JNIVE'S.TY C CALIFORNIA SAN DI6QO LIBRARY J 3 1 822 00502 6844 ^. DERMOCHROMES SIXTH REVISED EDITION PORTFOLIO OF DERMOCHROIVIES BY JEROME KINGSBURY, M.D. ATTEXDING PHYSICIAN KEW TOBK SKIN AND CANCER HOSPITAL; PHYSICIAN FOB DISEASES OF THE SKIN TO THE PRESBYTERIAN HOSPITAL DISPENSARY; MEMBER OF THE AMERICAN DEBMATOLOGICAL ASSOCIATION; MEMBER OF THE NEW YORK DERMATOLOOICAL SOCIBHT, ETC. CHAPTERS Oy 8TPBILI8 BY WILLIAM GAYNOR STATES, M.D. ASSISTANT SURGEON NEW YORK POLYCLINIC HOSPITAL; FORMERLY INSTRtJCTOB IN QENTTO- L'BINARY AND VENEREAL DISEASES; MEMBER OF THE AMERICAN MEDICAL ASSOCIATION; MEMBER OF STATE AND COUNTY MEDICAL SOCIETY OF NEW YORK, WEST SIDE CUNICAL SOCTETY, ETC. WITB TWO nUXDRED AXD 8IXTTSIX COLORED ILLCSTRATIOyS AyO SIX BALFTOyE FIOVRES Volume I NEW YORK REBMAN COIVIPANY herald square bliloing 141-145 West 36th Street All Rights reserved COPYRIOHT, 1921, BY REBMAN COMPANY New Yobk PRINTED IN AMERICA Preface This Portfolio of Dcrmochromes contains two hundred and sixty- six colored and six black and white illustrations. All of the colored plates are from Jacobi's "Atlas der Hautkrankheiten " and two hun- dred and seventeen of the figures appeared in the fourth American edition of this work, known here as the Jacobi Dermochromes. Tho re- maining forty-nine figures are from the fifth Geniian edition of tho Atlas and are now, by arrangement with the German publisher, pre- sented for the first time in this country. The black and white illustra- tions, representing different types of alopecia, are from photographs taken for me by Dr. William B. Trimble. Although many of the plates will be familiar to Amorioan phy- sicians, the accompanying text is entirely new. In its preparation the writings of the leading American, British, and Continental denna- tologists have been freely consulted, but preference has generally been given to the views of the fonner, as the work is intended chiefly for readers in tliis country. I particularly desire to acknowledge manifold obligations to Drs. Bulkley, Duhring, Pusey, and Stclwagon. The section on syi^hilis was intrusted to Dr. William Gaynor States, and I greatly appreciate the honor of having his able presentation of this disease incorporated in this work. To my clinical associates at the New York Skin and Cancer Hos- pital I am indebted for considerable assistance ; to Dr. Paul E. Beehet and Dr. Arthur M. Kane for valuable aid in preparing the manuscript and in passing the work through the press, and to Dr. Biuford Throne for the excellent chapters on the exanthemata. I here take pleasure in expressing to them my tlianks for their generous cooperation. The subjects have been grouped, as far as practical, according to generally accei)ted pathological classifications, jind with but few excep- r tlons the nomenclature recommended by the American Dermatological Association has been adhered to in the text. "While fully realizing that in a work of this scope individualism is out of place, I must confess that I have not always refrained from the temptation to interject personal impressions and opinions. JEROME KINGSBURY. Plate Fig. List of Plates Text Page * > Erythema multiforme 1 2^ ^ ^ [ Erythema iris 2 4j ^ 6 3 5 Erythema nodosum ^ > Purpura hemorrhagica 4 1) ^ > Herpes progenitalis 5 9) . , 14. 5 10 Herpes smiplex i; 11) , 16 2 ,„> Herpes zoster 7 12^ . 19 7 13 Pompholyx (Dysidrosis) ^^ 8 14. Impetigo contagiosa ^4, 9 16 Hydroa vacciniformis ^g 10 16 Pemphrigus vulgaris ^9 11 17 Pemphigus foliaceus ^^ 12 18 Pemphigus vegetans gg 13 19 Pemphigus neonatorum 13 ^H Dermatitis herpetiformis 14 21^ ^ 38 15 22 Urticaria g^^ 16 23 Urticaria chronica infantum ^^ 17 24. Urticaria rubra gg 17 25 Urticaria pigmentosa • ^^ 18 26 Antipyrine rash \ ' ^g 18 27 Arsenic rash I ' ' ^^ 19 28 Copaiba rash I 20 29 Bromine rash V Dermatitis Medicamentosa ... 44 20 30j jj^^^3h ( ** 21 3lJ \ 44 21 32 Chloride rash I ^5 22 83 Mercury rash / vii Plate Fig. Text Page 23 84 Lichen simplex chronicus ( I'idal) 46 23 35 Pityriasis rubra pilaris 47 24 36 Eczema acutum cum pigmentatione 49 24 87 Eczema folliculare 49 25 38 Eczema madidans 49 26 39 Eczema crustosum mamnjje 49 26 40 Eczema crustosum axillae 49 27 41 Eczema orbiculare oris 49 27 42 Eczema e professione 49 28 43 Eczema chronicum squamosum 49 28 44"! 29 45 \^ Eczema chronicum corneum 49 29 46j 30 47^^ . _« 31 49 Lichen planus 69 31 50 Lichen planus atrophicus 69 32 51 Lichen planus verrucosus 69 33 52 Lichen planus annularis 69 33 53 Lichen planus mucosa; oris 59 34 64 Psoriasis gyrata et serpiginosa 63 35 55 Psoriasis vulgaris guttata et ostracea 63 35 66] 36 67 1 36 68 \ Psoriasis vulgaris 63 37 69 1 37 60j 38 61 Psoriasis vulgaris unguium 63 38 62 Psoriasis vulgaris rupioides 63 39 63] 40 64 ^ Eczema seborrhoicum 69 40 65j 41 66 Alopecia from eczema seborrhoicum 70 42 67 Perniones 72 42 68 Raynaud's disease 73 43 69 Gangrcna diabetica 75 44 70 Ecthyma gangrenosum 76 45 71 Ulcer from Roentgen Rays 78 46 72) „ ,, 7q 48 74 Varicella 87 viii PlUTT FlO. TlXT PAOr 48 "75 Variola discreta 82 49 76 Variola 82 49 77 Varicella in adult 87 50 78 Varicella 87 51 79 51 80 Vaccinia 89 52 81 52 82 [MorbilH 91 53 83 Rubella 94 55 85 r^'^'"'**'"* ^^ 55 86 Erysipelas 100 56 87 Exfoliatio areata lingua; 103 56 88 Leukoplakia 105 57 89 Lingua scrotalis 107 57 90 AphthK 108 58 91 stomatitis niercurialis 110 58 92 Dyschromia gingivje satumina 112 59 93 Miliaria rubra 113 60 94 Folliculitis barbte 114 60 95 Acne varioliformis 116 Ij. q^^Acne vulgaris 118 62 98 Acne rosacea 1 24 62 99 Rhinophyma 128 63 100 Dermatitis papillaris capillitii 129 63 101 Granulosis rubra nasi 130 64 102 Alopecia areata 131 65 103 Alopecia congenita 136 66 104 Vitiligo 138 66 105 Chloasma 140 67 106 Na?vus vascularis 142 67 107 Na;vus linearis 144 68 108 Njbvus papillaris pigmentosus 145 69 109 Nffvus pigmentosus (sarcoma) 145 69 110 Adenoma sebaceum 147 70 111 Ichthyosis simplex 148 71 112 Ichthyosis hystrix 150 72 113 Ichthyosis congenita 152 72 114 Keratosis pilaris 153 73 115 Fibroma molluscum 155 iz 16 Dermatomyoma multiplex 156 17 Verrucae vulgares , 157 18 Papillomata (condylomata acuminata) 159 19 Verrucas seniLes (cavernomata senilia) 161 20 Keratosis senilis 162 21 Xeroderma pigmentosum 163 22 Keratosis follicularis 164 23 Elephantiasis penis et scroti 166 24"! 25 [Scleroderma 167 26j 27 Atrophia cutis idiopathica 170 28 Striae distensjE 172 29 Molluscum contagiosum 173 30 Keloid 176 31) ac, \ Xanthoma tuberosum multiplex 177 33 Xanthoma palpebrarum 179 34 Atheroma multiplex (cystes sebaceae) 180 35] 36 37 [-Lupus erythematosus 182 38 39 40 Lupus pernio 187 41 Lupus vulgaris incipiens 188 42 Lupus vulgaris verrucosus 188 43 Lupus vulgaris 188 44 Lupus vulgaris (comu cutaneum) 188 45 Lupus vulgaris (epithelioma) 188 46 Lupus vulgaris 188 47 Lupus vulgaris serpiginosus 188 48 Lupus vulgaris (elephantiasis consecutiva) 188 49 Lupus vulgaris (mutilatio) 188 50 Lupus vulgaris hypertrophicus 188 51 Lupus vulgaris 188 52 Lupus vulgaris mucosae oris 188 53 Verruca necrogenica 193 54 Tuberculosis linguae 195 55 Tuberculosis nasi 196 56 Lichen scrophulosorum 197 113 114 P"" F'°- TrxT Pace 96 157 Erythema induratum scrophulosorum (Bazin) 199 97 158 Scrophuloderma 201 97 159 Papulo-necrotic tuberculide 203 98 160 Ulcus endemicum tropicum 205 99 161] 99 162 It . , , „^ ^Lcpra tubcrosa 206 100 164.J 101 165 Lepra anaesthetica 208 102 166 Lepra (ulcus pcrforans) 208 102 167 Rliinoscleroma 212 103 168 Leukaemia cutis 214 104 169) „ , , ., 105 i'~Q("'"*nuloma fungoides 216 105 171 Sarcoma idiopatliicum multiplex hasmorrhagicum 219 106 172 Sarcomatosis cutis 219 107 173|.,, , 107 174) rodens 221 108 175 Paget's disease of the nipple 224 109 176 Carcinoma lingua? 226 109 177 Carcinoma penis 228 110 178 Carcinoma cutis 229 111 179)„. , 111 180) ^'"*^* favosa 230 112 181 Alopecia from favus 230 182) . ■joo^Tmea trichophytina capitis 233 115 is-i! 116 1 85 > Tinea trichophytina corporis 237 116 186) 117 187 Tinea trichoph3'tina unguium 240 117 188 Tinea barba; 242 lis 189 Tinea versicolor 244 119 190 Erythrasma 246 119 191 Pityriasis rosea 248 120 192 Anthrax (pustula maligna) 251 120 193 Actinomycosis cutis 253 121 194? 121 195 (Sporotrichosis 255 122 196 Sporotrichosis verrucosa 255 122 197 Sporotrichosis epidemica 255 zi Plate Fio. Text Paos 123 198] 124 199 ^Scabi'es ., 258 124 200j 125 201 Pediculosis capitis (eczema inipetiginosum ) 263 125 202 Pediculosis vestimentorum 265 126 203 Melanodermia e pediculis vestimentorum 265 126 204 Maculse ceruleje (ulcus molle elevatum — bubo inguinalis). . 267 127 205 Myiasis linearis 269 127 206 Onychogryphosis 271 1 2R onof Alopecia syphilitica 323 129 209] 293 129 210 ^Scleroses syphilitica 294 130 21lJ 302 130 212 Sclerosis phagedasnica 302 131 213 Sclerosis labii majoris 295 131 214 Sclerosis et edema indurativum (in infants) 295 132 215" 132 216 133 217 ► Scleroses Syphilitica 298 293 133 218j 134 219 Sclerosis syphilitica tonsillae 298 135 220 Syphilis maculosa (roseola) 308 136 221 Syphilis maculosa conflucns (leukoderma) 309 137 222 Syphilis maculosa recidiva (roseola recidiva) 309 138 223 Syphilis maculosa follicularis 309 138 224 Syphilis papulosa annularis 309 139 225 Syphilis papulosa lenticularis 310 139 226 Syphilis papulosa mucoss oris 310 140 227 Syphilis papulosa orbicularis 310 140 228 Syphilis papulo-squamosa 311 141 229 Syphilis corymbiformis 314 142 230 Syphilis milio-papulosa (lichenoides) 311 142 231 Syphilis circinaria 314 143 232 Syphilis papulo-pustulosa 315 143 233 Syphilis papulo-squamosa 315 144 234 Paronychia syphilitica 322 144 235 Leucoderma sypliiliticum 322 145 236 Syphilis papulosa (condylomata lata) 325 146 237 Syphilis papulosa mucosas et anguli oris 328 146 238 Syphilis papulosa linguae 315 xii Plate !