers of rete cells with large oval unstained nuclei lying subjacent to the horny stratum fail to take the polychrome stain, but are colored yellow with the orange. Beneath this altered rete is an enormous mass of deeply stained leucocytes with detached Malpighian cells lying in the interspaces. The blood vessels and lymphatic spaces laterally adja- cent to the epidermal elevation exhibit a considerable dilatation. Subjacent to the epidermal vesico-pustule, the corium from the papillary layer to its deepermost portion shows a circum- scribed dense cell mass. This is made up chiefly of round cells, but in certain areas there is a considerable admixture of polymor- phonuclear leucocytes.

In the mid-corium, the latter are seen in large number lying in the lumina of dilated blood vessels and man- tling their walls; they are also seen here and there between the col- lagenous bundles. The exudation can be traced down to a coil of sweat glands. The dilated vessels leading to and from the glands exhibit a large number of round and polymorphonuclear cells in and around them.

These cells likewise surround some of the deep- seated sweat coils. Mast cells are present in abundance, particu- larly in the middle and deeper portions of the corium and more especially in the neighborhood of the blood vessels. They are oval, stellate and fusiform with granules that take the stain well. Fragmentation of the leucocytic nuclei is present to a limited degree.

The histopathological changes are essentially those of an urticarial lesion. Production of the Cutaneous Lesions. Unlike the scabies mite, the pediculoides does not burrow into the skin. Microscopic examination of vesicles and pustules has demonstrated the absence of the mite or any part thereof beneath the surface of the skin. The probabilities are that the pediculoides in the process of extract- ing liquid nourishment from the skin, synchronously injects an irri- tating substance which gives rise to the lesions. Upon this phase of the subject, Laboulbene and Megnin, quoted by Moir'ez, say: ' One cannot doubt that this acarus is endowed with a venomous saliva, the inoculation of which is principally the cause of the death of the larvae and nymph insects on which it lives and GRAIN ITCH.

75 multiplies. This saliva is secreted by four pairs of vesicles dis- posed along the oesophagus and opening into the larynx. The emis- sion of this saliva follows immediately upon the puncture by the mandibles acting as a lancet.' The affection is apt to be confounded in different cases with one of three diseases — urticaria, chicken-pox, and scabies. I have known many such errors to be made. In one case with a par- ticularly profuse eruption, the patient was under suspicion of suffer- ing from smallpox. The affection may be distinguished from ordinary ' hives ' by the longer duration of the individual lesions, by the central vesicula- tion, the constitutional disturbance, the greater persistence of the attack and the occurrence of the disease among groups of persons.

Chicken-pox, which is at times quite closely simulated by the eruption, may be excluded by the duration of the disease, the small- ness of the vesicle, the violence and persistence of the itching and the great incidence of the disease among adults. Scabies or ' itch ' may be strongly suggested when the lesions arc excoriated by scratching; it may be eliminated from consider- ation by the freedom of involvement of the hands, by the uniform eruption of ervthemato-urticarial lesions surmounted by small vesicles, and by the distribution of the eruption.

Pediculosis corporis could be excluded by studying the character of the individual lesions and by the failure to find the pediculi. The history of contact with straw is, of course, of great diag- nostic value. As the pediculoides does not burrow beneath the skin, but merely perambulates upon the surface, it is a comparatively simple task to rid the patient of the parasites. Frequent warm baths with the use of soap would doubtless suffice. I have found the follow- ing ointment especially efficacious, as it not only destroys the mites, but also relieves the cutaneous symptoms: TJ Betanaphtol gr. Adipis Benzoat *i.

In order to prevent reinfection of the patient, his clothing should be disinfected either by boiling or careful sulphur or formal- dehyde fumigation. Where the source of the parasites is a straw mattress, the latter may be rendered free of the mites by exposure in a closed chamber to steam, sulphur fumes, or formaldehyde.

76 ORIGINAL COMMUNICATIONS. Ordinarily, the itching will subside within twelve to thirty-six hours, and the eruption will disappear in a week or ten days.