■ io. Text PaM 147 239 Syphilis papulosa 315 148 ~iO Syphilis papulosa (condylomata lata) 326 148 Sll Syphilis papulo-pustulosa 318 149 242 Syphilis nmlignn (rupia syphilitica) 341 149 243 Syphilis franiboesifomiis 320 150 244 Syphilis tuboro-serpiginosa 839 150 245 Syphilis tertiaria 339 151 246 Syphilis tubcro-serpiginosa 339 151 247 Syphilis ulcero-serpigiiiosa 339 152 248 Cicatrices palati mollis post ulcerationes syphiliticas 350 152 249 Caries syphilitica ossium cranii 336 153 250 Syphilis ulcerosa palati molHs 350 153 251 Syphilis ulcerosa palati duri 350 154 252 Syphilis gummosa lingua; diffusa 348 154 253 Syphilis ginnmosa digiti 348 155 254 Syphilis gummosa 349 155 256 Syphilis gummosa glandis (pseudo-chancre) 303 156 256) „ .... .,, 1 'ifi 257 \ •^yP'""^ gummosa 347 157 258 Syphilis ulcero-serpiginosa 351 IKft 0«f»l ^yP'^'''* I'creditaria bullosa (peiiiphigua syphiliticus) 335 159 261] 160 262 ^Syphilis hereditaria papulosa 354 160 263 J 161 264 Syphilis hereditaria ossium nasi 355 161 265 Hutchimon teeth 355 162 266 Syphilis hereditaria tarda 357 163 267 Ulcus molle orificii urethrae 369 163 268 Ulcus molle digiti 367 164 269 Ulcera mollia (bubonulus) 369 164 270 Ulcus molle gangrenosum 370 165 271 Ulcera mollia vulva; 368 165 272 Ulcus molle phagedtenicum 303, 370 Alphabetical List of Figures (The Numbers quoted are tlie pages of the Text on which reference to the Figures is made) PAGE Acne keloid 129 rosacea 12'! varioHformis 116 vulgaris 118 Actinomycosis cutis 253 Adenoma sebaceum 147 Alopecia adnata 136 areata 131 congenita 136 syphilitica 323 Anthrax 251 Antipyrin rash 43 Aphthae 108 Arsenic rash 43 Atheroma multiplex 180 Atrichia, universal congenital 136 Atrophia cutis idiopathica 170 Bazin's disease 199 Body lice 267 Bromine rash 44 Carcinoma cutis 229 lingu» 226 penis 228 Caries syphilitica ossium cranii 336, 252 Chancre, hard 291 mou 367 soft 367 syphilitic 291 Chancrelle 367 Chnncroid .... 367 Chancroide 367 xiv PAGE Cliciro-pompholyx 19 Chickcnpox 87 Cliilblrtins 72 Cliloiisiiia 140 Chlorine rash 44! Cicatrices palati mollis post ulccrationes syphiliticas 350 Condyloniata acuminata 159 Copaiba rash 44 Crab lice 267 Dermatitis contusiformis 6 herpetiformis .35 medicamentosa 42 papillaris capillitii 129 pruriginosa 35 seborrheica 67 Dermatomyoma multiplex 156 Diabetic gangrene 75 Duhring's disease 35 Dyschromia gingivse saturnina 112 Dysidrosis 19 Ecthyma gangrenosum 76 Eczema 49 scborrhoicum 69 Elephantiasis Grccorum 206 penis et scroti 166 Erysipelas 100 Erythema induratum scrophulosorum 199 iris 4 multiforme 1 nodosum 6 pernio 72 Eryth^me nouvcux 6 Erythrasma 246 Exfoliatio areata lingua* 103 Favus 230 Fibroma molluscum 155 Folliclis 203 Folliculitis barbae 114 Gangrene, diabetic 75 Geographical tongue 103 Gcnnan measles 94 Gibert's disease 248 XV PAGE Granuloma fungoides 216 Granulosis rubra nasi 130 Herpes facialis 14 genitalis 11 iris 4 labialis 14 preputialis 11 progenitalis 11 simplex 14 zoster 16 Hives 38 Hutchinson teeth 355 Hydroa »stivale 24 herpetiformis 35 vacciniforme 24 Ichthyosis congenita 152 hystrix 150 simplex 148 Impetigo contagiosa 21 Iodide rash 44 Itch 258 Keloid 175 Keratosis follicularis 164 pilaris 153 senilis • 162 Leontiasis 206 Lepra 206 Leprosy 206 Leucoderma 138 syphiliticum 322 Leukemia cutis 214 Leukopalkia 105 Lichen pilaris 153 planus 59 scrofulosorum 197 simplex chronicus Vidal 46 tropicus 113 Lingua scrotalis 107 Lupus erythematosus 182 pernio 187 vulgaris 188 xvi FACE Maculaj cerule« 267 Measles 91 Mercury rash 45 Miliaria rubra 113 Molluscum contiigiosuiii 173 fibrosum 155 pendulum 155 Morbilli 91 Myiasis linearis 269 N£e^■us linearis 144 papillaris pignicntosus 1 45 vascularis 142 Necrotic granuloma 208 Nettle rash 38 Neurodcrmititis 46 Onychogryphosis 271 Onychomycosis 240 Paget's disease of the nipple 224 Papillomata 159 Papulo-necrotic tuberculide 203 Paronychia syphilitica 322 Pediculosis capitis 263 pubis 267 vestimentorum 265 Pellagra 79 Pemphigus foliaceus 29 neonatorum 33 vegetans 31 vulgaris 26 Pernio 72 Phthisiasis capitis 263 Pityriasis lingua; 103 niaculata et circinata 248 rosea 248 rubra pilaris ^1 Pompholyx 19 Post-mortem wart 198 Prickly heat 118 Prurigo 57 Pscudochancre 303 Psoriasis 63 Purpura hemorrhagica 9 Pustula maligna 251 xvii PAGE Quinine rash 45 Raynaud's disease 73 Rhinophyma 128 Rhinoscleroma 212 Ringworm of the body 237 nails 240 Roentgen ray ulcer 78 Roethcln 94 Rubella 94 Rubeola 91 Sarcoma cutis 219 Satyriasis 206 Scabies 258 Scarlatina 96 Scarlet fever 96 Schanker 367 Scleroderma 167 Sclerosis et edema indurativum (in infants) 295 labii majoris 295 phagedenica 302, 351 syphilitica 293, 297, 300, 302 tonsillae 298 Scrophuloderma 201 Seborrheic eczema 67 Shingles 16 Smallpox 82 Spedalskhed 206 Sporotrichosis 255 Stomatitis mercurialis 110 Striae distensje 172 Sycosis, non-parasitica 114 Syphilides, moist 324 papular 310 tertiary 332 tubercular 337 Syphilis 273 circinaria 314 corymbifonnis 314 framboesiformis 320 gummosa 347, 349, 351 digiti 347 glandis 303 hereditaria bullosa 354 papulosa 354 tarda 351 xviii PACE Syphilis, hereditary 351 niJiculosii ( roscohi) 308 confluens (leukoderma) 309 follicuhiris 309 recidiva 309 maligna 341 milio-papulosa (lichenoides) 311 papulosa 315, 326 (condylomata lata) 325 lenticularis 310 mucosa; et anguli oris 328 orbicularis 310 papulo-pustulosa 318, 354 squamosa 311, 315 tertiaria 339 tubero-serpiginosa 339 ulcerosa palati mollis 350 ulcero-serpiginosa 335, 352 Syphilodenna 306 Tinea barbfe 242 circinata 237 favosa 230 trichophytina capitis 233 corporis 237 unguium 240 versicolor 244 Transitory benign plaques of the tongue 103 Tuberculosis linguas 195 nasi 196 Ulcer from Roentgen ray 78 simple venereal 367 T'lccra moUia (bubonulus) 369 vulvas 368 Ulcero molle 367 Ulcus endcmicum tropicum 205 molle 355. 367 digiti 367 gangrenosum 370 orifJcii urethrw 355, 369 phagednenicum 370 rodens 221 Urticaria 38 Vaccinia S9 Vagabond's disease 265 PAGE Varicella 87 Variola 82 Verruca necrogenica 193 Verrucae seniles 161 vulgares 157 Vitiligo 138 Warts, common 157 senile 161 Xanthoma palpebrarum 179 tuberosum multiplex 177 Xeroderma pigmentosum 163 Zona 16 Appendix 378 Index , 379 XX Plate 1. Fig. 1 . 2. Erythema multiforme. Erythema Multiforme Plate 1, Figs. 1 and 2 Erythema multiforme is an acute dermatosis having certain affin- ities with urticaria and purpura and hence believed to be essentially angioneurotic in character and dependent on some irritant within the blood which is chiefly of intestinal origin. It differs from an ordinary toxic rash in the large amount of infiltration, and in its appearance in successive crops. "While eminently multiforme, in the majority of cases, the lesions are more or less uniform in that there is a predom- inant type. The affection differs from those which most resemble it in a tendency to appear in certain localities, as the upper extremities below the elbows, the legs and feet and the face. It prefers the exterior surfaces, as a rule. In certain cases the entire surface of the body may be involved, and even some of the adjacent mucous membranes. Unlike most acute eruptions, it gives rise to little sub- jective discomfort. A constitutional reaction from the eruption or in association with it seldom occurs, but erythema multiforme may represent a manifesta- tion of some general infection which is akin to acute rheumatism. In occasional cases there is serious organic disease of the abdominal organs. These modes of behavior make it appear probable that the affection is a syndrome and not an actual disease. The conunonest form is a papular efflorescence, the lesions of which do not exceed the size of a large pea. The papules may be dis- crete or aggregated. Less common are tubercles which are consider- ably larger and accompany the smaller lesions. All these lesions tend to flatten and broaden and leave a depression, so that a ring may be formed. The color, a dark vinous red, is almost characteristic. Some- times rings of considerable size are formed, and segments of rings may be combined to form certain patterns; or one ring may form within another. In severe cases a papule or tubercle may have a vesicular centre. Aside from this there is a typical vesicular form known as erythema iris which will be described later. Bullous and purpuric forms bear a close resemblance to pemphigus and purpura and perhaps tend to partake of the nature of those affections. Etiology As already stated, the affection appears to be a syndrome which may be due to a great variety of causes — ^various circulating poisons, some of which may be the product of intestinal autointoxication. The affection may sometiines appear as an equivalent to an attack of dermatitis medicamentosa, and at times it is doubtless the result of a bacteriotoxemia. It is a disease of relatively early years and fre- quently attacks unacclimated subjects. Its most salient anatomical feature appears to be the cell proliferation which gives the peculiar fixed character to the lesions. Diagnosis The disease most closely resembles urticaria when the wheals of the latter are red. Urticarial lesions, however, are very fugacious, accompanied by much itching and burning, and seldom form rings. The latter when highly developed suggest ringworm, but this can hardly appear as a more or less extensive, symmetrical eruption. While erythema nodosum may coexist, there should be no confusion, for although the two affections have much in common, their lesions are quite dissimilar. Prognosis If the affection be regarded as a syndrome, the prognosis will de- pend on the actual cause of the disease. The eruption subsides com- pletely in two or three weeks, but some cases tend to recur at short intervals. Treatment The bowels should first be well evacuated, and after this intestinal antiseptics and antirheumatic medication administered. Capsules of salol gr. v., three or four a day, are useful, and frequent and mod- erately large doses of quinine are at times of service. If rheumatic symptoms are at all marked salicylate of soda should be given in full doses. There is but little local treatment required, as the lesions soon run their course and give rise to but little disturbance. In some cases, however, the itching and burning are quite troublesome, and for one that is generally found satisfactory : these cases antipruritic lotions may be prescribed. The following is ^ Acidi carbolici Sss. Magnes. carbonat 3i Zinci oxidi 3i Aquae rosa; ^iv M. et ft. lotio. Figs. 1 and 2. Models in Neisser's Clinic in Breslau {Kroener), 8 Erythema Iris Synonym: Herpes iris Plate 2, Figs. 3 and 4 Whether this eruption is a simple clinical variety of erythema mul- tiforme or a distinct affection affiliated with it, was formerly a vexed question, but at present authorities seem to have decided upon the vir- tual identity of the two. There may, however, be as good reasons for the dualistic view in the case of erythema iris as in erythema nodosum. In erythema iris we see a particular type of erythema, attended in the great majority of cases with vesiculation ; so that the former may be regarded as an abortive phase. In other forms of erythema multi- forme vesiculation is exceptional. The process of vesiculation in erythema iris also resembles that of true herpes, for the vesicles ap- pear promptly and with the same stinging sensation. Moreover, it is sometimes seen in association with herpes facialis and herpes pro- genitalis. Erythema iris consists of concentric rings of erythema, which, like other lesions, run their course rapidly, and since the rings appear in succession, exhibit different shades of color suggestive of the deeper hues of the rainbow — bright red, purple and violet, the older rings being of the latter shades. In this process the new rings form outside of the old ones, developing from a red areola ; and the nmnber may vary from two to six. As already stated, the process of vesicula- tion begins early, within twelve hours, so that lesions of different degrees of development appear side by side. From the formation of concentric rings, large patches are formed and may coalesce. The vesicles are essentially small but coalesce in the rings, and ex- ceptionally the central vesicle may form a bulla of variable size with which the outside vesicles may coalesce. The vesicles last about a week and disappear by absorption. The distribution of erythema iris agrees mth that of erythema Plate 2. Fig. 3. 4. Erythema Iris. multiforme in every respect in both typical and exceptional cases, and the treatment presents no peculiarities, save that large bullae may require evacuation. Fig. 3. Model in Neisser's Clinic in Breslau (Kroencr). Fig. 4. Model in Neisser's Clinic in Breslau {Krocner). A repeatedly recurrent vesicular eruption in a tailoress, twenty-five years of age, with high fever and joint symptoms. Erythema Nodosum Synonyms: Dermatitis contusifonnis. (Fr.) Erytheme nouveux Plate 3, Fig. 5 This affection is in many respects very closely related to erythema multiforme. It possesses, however, features particularly its own, thus affording a convenient excuse to describe it as a separate disease. In most text-books it is referred to as an affection of childhood and adolescence, but adults are by no means immune, and I can re- call, from my own practice, a typical case that occurred in a woman sixty years of age. For some unknown reason the disease is very much more common in females than in males. The characteristic le- sions of erythema nodosum consist of more or less elevated node-like swellings. These occur most commonly over the shins, and as a rule both legs are affected. The nodes have no well-defined border, and in size they vary from that of a hazel-nut to a mass sometimes as large as a hen's egg. They are generally oval in shape, and their long axis corresponds to that of the limb. The color is at first bright red, but soon blue, and then purplish tints appear, and as absorption pro- gresses, it gradually fades to a yellowish hue, and at this time the lesions resemble bruises ; this explains one of the titles that has been given to this affection by some authors (dermatitis contusiformis). The swellings when they first appear are hard and tense, but they be- come softer as the inflammation subsides. At times a sensation of fluctuation is obtained, but the lesions never suppurate. Nodes not in- frequently occur on the flexor surface of the legs and occasionally on the thighs, buttocks, and forearms. The individual nodes last about two weeks, but new lesions sometimes continue to appear, even in cases that are under treatment, and the duration of an attack ranges from three to six weeks. When the nodes first appear, they are gen- erally preceded and accompanied by a greater or less degree of con- stitutional disturbance. At times there are symptoms referable to derangements of the gastro-intestinal tract, but the most constant Plate 3. Fig. 5. Erythema nodosum. Fig. 6. Purpura hemorrhagica. concomitant symptoms are tliose of acute articular rheumatism of the extremities, the lower being more frequently affected. Etiology Erythema nodosum is so frequently associated with dofinito rheu- matic symj)toms, that it is now very generally looked upon as an ex- pression of rheumatism. Diagnosis This is seldom difficult, but at times the resemblance of inflamed syphilitic gummata to the lesions of erythema nodosum is quite marked. In sj-philis, however, the development of the lesions is more indolent, their number less, and they are not likely to be accompanied by constitutional sj-mptoms. In complicated cases the Wassermann or the Noguchi reaction should be of considerable assistance. Occasionally cases of erythema induratum are confused with those of erythema nodosum, but the former affection is a more chronic one, the lesions are much smaller, are generally found on the calf of the leg, and even in comparatively recent cases there is generally either ulceration or evidence of beginning central necrosis. In erythema induratum a positive tuberculine reaction is invariably obtained. Prognosis This is favorable as far as the disappearance of the lesions is con- cerned, but their development should be looked upon not only as an evidence of rheumatism but of impaired vitality as well, and the pos- sibility of an already existing endocarditis should be ascertained. Treatment If the swellings are very painful and the rheumatic symptoms se- vere, it is advisable to have the patient remain in bed for a few days or a w^eek. Although desirable, this is seldom absolutely necessary. The diet, however, should be restrictive, especially so if the febrile sjTnptoms are at all marked. In adults the bowels should be well moved by calomel, followed by the usual saline, but with children a dose of castor oil may be substituted. Although some observers have questioned its rheumatic relationship, it is a clinical fact that in erythema nodosum better results are obtained with antirheumatic medication than with any other. In mild cases, three to eight grains of aspirin or salicin in capsules may be given three or four times a day, but in cases where the rheu- matic symptoms are well defined it is better to administer full doses of the salicylate of soda, preferably in a mixture. The following for- mula is most efficacious : IJ Potassii acetatis oiii Sodii salicylatis 3iv Tinct. nuc. vomicas oil Syr. zingiber ad §iii M. et ft. mist. Signa Si in water after meals. After the swellings have disappeared, tonic doses of quinine may be given. For the anaemia that is frequently present iron and arsenic is indicated. The following is a valuable mixture : ]J Ferri et ammon. citrat 9 ii Liq. potassii arsenitis 3i Liq. potasssB 3iss. Vini ferri dulcis ad ^iii M. et ft. mist. Signa 3i in water after meals. Local applications are seldom necessary, but in the acute stage if" the nodes are particularly painful relief may be obtained from com- presses of ice, cold water, or of lead and opium wash. Fig. 6. Model in Lesser's Clinic in Berlin (Kolbow). Woman, thirty-six years old, without joint symptoms, treated as an out-patient. 8 Plate 4. 