Where, however, the cause is not recognized and the use of the mattress is continued, I have known patients to suffer severely for periods vary- ing from three to seven weeks, when gradual recovery would take place. It would seem, therefore, that the mite dies after a time and permits the patient to get well. It should be remembered that the disease may be contracted from straw used for other purposes than mattresses. Patients have acquired the disease from straw used for packing purposes, from straw used under carpets, from contact with plants mulched with straw, etc. Sacks of infected wheat, barley, and other grains have likewise given rise to the disease. New Diseases in this Vicinity.

The affection above described was simultaneously observed by various skin specialists of Phila- delphia in 1901, and recognized by them at that time as a new disease in this vicinity. While there is evidence to show that this disease is far more prevalent in the United States than was at first thought, yet the clinical picture is unfamiliar to specialists in most of the large cities of this country. At a meeting of the American Dermatological Association held in Philadelphia in June, 1909, I exhibited a patient showing the characteristic eruption of this disease before prominent skin specialists from New York, Boston, Chicago, St.

Louis, San Francisco, London, etc. The dermatolo- gists from these localities stated that they had not encountered any cases of the character presented. Within recent months, however, I have received letters from physicians and laymen residing more particularly in Ohio, Indiana, and Pennsylvania alleging that a disease of this same nature has prevailed from time to time during recent years in their sections. Most of these letters came from towns in Ohio, particularly Zanes- ville, Columbus, Vincent, Springfield, etc., where the affection is popularly believed to be due to ' jiggers.' A physician from the last named town writes that in the fall of 1908, during harvest and threshing time, he saw in Washington County some eighty-seven cases of the disease in question. It affected the harvesters and threshers. This spring he observed thirty-eight cases from contact witli straw ticks refilled with straw of last fall's crop.

The disease is said to have been more prevalent last year than ever before. In- formation has come from Columbus, Ohio, that potters who used GRAIN ITCH. 77 straw for packing have been so badly attacked at times that the entire force of packers has been off duty.

Many times a whole car-load of straw has been so infested that the use of it has been abandoned. In Springfield, Ohio, it is said that the disease was so bad a year or two ago in the lowlands west of this city as to seriously hamper the progress of the construction of a large sewer. In Zancs- ville, Ohio, the potters have been obliged to abandon the use of straw and employ ' prairie hay 99 for packing purposes. I am informed by a physician of Pittsburg that a young woman patient has suffered from an affection closely resembling, if not identical, with the one under consideration, each time that she has assisted in emptying eases of dishes packed in straw.

Both the physician and the patient had come to believe that something in the straw was the cause of the eruption. In August, 1909, Dr. Rawles, of Huntertown, Ind., published a paper on the ' Straw Itch ' (Indiana State Medical Journal, August, 1909), in which he reported a series of thirty-seven cases of the disease under consideration occurring in eight families under his observation and twenty-four cases occurring in the prac- tice of Dr. Rawles states that the disease first appeared in his section of the country in epidemic form in May, 1909. The people generally attacked were farmers and those living in small villages where straw is used in beds, under carpets and around stables.

Horses and cattle have been seen with a disease almost identical with that seen in man. Rawles gives an excellent description of the disease from which it is evident that the affection is identical with that observed here in Philadelphia. A mite was found in the straw and likewise certain insect hosts. I had an opportunity of seeing this mite through the courtesy of Professor F. Webster, of the Bureau of Entomology, Washington, and it is the same that we have found in our eases. Kenneth Wills, of Bristol, England, published in the British Dcrmatological Journal, August, 1909, a series of cases of ' barley itch,' occurring in some fifteen grain porters who had unloaded a cargo of barley coming from Casa Blanca, West Africa. The itching began within a half hour of the commencement of the w r ork.

A profuse, rose-colored papular eruption of an urti- carial nature was present mainly on the chest and abdomen, but also on the neck, face, arms, forearms, shoulders, and a few on the 78 ORIGINAL COMMUNICATIONS. Back and legs. The men had had no sleep for several nights on account of the itching. Wills, after a painstaking study, came to the conclusion that the urticarial lesions were due to vegetable hairs in the barley dust. Acari were found by one of the experts consulted, but were so macerated that they could not be classified.

This was unfor- tunate, as they doubtless would have been identified as ' pedicu- loides 99 and their agency in the production of the eruption sus- pected. Prevalence of the Affection Elsewhere. Webster, of the Bureau of Entomology, of the United States De- partment of Agriculture at Washington, informs me that a letter received by him from a farmer in Centreville, eight miles north of Dayton, Ohio, contains the following information: ' About four years ago a parasite was found when threshing wheat out of barns. The eruption consists of hive-like spots with a water-like biister, which changes to pus and then small scabs. Recently baled wheat straw bought by a farmer seemed to be alive with the parasites. They attacked everyone that went into the barn and one of my horses that was perspiring from the effects of a drive was simply covered with little knots or swollen places, and bit and rubbed himself con- tinuously. The farm hands have a great fear and dread of the condition.'

In September, 1908, upon unloading a car-load of baled wheat at Pittsburg, a half dozen men and even the horses used in hauling the straw ' became suddenly attacked by an irritation that affected both men and animals after the manner of poison ivy.' The straw came from Washington Court House, Ohio.

The ' Isosoma tritici ' were found in samples of the straw, but no search was made for the Pediculoides ventricosus, as the causative relation of this mite was not known to the investigator at that time. In another letter received by Professor Webster, the writer states that in the neighborhood of Waterloo, Indiana, from July to November, 1908, ' a parasite in the wheat was so bad that the people at threshing time were almost crazy.' In the Spring of 1909 people who used straw chaff ticks were ' about crazy with the itch, as they c alled it.' The bitten spots ' would swell and be inflamed with a yel- low spot in the centre which contained either water or yellowish matter.' The writer found the Pediculoides ventricosus or the joint- worm (Isosoma tritici) present.

Three cases of ' grain itch ' due to sleeping on straw mattresses GRAIN ITCH. 79 were recently observed in Baltimore. A number of people in a subur- ban hotel were also said to have been affected. (From a letter received by Professor Webster of the Bureau of Entomology, Depart- ment of Agriculture, Washington, D. C.) Possible Explanation of the Seasonal Prevalence of ' Grain Itch.' As has been previously stated, cases of ' grain itch 99 have been observed to appear in Philadelphia each year since 1901 about the early part of May.

The straw which contains the mite is said to have been stored for a considerable time in barns. In view of the life history of the grain moth, it is possible that as the warm weather of May comes on, the grain moth in the straw develops from the larval stage and, acquiring wings, leaves the straw, thus depriving the pediculoides of their nourishment. The famished mites thereupon attack human beings when brought into contact with them. History of the Pediculoides Ventricosus and Its Attacks Upon Man.

A search of the literature has revealed the information that the Pediculoides ventricosus or other allied species has been reported in Europe to have attacked the human subject. Newport, of England, in 1850, gave the name ' Heteropus ven- tricosus 99 to a mite found on the larva of a wasp.

Since this time, the mite has been found on various soft-bodied insects both dead and alive. As the name heteropus was preoccupied, Targioni-Toz- zetti, in 1875, employed the name ' Pediculoides ventricosus.'

Moniez (Traitc dc Parasitologic Animate et Vegetale, Ap- plique a la Mcdecine, Paris, 1896), in his admirable book on Animal and Vegetable Parasitology, gives an account of outbreaks of erup- tive disorders in which the pediculoides was found. The following material is translated and abstracted from the book of Moniez: 1. Observation of Lagreze-Fossat (naturalist) and Montane (pharmacist). In 1849, in Espalais (France) a number of men en- gaged in carrying and handling sacks of wheat experienced immedi- ately thereafter violent itching. The wheat in question was sent to Bordeaux and Moissac, where the same symptoms were produced on workmen who unloaded the cargo; the men refused to work on ac- count of severe itching which developed immediately on the chest, arms, face, neck and shoulders.