'S o c a, a 00 bio ao o e CD 3 a. Purpura Hemorrhagica Plate 3, Fig. G; and Plate 4, Fig. 7 This affection is an unsatisfactory one to discuss because purpura is a generic term for all hemorrhages of the skin, and thus in a sense all purpura is hemorrhagic. The term was originally applied to morbus maculosus WerDiolii or land scurvy, an affection long believed to be sui generis and to exhibit no lesions other than hemorrhages into the skin, mucosae and often in the viscera ; in other words, an idio- pathic acute or chronic hemorrhagic diathesis or acquired hemophilia. In recent times good authorities have insisted that the condition is only an intensive form of purpura simplex, while others appear to be- lieve that there is no form of purpura which may not develop into the affection in question, and the latter may appear as an equivalent of other clinical forms of purpura. In some cases a constitutional reaction of malaise, fever, rhemiia- toid pains, gastro-enteric disturbances, etc., precedes the hemor- rhages, but the more marked are these the more certain it seems that the disease in the special case is essentially one of the ordinary erup- tive forms of purpura. Prodromes do not seem essential to the de- velopment of the disease and the earliest sjTnptoms may be directly dependent upon the loss of blood. The eruption appears on the trunk and limbs and at times upon the face, which latter location is regarded by some as pathognomonic of purpura hemorrhagica, as is also the occurrence of hemorrhages in the visible mucosa?. A fact of importance in purpura hemorrhagica which may assist to some extent in differentiating it from minor forms is the semitraumatic character of the lesions. The eruption may comprise every tj^pe of hemorrhagic cutaneous lesions from petechias to ecchymomata. The typical lesion is probably a large, flat extravasation or ecchymosis. A patient with purpura hemorrhagica may present sj-mptoms as- sociated with the exciting causes Avhen these are markedly in evi- dence, and also others due to loss of blood, such as pallor and prostra- tion. The disease may run a brief and benign course, recovery ensu- ing within a fortnight, or a sort of status may be established in which hemorrhages recur and the condition may then be termed chronic or at least subacute. The very acufe, fatal cases in wliich death occurs from internal hemorrhages have sometimes begun as relatively mild purpura. Etiology The chief point of interest in this connection is the nature of the factors which cause this severe degree of purpura. The latter has often been noted in a relatively pure form in syphilis, tuberculosis, nephritis, influenza, etc., differing essentially from the hemorrhages which depend directly on the exanthemas of variola, scarlatina, etc. Of vital significance especially in cumulative incidence is the possi- bility of a dietetic factor — insufficient nutriment with especial refer- ence to potash. Cases of so-called "land scurvy" occurring in pseudo epidemics are still reported from time to time, and usually recover as soon as the diet is regulated. The pathology is of the simplest, yet quite obscure in essence. The blood-vessels and blood seem both at fault. The former permit diapedesis and also readily rupture. The blood which escapes shows delayed coagulation. The absorption of the extravasated blood occurs more slowly than in traumatic cases. Diagnosis The implication of the mucosae and face, as well as evidences of internal hemorrhage will serve to differentiate purpura hemorrhagica from the more common and comparatively benign forms of purpura. Treatment The general management consists essentially in the use of hemo- static remedies, as rest in bed with foot of same elevated, cold appli- cations and the internal administration of ergot and adrenalin. Roller bandages on ihe legs may prevent further extravasations. If several cases develop in a small community or house, the diet should be carefully considered as to the content of the food in potash. For the debility following an attack the patient should be put on a gener- ous diet of meat and fresh vegetables, with wine. Iron, quinine, and strychnine in suitable doses wull also help to restore the saline ingre- dients of the blood. Recently subcutaneous injections of human blood serum have been employed with good results. Fig. 6. Model in Vienna Clinic {Henning). Many intra- and sub- cutaneous hemorrhages. Skin shows icteric purpuric spots. Fig. 7. Model in Neisser's Clinic in Breslau {Kroener). 10 Plate 5. Fig. 9. Herpes progenitalis. Fig. 10. Herpes labialis. Herpes Progenitalis Synonyms : Herpes preputialis ; Herpes genitalis Plate 4, Fig. 8 ; and Plate 5, Fig. 9 The above affection possesses an unusual degree of interest be- cause its consideration belongs alike to the dermatologist and genito- urinary surgeon. It may follow coitus (as a result of mechanical irritation) and it frequently serves as a port of entry for the virus of syphilis. It is also prone to develop in male subjects who have had gonorrhea, apparently as the result of irritating pathological condi- tions in the urethra, vesicles, or prostate. Herpes progenitalis is emi- nently a relapsing affection. One attack may be succeeded almost immediately by another. In the male the little clusters of vesicles appear either on the inner aspect of the prepuce and the glans, or on the integument of the penis. In the latter case a typical cluster of vesicles is evident as in Fig. 8. These behave exactly like herpes on the face and the nature of the group of shiny vesicles is manifest. On a patient with no prepuce, or only a short one, the mucosa resembles skin and the vesicles behave in the same manner, but in subjects with long foreskins the vesicles occurring on the glans are quickly ruptured and the clinical appear- ance is more that of a balanitis. As a rule it is not easy to recognize the site of the vesicles in these cases, owing to the edema and retained secretion that is often present. We know comparatively little about genital herpes in women and authorities differ as to its frequency. The labia minora and clitoris are the parts most frequently affected although the eruption often occurs on the labia majora and adjacent integument, as sho^\^l in Fig. 9. In certain cases the vesicles enlarge to a considerable size and show a yellowish floor suggestive of a chancroid. These enlarged vesicles may also coalesce, so that a large eroded surface results. There is an offensive discharge and the itching and burning is often 11 intense. The inguinal glands are frequently enlarged and v/aUiing becomes difficult. Diagnosis This should not be difficult in an uncomplicated case, but when the vesicles have been ruptured and suppuration has taken place it is not always easy to exclude a chancroid. The latter, however, will gener- ally show deeper ulceration and a fouler base. Time and treatment will also help to clear the question. An attack of herpes is usually cured in a few days by the use of mild antiseptic applications, whereas a chancroid under the same treatment would increase in size. Auto- inoculation of a chancroid is seldom justified, but pus may be scraped from the border of the ulcer, fixed and stained, and in the case of a chancroid the microscope will show the characteristic bacillus of Ducrey. Primary syphilis should be readily excluded by the clinical history, the absence of induration, and by a negative laboratory report as to the presence of the spirocheta pallida. A simple balanitis often resembles the condition seen in herpes of the prepuce after the vesicles have ruptured, but in the former affection there is no history of the presence of previous vesicles. A diabetic balanitis is easily excluded by examination of the urine for glucose. Local Treatment The treatment of the lesions of herpes progenitalis is usually as efficacious as it is simple. Few cases fail to respond to cleanliness and mild antiseptic dusting powders. In male patients the prepuce should be retracted and the glans and contiguous mucous membrane cleaned with a weak boric acid solution and an application of aristol made over the vesicles. If there is infection or ruptured vesicles, it is well to use a 50% solution of hydrogen peroxide before applying the aris- tol. Other powders that may prove efficient are acetanilid, calomel, subnitrate of bismuth, and oxide of zinc. A redundant prepuce should be separated from the glans by a strip of gauze or pledget of cotton. If there be much edema the patient should be instructed to hold the penis in a cup of warm water for several minutes, two or three times a day. To hasten the healing of ruptured vesicles, the use of an astrin- gent wash is often beneficial. Powdered alum, gr. xx to gr. xxx to the ounce of water, makes a very good one. For superficial ulcerations the silver nitrate stick may be used. 12 Prophylaxis Under this caption may be considered treatment designed to pre- vent the reguhir or irregular recurrence of the affection. First of all, the general health, which in these patients is nearly always lowered, should be improved. Tonics containing iron, quinia, and strychnia are often beneficial and in certain chronic cases arsenic has proved of distinct value. Errors of diet should be corrected and careful attention given to gastric and intestinal derangements. Alco- holic and fermentative liquors, as well as tobacco, generally act prejudicially. Patients should be thoroughly instructed in sexual hygiene as the congestion of the genital organs following prolonged sexual excite- ment is often a prominent factor in the causation of this affection. "Wliile it is advisable to have a long tight foreskin removed it must be borne in mind that circumcision does not always prevent recurrent attacks. Some of the most rebellious cases that I have had under observation occurred in individuals who had been circumcised in early infancy. In some cases benefit follows the regular passage of cold sounds and instillations of argyrol. One phase of the prophylac- tic treatment that is rarely spoken of in text-books is the treatment of pathological conditions of the seminal vesicles. A number of my cases apparently depended upon a chronic catarrhal inflammation of the vesicles and treatment directed to the vesiculitis caused a cessa- tion of attacks after numerous other forms of treatment had failed. Fig. 8. Model in St. Louis Hospital in Paris, No. 1923 (Baretta). P'ournicr's case. Fig. 9. Model in Dermatological Clinic in Freiburg {Vogelbacher). 