Some said the itching was worse than that caused by the ' itch.' In the majority of workmen, the irritation of the skin was followed by an eruption of papules more or less inflamed, some of which contained serum. The matter was brought to the attention of the Board of Health of Bordeaux. Ex- perts later reported the presence of numerous mites in the wheat. 80 ORIGINAL COMMUNICATIONS. The wheat after being washed and dried in the sun was rendered free of the mites, and the workmen who transported it thereafter remained free of itching.

The memoire just analysed was accompanied by a drawing of the incriminated parasite. This belongs to the genus pediculoides. The writer gave the name ' Acarus tritici ' to the mite. (Lagreze- Fossat et Montane, ' Sur la Mite du Bie.' Registre agronomique de la Societe des sciences d' 'agriculture et belles lettres de Tarnet- Garome, 1851, xxxii.) 2.

Observation of Robin. In 1867, Robin, in the name of M. Rouyer, communicated to the Societe de biologie, the relation of a cutaneous disease observed epidemically in a large number of com- munes of the department of l'Indre during the previous summer. The peasants engaged in gathering the wheat after the long rains of summer, developed an itching eruption on all exposed parts of the body.

The disease began with severe itching which lasted several hours and was followed by reddening of the skin and a miliary erup- tion covering the surface. The eruption disappeared in three to four days spontaneously or after the use of lotions of vinegar. Rouyer saw on the surface of the skin of these patients a great number of small black points which moved. He noted the same on the diseased wheat. Further study showed the presence of the Acarus or Pediculoides tritici. Seances et memoires de la Societe de biologie, 4th series, 1867, iv, p. Observation published by the Sante publique, May 1, 1872.

(Extract.) A baker in the canton of Creon received a num- ber of sacks of wheat from Bordeaux. Five men who carried the sacks promptly developed severe itching on the back, shoulders and arms, and then an eruption of somewhat pointed red papules. This eruption during the night became generalized over the body and led to fever, insomnia, agitation and marked thirst.

Fear seized the patients and their families, who thought themselves poisoned. Experts were charged to examine the wheat and determine the cause of the trouble.

The Acarus tritici was found in the wheat. The journal continues: 'It is the wheat-mite, a microscopic insect analogous to the Acarus scabiei, which on the human skin, causes the ' itch.' The condition caused by this mite has been called 4 grain fever.' Prolonged tub baths cause a disappearance of the itching and of the eruption.' Targioni-Tozzetti, in 1875, reported an eruption produced in a laborer who had carried sacks of wheat. A drawing of the GRAIN ITCH. 81 parasite accompanied the report.

(Targioni-Tozzetti, ' Relazione intorno ai lavori della Statione di Entomologie agraria di Ferenze per Panno 1876,' Annoli dell Agricultural 1878, i.) 5. In 1879, Geber, (Geber, ' Entziindiiche Prozesse der Haut durch eine bis jetzt nicht bestimmte Milbe Verursacht; ' Wien. Presse, 1879, et v. Ziemssen's Handb. Therapie, xiv, Handb. Hautkrank., 1884, ii, pp.

412), observed in Lower Hungary an eruptive epidemic coming from barley, and due to a small animal parasite. This will be referred to later. Roller's Cases. In July, 1882, thirty-six workmen in Buda- pest, who were engaged in unloading sacks of barley coming from Kalafat, Roumania, were seized within a half hour by intense itch- ing. The phenomena increased in intensity during the several suc- ceeding days. The neck, chest, arms, abdomen and thighs presented crowded vesicles, the largest of which were millet-seed-sized upon inflamed bases. The patients could not sleep during the following night.

Several years previously, the same author had observed a similar malady contracted after unloading sacks of wheat from a boat. Professor Howath found a mite in the wheat which completely resembled that described by Robin. Several years prior to this, similar observations had been made on the banks of the Theiss and there was no other way of avoiding the trouble but to submerge the boat with its' cargo. At the time Koller observed these cases, the same trouble was observed at Cologne with wheat coming from Rus- sia. ' Eine Getreide-Milbc als Krankheitserregerin.' Analysed in Biol.