13 Herpes Simplex Synonyms: Herpes facialis, Herpes labialis Plate 5, Fig. 10 Strictly speaking, genital herpes belongs in this category, but for practical reasons it is better to regard it as a distinct affection. Herpes simplex may occur in almost any locality as the result of a possible nerve injury or irritation. In practice, however, the affec- tion is limited to the face — chiefly about the lips and outlying skin. Occurring at the junction of the skin and mucous membrane at the mouth or nostril it is the familiar "cold sore," which accompanies an acute coryza. These forms are extremely common, and are limited, as a rule, to a single small cluster of vesicles. Herpes facialis, so called, is a cutaneous eruption, not necessarily limited to one area, but able to involve a large portion of the face. It is usually associated with acute affections like pneumonia and influenza, the "fever blis- ters" of the laity, and is not, as has sometimes been thought, any criterion of the severity of the disease. The lesions are composed of clusters of vesicles, the numbers of both vesicles and clusters varying. The clusters are usually grouped together, forming large patches. The vesicles appear on a slightly hyperemic base and are nearly always attended with pricking sensations and soreness. They are naturally minute, but may attain considerable size as if from coalescence (hence the popular word blister). The liquid contents are absorbed or become desiccated, and a discharge never occurs. The disease runs a definite course, lasting a week or ten days, at the close of which period a scab is detached. There is considerable tendency to recurrence in the same area ; in fact, in the minor forms one attack appears to predispose to others. The peculiar nervous sensations, the character of the little vesicles and the occasional association of slight irritation — for example, the irritation of the nostril and upper lip at the outset of a cold — show plainly a nerve element in the make up of the affection — reflex or ganglionic. 14 Diagnosis Extensive facial herpes with much crusting may have to be dis- tinguished from other facial eruptions — eczema and impetigo — but this should not be difficult. Treatment The frequent application of spirits of camphor to the lesions will relieve the burning and hasten their disappearance. AVhen the crust- ing stage is reached ointments are indicated. The following is a good one, particularly for herpes labialis: IJ Tinct. camphor IlKvii Pulv. calamine prep gr. v Zinci oxidi gr. vii Aquae rosae 3ii M. et ft. ungt. In the troublesome, periodic form Norman Walker recommends the painting of the affected area with argent, nitralis (gr. xx) spr. a'ther. nitrosi (gi). This he believes will often increase the intervals between attacks, and will in time bring about a cure. Fig. 10. Model in Dermatological Clinic in Freiburg (Vogelbachtr). 15 Herpes Zoster Synonyms: Shingles, Zona Plate 6, Fig. 11; and Plate 7, Fig. 12 Herpes zoster differs from all other acute affections of the skin in that it is a secondary manifestation, due to an acute inflammation of the nerve fibers which are distributed in the affected area. There are few cutaneous affections of which the mechanism is so simple, even if the ultimate causal factors are obscure. The disease has points in common with herpes simplex, in which the terminal nerve-filaments are doubtless involved, but not the main nerve-trunks. In both herpes simplex and progenitalis, clusters of vesicles arise rapidly on a hyper- emic base with unpleasant tingling and pricking sensations; but in zoster the pain may be extreme — neuralgiform — and is associated often with intense hyperesthesia. In some cases the pain antedates the eruption by several days. Like simple herpes, zoster runs a definite course and is self-limited. The eruption requires about two days for its evolution, and on an average a week elapses before it begins to subside. The vesicles, as in herpes simplex, do not rupture and dry into scabs. Unlike the former they may leave permanent scars. Although herpes zoster is almost necessarily unilateral, bilateral cases have occurred. In the great majority of cases the affection occurs on the trunk or region of the eye. The areas that may be in- volved vary greatly in extent. In zoster of the ear, an affection not much discussed by dermatologists, a few vesicles only may suffice for the expression of the disease. Conversely in zoster of a lower extrem- ity the area affected may be very extensive. Differences also occur based on the severity of the case. Thus in a given area there may be only a few vesicles localized at one point or the entire area may be the seat of clusters. Zoster of the face and head seems more severe than elsewhere, because for some reason acute trophic lesions may accompany the ordinary phenomena. Naturally in zoster involving the eyeball a few vesicles on the cornea may result in opacities ; but there is added a 16 Plate 6. fig. 11. Herpes zoster. cortain pernicious quality to tlie eruption by reason of wliicli tlio eye- ball may be destroyed. Deep scars often remain on the forehead, due perhaps in part to diminished resistance of the tissues. For the same reason the vesicles may become infected, and as a result of thrombo- phlebitis fatal intracranial mischief may be set up. Zoster affecting the face may be accompanied by vesicles on the mucous membranes and trophic alterations in the teeth. Contrary to what one would expect, the motor component is almost negligible in zoster. Cases of paralysis, some permanent, have been recorded ; also isolated cases of spasm. Eiiologj/ It has been conclusively demonstrated by Head that the affection is due to a hemorrhage or other pathological change in a posterior spinal ganglion and that with almost unfailing regularity the location of the eruption is determined by the cutaneous distribution of the nerve-fibers that i)ass through the affected ganglion. In regard to the factors which determine the nerve-lesion, these seem to be legion. The most important appears to be a specific conununicable virus which often causes small epidermics. In this type of zoster we see malaise, fever and other phenomena observed in acute infectious diseases. Generally speaking, any circulating poison in the blood, any form of reflex irritation and traumatic influences (as in herpes simplex) may be able to produce zoster; whence some would distin- guish between true zoster and zosteroid eruptions. "Well recognized indi\'idual causes are arsenic (it frequently follows injections of salvarsan), carbon monoxide, and malaria. It is not uncommon in tuberculosis. The evidence in support of reflex causation seems weakest. Diagnosis The earliest vesicles of zoster, associated as they usually are ^^'ith pricking sensations, are sometimes mistaken for local effects of bites or other traumatism. Typical herpes zoster should hardly be con- founded with any other eruption because of its unilateral distribution and peculiar subjective sensations. Zoster on the face may of course be confused with herpes facialis and conditions resembling it. In se- vere cases, however, it would be more likely to suggest erysipelas. The latter, however, has constitutional s>nni)toms, is bilateral, infil- trated, and has the characteristic sharply defined margin. Zoster may run an abortive course and these cases are sometimes misleading. 17 Prognosis Certain features of zoster may bring up the question of prognosis, although generally speaking a mild self-limited affection can have but one prognosis. If the affection occurs in connection with a neuritis or neuralgia the pain may persist and even increase. The pitting about the face and head may be deep, and the practitioner may well be on his guard in calling the affection a trifling one. This obtains even more strongly in zoster ophthalmicus, in which the cornea may be rendered opaque with resulting blindness. The fact must not be lost sight of that zoster has been known to end in gangrene. Treatment Some authors, who evidently confound the predisposition with the actual disease, advise the general regimen for neuralgia, such as nerve tonics (arsenic, iron, quinia), coupled with change of climate neces- sary for all gouty and malarial subjects. Since zoster seldom recurs, it is difficult to understand how this regimen could influence an acute self-limited affection. We can only interpret this management as something directed to the underlying condition of which the disease is a transient expression. The pain may be the chief cause of the patient's visit, and as pain is almost always in evidence the practitioner should be prepared to mitigate it. Among anodynes a hypodermic of morphine close to the area involved is usually effective, but satisfactory results may often be attained by the use of acetanilid or phenacetin. A remedy upheld for many years is galvanism along the affected nerve to the extent of five milliamperes with a ten-minute exposure. Measures well spoken of are blisters over the part of the spine at the point of exit of the sensory nerve, and mild freezing, with ethyl chloride or dry cupping, at the same point. Of the numerous local applications recommended, not much is to be expected ; they may all be summed up under pro- tection and immobilization, which may be effected by dusting the area heavily with talcum powder and then applying a tight bandage, the inside of which is also thickly coated with the same powder. Such a dressing, which need be changed but once, will usually suffice for the local treatment of an ordinary case. Care should be taken not to rup- ture the vesicles so as to prevent the possibility of infection with sub- sequent scars. Fig. 11. Model in Neisser's Clinic in Breslau {Kroener). Fig. 12. Model in Lesser's Clinic in Berlin (Kolbow). 18 P ate 7. o c c o CN be Pompholyx Synonyms: Dysidrosis, Clieiro-pompholyx Plate 7, Fig. 13 This is a purely topical affection, limited to the extremities and chiefly the palmar and plantar aspects. The fingers are commonly in- volved, and the eruption is usually sjTnmetrical. The lesions consist of vesicles and bullse, the latter resulting from distention and coales- cence of the former. These lesions tend to appear in clusters, and are quite deeply seated, so that they have been compared to boiled sago grains. If not too crowded, there may be no coalescence to form bulla;, and the enlarged vesicles may disappear from absorption of their contents. If absorption does not occur, the contents become cloudy and at times purulent; when coalescence takes place actual bullap may form or the entire epidermis may exfoliate. The eruptions appear in crops or more or less continuously, and after a variable interval, perhaps of several months, spontaneous recovery occurs. The affected parts usually show poor circulation and excessive per- spiration, and the eruption is usually attended A\nth burning and itching. There is more or less absence of type, so that cases show considerable individuality. There is some reason to believe that abortive forms, limited to a few transitory vesicles, may not be as rare as the disease itself is believed to be. Etiology The earliest observers had no doubt that the affection represented a disorder of the sweat-glands and that the vesicles were simply re- tained perspiration— whence the name dysidrosis. This error— for an error it was — was most natural, for the affection is limited to areas where the sweat-glands are both large and numerous, and the patients, as a rule, showed habitual hyperidrosis of the extremities. That the lesions are not mere retention cysts containing sweat was soon made evident. This fluid is pure blood serum, and pomphoh-x, while not strongly resembling a weeping eczema, is more closely 19 allied to it than to any other known affection. Little is known of the cause; but the disease is common in women during the repro- ductive cycle, and nervous and psychic influences are often in evidence in relation to an attack. Diagnosis Since pompholyx is a local affection limited to certain areas, diag- nosis should not be difficult. The indirect method of exclusion may be necessary in certain atypical cases. The only affections which might cause confusion are acute vesicular eczema and certain forms of localized dermatitis venenata, notably ivy poisoning. Some confusion has arisen in past years between pompholyx and pemphigus ; this is due to the common bullous character and similarity in sound of the names — also perhaps to the fact that pemphigus is sometimes located on the extremities. The two conditions, however, should never occasion any confusion in practice. Prognosis A case of dysidrosis is often tedious, but the individual attack will undergo involution sooner or later. The unfavorable element is con- nected with recurrence, which is likely to occur under precisely those conditions which cannot be foreseen or prevented. Treatment The best results, both in arresting an attack and preventing a re- currence, will come about through internal medication. Arsenic fre- quently appears to have considerable control over the eruption, and arrests its development. Other drugs of value are iron, quinia, strychnia, and the hypophosphites. The external applications should consist of soothing and drying applications. Relief is generally afforded by Lassar's paste or by Hebra's diachylon ointment. Here is the formula of the latter: T^ Olei oli'varum optimi ^v Plumbi oxidi 5i Olei lavanduliB 9 ii M. et ft. ungt. Lotions of calamine and zinc and of lead and opium are also useful. Fig. 13. Model in Neisser's Clinic in Breslau (Kroener). 20 Plate 8. Fig. 14. Impetigo contagiosa. Impetigo Contagiosa Plate 8, Fig. 14 This affection, highly contagious, often disfiguring and well cal- culated to cause alarm, is, in reality, a very benign, superficial malady, which would demand but little attention were it not so liable to con- fusion with other and much more serious dermatoses. It yields to the simplest treatment, and even if left to itself would recover within a comparatively short time, despite the fact that it is auto- inoculable, and that many of its lesions doubtless originate in this manner. The name impetigo is a decided misnomer, as tliis implies that the affection is essentially pustular. As a matter of fact the essential lesions are vesicles and bullfc, the contents of which quickly become turbid from leucocytes ; so that when rupture occurs and the fluid evaporates, thin crusts are formed which adhere rather closely to the skin. These, when detached, show a slightly reddened integu- ment, which exhibits a slight tendency to ooze at the sites of the original vesicles or bulls'. While this affection may occur in a typical form, and spontaneously, we also see cases in which it apparently complicates some other affection in which scratching and abrasions are features. It is not uncommonly determined by vacci- nation; and in pediculi capitis in children it is so closely associated by authors Avith the vesiculo-pustular outbreaks on the neck, etc., that some have gone so far as to state that pediculosis is one of the most common causes of impetigo contagiosa. In ordinary cases of the latter they would always look for pediculi. A point not sufTicioiitly discussed is the relation of impetigo to scabies. Some claim that the frequent location of the affection about the lips and nostrils may have some bearing on the secondary infection of a herpes simplex. It will thus be seen that impetigo may behave as a primary or secondary affection. It is commonly stated that impetigo contagiosa is due to ordinary pus exciters — staphylo — and especially streptococci. It is interesting to note that the secretions of tliese lesions are being continually in- 21 oculated, but that local and general infection never appear to develop even in abortive forms. In some cases, however, where the out- break is extensive, we note a mild general reaction with fever and adenopathy. Impetigo contagiosa is very largely an affection of childhood, at- tacking chiefly the dirty and unkempt, in whom it pursues a fairly typical course. But it is of much greater significance when it attacks adults, especially those who are of neat habits. Here its behavior is often highly atypical, and the sudden appearance of lesions on the face and throat usually leads the patient to believe that barber's itch or syphilis, or some other more or less reprehensible malady, has been contracted. Petty epidemics sometimes arise in coimection with public swimming baths. The sole lesion, in the vast majority of cases, is the flattened crust, which may be gray, yellow, or broA\Ti. This occurs by pref- erence on the exposed surfaces — face, neck, hands, wrists, etc., and, in children who go barefoot, on the feet and legs. But no one should rest satisfied with this picture, for lesions may not only appear in almost any locality, but may exhibit a bizarre behavior. Thus Scliamherg illustrates a case in which the lesions occupied the groins and axillae, and exhibited a cireinate, serpiginous progression. If we bear in mind that the affection can be grafted upon other conditions we must be prepared for much variety and ambiguity in expression in selected cases. Etiology In the absence of any specific cause Bocl:hart's view that it may be caused by a variety of germs which exert a very superficial action may be accepted for the present. The lesions, as becomes vesicles and bullae, occupy the space between the horny and mucous layers, which accounts for the fact that the latter, the corium, lymphatics, etc., escape all serious implication. Diagnosis We have to exclude eczema, and as impetigo may be grafted upon the latter the differentiation is not always easy. Results of treatment in eczema, as in other maladies, must decide, for impetigo yields very promptly to treatment. There should be no confusion with sycosis of either type, because there is no involvement of the hair-follicles. Exclusion of syphilis is sometimes difficult, but as good a diagnostic procedure as any is the simple detachment of the crusts which demon- 22 strates the entirely superficial character of the lesions of impetigo contagiosa. Treatment The affection is perhaps more easily cured than any other of its class. Hence tliere is no need to use applications in any notable concentration. If there should be any dilhculty in detaching the crusts they may be softened with borated vaseline. The exposed surface sliould tlion be cleansed -with an antiseptic solution, and if the eruption is general an antiseptic bath may be given. The best application for the lesions is an ointment of white precipitate. The usual strength of thirty grains to the ounce is unnecessarily high, and wliile comparatively harmless, is less effective than a two per cent, ointnient. An efficient formula is : IJ Hydrarg. ammon gr. x Zinci oxidi 9 i Ungt. aq. rosse 51 M. et ft. ungt. Fig. 14. Model in Dcrmatological Clinic in Freiburg (Vogclbacher). 