Centralbl., 188-1, iii, p. Fleming (Fleming, J. ' Ueber eine Geschlechtsreife Form der als Tarsonemus beschriebene Thiere,' Zeitschr. X at unci s- sensch., 1884, lvii, p. 2), in 1884, published an analogous observation to the above. Workmen in Klausenburg, who unloaded wheat imported from Russia, were suddenly seized with an eruption similar to the ' itch.'

It was recognized as being caused by the mites which were found by Fleming. ' The following observations have not been reported by the authors who have recently occupied themselves with this question.

We give in extenso three interesting analyses which we owe to Berther and which have been written in a review but little known.' (Translated from R. Moniez, Treatise on Parasitology) [Journal de Medecine et de Pharmacie de VAlgerie, xlii, pp. 103, 888.] 82 ORIGINAL COMMUNICATIONS Cutaneous Eruptions from the Dust of Grains or Cereals. ' Some time ago,' said Professor Layet, 'my friend, Dr. Mondot, (D'Oran) communicated to me the observation of several cases of fever with cutaneous eruptions of an erythematous and vesic- ular character, occupying the exposed surface of the body, namely, the face, neck and hands. The affection developed in persons who had sojourned in a neighboring room to an apartment containing moist barley coming from Silos.

In the yard of this habitation our colleague saw several dead chickens and he was told that for a week they had been found this way every day. In the stable a horse was sick and showed on the neck a pustular eruption.

The barley had been purchased twelve days before and the chickens and horse had eaten of it at this time. Mondot sent me a sample of this barley. At first sight I found nothing particular in it, but in plac- ing the grain in a moist, hot, shaded place, I observed the appearance on the grain itself of a whitish dust. I could not determine the nature of this dust which appeared to me to be composed of spores, etc.' This observation appears to me to be related to analogous facts already noted in Algeria in 1870. Peggle Nights Serial Keygenreter.

Nouffert, of Guelma, observed on himself and a member of his family who likewise had descended into a cellar, a series of large, red circles on the arms, the trunk, the neck, and the legs, irregularly circumscribed, hard, slightly rosy plaques of varied diameter, coming on suddenly accom- panied by violent itching and insomnia and disappearing towards the seventh or eighth day. This phenomenon developed as a result of the descent into the cellar where there were stored twenty sacks of barley of good quality. Our confrere observed them to be covered with a reddish dust.

The microscope demonstrated this dust to be exclusively formed of animalcules of great vivacity. Nouffert gave the name of ' Acarus urticans ' to this insect. The best means to destroy these parasites was boiling salt water sprinkled over them with a watering can. Since this time our distinguished confrere lias had occasion in several instances to observe the same accidents among Europeans and natives. (T Alger., 1875, 1st trimester.) 3. Collard, physician of Gouraya, on coming into a room containing a quantity of barley intended for a mule, expe- rienced on the logs;i burning and itching, and found them covered witli a redness in certain areas on which there developed isolated vesicles.

There was a complete disappearance of the lesions after GRAIN ITCH. 83 painting them with strong carbolic acid. A neighboring lady had the same trouble. The mule was seized with cough and dyspnoea. Examination of the grain showed the presence of an acarus.

Geber's Observations. Professor Geber, of Klausenburg, pub- lished an article in the Wiener medizimsche Presse, 1879, page 1362, on M An Inflammatory Process of the Skin Produced by Hitherto Undetermined Species of Mites.' In the early days of June, a cargo of barley was received in sacks from Lower Hungary. Those unloading the cargo were seized a few minutes afterwards with a violent itching and burning to such an extent that they were with difficulty persuaded to continue the work. Powder obtained from shaking the barley was examined with the naked eye and under a magnifying glass without disclosing anything, but under the micro- scope, it was found to be almost exclusively made up of dead and living minute animals and their rudiments. The living animals were of a long oval form, of yellowish-white color, and averaged 0.022 in length.

They could only be seen with the naked eve when they were moving. Geber thoroughly described the parasite in detail and published drawings of the male and female: believing the mite to be hitherto undescribed, he gave it the name.