23 Hydroa Vacciniforme Synonym: Hydroa aestivale Plate 9, Fig. 15 This is an affection of cliildliood and adolescence, hence in part de- velopmental, which tends to appear in successive summers. It may be papular, but is usually vesicular and, like vaccine vesicles, leaves pits. It is very largely limited to males. Since it occurs by preference on exposed surfaces it presents almost the same causal factors as freckles. It is, moreover, a familial affection in certain cases. The lesions come out somewhat like a rash, with some general disorder and local sensory disturbance — burning, or more rarely itching. In a well-marked case the nose, cheeks and ears are first the seat of a diffuse or circumscribed redness. As a rule, small vesicles, the largest pea-sized, appear on this basis. The considerable size of some of the vesicles is responsible for the term hydroa. Coalescence is rare, but blebs have sometimes formed. The contents of the vesicles are at first clear, then turbid. The majority of them undergo distinct umbilication, after which crusts form and come away, leaving small scars. The vesicles may appear in several successive crops during the summer, at intervals of several weeks ; or, more commonly, there is a more or less continuous evolution of them. This, with the annual re- currence, will tend in the worst cases to very extensive pitting of the nose and other localities. There are numerous atypical forms. The affection may be abortive and may not reach the vesicular stage ; or it may appear in cool weather and in adults. In some cases there may be considerable scattered eruption on the covered regions. Etiology Aside from the predisposition the sole causal factor appears to be the summer sun, and wind. The pathologic process is an inflamma- tion of the papillary layer of the corium. 24! Plate 9. Fig. 15. Hydroa vacciniformis, Diagnosis Several somewhat sinxilar conditions liave been described, and it is a question whethei- or not they are simply atypical forms of hydroa vacciniforme. Unna's hydroa puerorum shows no tendency to a sea- sonal incidence and does not lead to scarring. Summer prurigo is a papular itchy eruption, diffused over the integument. Treatment The face should be protected from the chemical rays of the sun, and most authorities reconmiend the wearing of orange or red or dark-colored veils. Theoretically, this may be good prophylactic treatment, but it must be remembered that our patient is a small boy at play with his fellows and, well, a small boy is a small boy the world over. The application of a thick lotion containing calamine, mag- nesia, and zinc would be more practical and quite as effective. Nor- man Walker suggests that in mild cases it is often best to explain the nature of the disease to the parents, and tell them not to worry too much about it. Fig. 15. Model in Dermatological Clinic in Freiburg (Vogelbacher). 25 Pemphigus Vulgaris Plate 10, Fig. 16 Pemphigus is a term that has been applied to a variety of bullous affections, certain of which have but little in common beyond the presence of the bullae themselves. Since any intense inflammation of the skin, however produced, may give rise to bullae, it is necessary first of all to distinguish between pemphigus proper and the pemphi- goid eruptions, especially such as dermatitis herpetiformis, urticaria bullosa, etc. It must not be forgotten that in nearly all vesicular af- fections bullae may result from coalescence, sometimes as a rule, some- times only exceptionally. The presence of bullae under such circum- stances may be obscured by their rapid rupture, or by the drying of the turbid contents into crusts or scabs. Thus some writers affect to believe that impetigo contagiosa measures up to the standards of true pemphigus. There are also eruptions in which the lesions are inter- mediate in size between vesicles and bullae which are termed hydroa, and some of which appear to present no essential differences from pemphigus. Finally, the affection known as pompholyx has often been confused with pemphigus. It is therefore highly important to determine not only whatever does not belong to true pemphigus, but to give to the latter all the positive attributes possible. First of all pemphigus must be regarded as a rare and a chronic affection. Its essential primary lesions are al- ways bullae at the very outset. They must arise either upon normal skin, or at most on skin which is slightly reddened. They have no limited areas of distribution, but may appear on almost any portion of the integument, and save in the universal forms, independently of any local or traimaatic factors. The fact that the mucosae suffer with the skin in severe cases also shows plainly the endogenous nature of the malady. Several well-defined types of pemphigus exist, but to what extent these represent separate affections or mere varieties or degrees of intensity cannot be determined. Plate 10. p;rr \ f\ Pf»»iit-vhi(Tii< \_iilnfiiriQ Pemphigus vulgaris is appropriately named, as it is the most coimnon type of the alTection. It is a chronic affection only in the sense that new lesions continue to appear. They do not, however, change their type, for the bulla; in a long-standing case do not differ from those of the first outbreak. In the main the lesions appear in crops, with intervals of latencj' ; but as in all diseases which manifest themselves by successive outbreaks, we may at times encounter serial or overlapping cases in which the surface appears to be constantly covered with bulla>. In these cases there is usually some marked con- stitutional involvement and the prognosis is grave, altliough death may not be due directly to the eruption, which may cause of itself but little general disturbance. Even if the single first outbreak is un- usually thick or confluent, the prognosis is much more serious than when it is sparse. The bulhe are therefore rather an index of some, perhaps grave, general state than a direct cause of death, which may be due to the most varied causes. As will be seen later, the two other forms of pemphigus appear to be able to destroy life directly, and it is no doubt true that pemphigus vulgaris may sometimes pursue a similar course. It appears justifiable to speak of benign and ma- lignant penipliigus \mlgaris. Under ordinary circumstances, or, as we may say in benign cases, a crop of bullae requires one or two days for its evolution and one or two weeks for its involution. Sooner or later a new outbreak ap- pears, followed by others, which are less and less pronounced, until after some months the process is arrested. Etiology Nothing is known of the intimate nature of pemphigus vulgaris, and even the conditions under which it occurs show little uniformity. Several causal factors are vaguely evident. One is a neurotic ele- ment, suggesting that in miscellaneous affections of the central and perhaps the peripheral nervous system there may be a lowered re- sistance of the skin to noxa; of various kinds. Another element is the frequent suspicion of contamination from human or animal disease products ; in some cases the causation appears to be septic infection of the ordinary sort. Autotoxemia, including the intestinal tj-pe, is a third factor often recognizable. Diagnosis Pemphigus vulgaris requires differentiation only from the other types of pemphigus and from such pemphigoid eruptions as eryth- 27 ema naultiforme, urticaria bullosa, and dermatitis herpetiformis. This should not be difficult after a given case has been under observa- tion for some time. Prognosis As a rule, the greater the freedom from local and general com- plications of any sort and the more scanty the eruption, the better the outlook, which is, under other conditions, always serious. Treatment Arsenic has an unquestionably specific action on pemphigus vul- garis, but whether it can save life in the grave cases is open to doubt. It is often combined with strychnia and quinia and other tonics. The patient should be studied thoroughly and be given the advantage of any improved hygiene. Locally, the management is practically that of intensive moist eczema — the same medicated baths, lotions, etc. Hehra, many years ago, treated pemphigus with the con- tinuous bath, and this resource is well calculated to make the patient as comfortable as possible under the circumstances. The same end may be attained by a system of dressings, as in the case of universal eczema, severe burns, etc. Fig. 16. Model in Dermatological Clinic in Freiburg (Vogclbacher). Ma- lignant pemphigus vulgaris. Death ensued within a few weeks. 38 Fig. 17. Pemphigus foliaceus. Plate 11. Pemphigus Foliaceus Plate 11, Fig. 17 In this form of pemphigus, as in pemphigus vulgaris, new buUffi constantly appear; but since the areas denuded show no tendency whatever to heal, the disease picture differs extremely from that of the ordinary form. Pemphigus foliaceus may develop from pem- phigus vulgaris or may appear de novo. "VNlien the bulla? do not rupture at once, they coalesce, and considerable quantities of sero- purulent fluid collect and, follo^\^ng the law of gravitation, form characteristic flaccid sacs, instead of tense, rounded bulla;. The ulti- mate tendency of the disease is to denude the entire corium. This is effected not only by the formation of new bulljp, but by burrowing at the periphery of those already formed. Upon the excoriated surface feeble attempts at epidermization are seen side by side with the for- mation of small abortive bulte in the imperfectly generated epidermis. The discharge also dries upon the denuded surface in the form of crusts having a sort of tile-like arrangement from the development of fissures. These dried crusts are shed as a result of the oozing be- neath and this phenomenon gives the disease its name. Ultimately nearly the entire integument A\dth the visible mucosa; may become involved, but death often occurs Avhile much of the skin is still intact along with the mucosae. In advanced cases one of the most distressing symptoms experienced by the patient is a sensation of constant cold and chilliness. The nails and hair are not necessarily lost, but the former become deformed and the hair shed abundantly. Etielogy The cause of the disease is unknown. Some authorities, however, believe that it is due to the presence of a toxin circulating in the blood and that the cutaneous manifestations are secondary. Diagnosis "When the mucosa; are involved pemphigus foliaceus is automat- ically differentiated from any of the forms of universal dermatitis. 29 There are, however, cases so mild that one would hardly be likely to associate them with so grave a condition. The flaccid bullae, and the excoriated surfaces which refuse to heal are sufficient for diagno- sis, but since the lesions at first may respond to the use of arsenic, the practitioner may regard the affection as ordinary pemphigus. Ultimately the disease is unmistakable and the odor is so characteris- tic that a diagnosis can often be made from a considerable distance. Prognosis This is always grave. Treatment There is no loiowTi efficacious treatment and considering the grav- ity of the disease any rational form of experimental therapy is fully justified. Some of the symptoms may be relieved by local treatment similar to that employed in pemphigus vulgaris. Attempts should be made at active disinfection of the exposed surfaces, for at present we do not know how much of the fatal ele- ments in pemphigus may be due to the absorption of toxic matter. Fig. 17. Model in Neisser's Clinic in Breslau (Kroener), 'SO Plate 12. \ \ \ Fig. 18. Pemphigus vegetans. Pemphigus Vegetans Plate 12, Fig. 18 This affection, like pemphigus foliaceus, is best described inde- pendently ; for despite the fact that it is a bullous dermatosis, it was originally not classed as pemphigus, and it is largely a matter of opinion even now as to Avhether it should be so regarded. There is no doubt, however, that it shades into the different forms of pem- phigus. Exceptionally pemphigus vulgaris and pemphigoid affec- tions may assume a vegetating character. In the typical disease, however, pemphigus vegetans is a distinct affection from the outset. It tends to attack moistened cutaneous surfaces and the visible mucosjE ; and to this peculiarity is to be attributed the fact that the excoriations resulting from the maceration of the skin tend to form condyloma-like excrescences. The affection therefore markedly re- sembles the so-called moist syphilides ; and as a matter of fact it was originally confounded with syphilis, even by such authorities as Kaposi. This resemblance to syphilis is so pronounced that an account of pemphigus vegetans is largely a matter of differential diagnosis. The disease is such a rarity tliat generalizations are hardly wise ; but its most pronounced differential feature in all typical cases is failure to respond to treatment of any sort. A lesion of pemphigus vegetans is to all extent and purposes a lesion which is semi-malignant. It has no tendency to heal nor can it be made to heal. In many cases there is an added tendency for the lesions to generalize from the moist to the dry surfaces. In these generalized eases there is an undeniable re- semblance of the lesions to those of ordinary pemphigus. The vege- tating feature, however conspicuous, is perhaps (like the continuous exfoliation) merely a detail, as is the case in syphilis. Death in certain cases if not in the majority is due to some intercurrent or pre-existent affection, but it frequently occurs from the disease it- self, possibly as the result of exhaustion. One of my patients, a woman of sixty, died three months after the appearance of lesions in the mouth. She was well nourished and at autopsy an experienced 81 pathologist was unable to discover any visceral lesion that would in any way account for death. Etiology Aside from the fact that most of the victims have been middle- aged women, some of whom had previously contracted syphilis, but little can be said under this head. There is no apparent connection with gestation or with the nervous system. In a very few eases the disease may have represented a septic infection, which lends some color to the hypothesis of a crypto-genetic sepsis. Histologically the vegetating lesions present a picture very much like that of syphilitic condylomata. Prognosis The course of the disease is much like that of pemphigus foliaceus. In typical cases the patient is almost sure to succumb to exhaustion within a year, while some perish as early as two months. Cases of reported recovery are usually found to be those which were distinctly atypical, either because grafted upon ordinary pemphigus, or some pemphigoid eruption, or because the lesions showed no tendency to generalization. Treatment Although arsenic is of little or no value in this disease, the employ- ment of salvarsan is worthy of trial. Mercury and potassium iodide do not appear to retard the progress of the disease. Aside from the general desiccating and soothing remedies in com- mon use in similar cases and the continuous bath, the only rational measure ever introduced in harmony with progressive therapeutics is disinfection, which is performed somewhat as in extensive burns. On account of the superficial character of the lesions mild measures may suffice, such as solutions of hydrogen peroxide, potassium per- manganate and Labarraque's solution in proper dilution. These may be used in spray form or on saturated cloths. Carbolic acid solutions have been advised whenever the danger of absorption can be minimized. Fig. 18. Model in Neisser's Clinic in Breslau {Kroener). 32 Plate 13. Fi^. 19. Pemphigus acutus neonatorum. Fig. 20. Dermatitis herpetiformis. Pemphigus Neonatorum Plate 13, Fu;. 1!J It is almost universally conceded that tins is a pemphigoid condi- tion having absolutely no connection -with the pemphigus proper. It has several sharply defined clinical characteristics. First it attacks the newly born only; second, it is contagious, and tends to occur m epidemics in maternity hospitals; third, it is dependent in some man- ner on conditions -svhich favor septic infection, and is often associated Avith septic conditions either in the infants themselves, the puerperal Avomen, or the attending physician and nurse. Thus it may be re- garded as one member of a group disease — acute sepsis of the newly born, which comprises such other members as umbilical sepsis, septic coryza, septic pneumonia, buccal sepsis, etc. Pemphigus is, in fact, by no means the sole type of cutaneous sepsis of the newly born, for under this head are commonly placed R itter's d isease (dermatitis V exfoliativa neonatorum) ; ecthyma (some forms of which cause gan- )^~grene) ; multiple subcutaneous abscesses, etc. Even erysipelas neona- torum has been placed in the same category. Associated with all these manifestations w^e find the ordinary pus-exciting microorgan- isms, which are commonly held responsible for puerperal sepsis in the mother. The mechanism of infection presents the same obscurity in the in- fant as in the mother. The pyogenic microorganisms are no doubt in- oculable, for adults sometimes contract bulUc from the children. But if that were all the disease signifies, it would only be plain im- petigo contagiosa. The latter, as stated elsewhere, is not knowTi to cause constitutional infection even under aggravated conditions, and is never regarded as in any sense septic. In pemphigus neonatorum, however, a large proportion of the children are already septic or soon become so. If the bullse are regarded as primary lesions, some consti- tutional reaction should occur, but that they should form a port of entry for germs is not in accordance with analogy. It is more likely that cachectic or premature children, while specially prone to contract the eruption, in reality perish from other causes; or that some more severe form of sepsis attacks the child at the same time. That the bullje are metastatic is not to be believed, for skin lesions, secondary to knoAVTi sepsis, are very rare and behave in a very different manner. 83 To understand better a problematic affection of this sort, the study of an individual epidemic is instructive. In tlie fall of 1906 twenty-seven babies were attacked in the Lying-in Hospital of the City of New York. The great majority developed the affection from the fourth to the seventh day. Nine babies died, but in only six cases could it be held that pemphigus caused death, and in none was there evidence of general sepsis. The more severe as a rule the eruption, the graver the prognosis ; in other words, the eruption fur- nished an index of severity, arguing the existence of a strong predis- posing element. The absence of fever in some of the worst cases seemed to indicate a profound toxemia of the sore sometimes seen in rapidly fatal diseases. In certain cases contagion could be showm. Staphylococci could be cultivated from the bullae. None of the mothers were septic. H. J. Schwartz, who describes the preceding, is inclined to believe that toxins formed by the local suppuration caused death in the fatal cases, and it is possible that in this as in similar maladies a toxic substance is produced in the skin analogous to that now known to be the essential cause of death after burns. Such cases at least suggest the possibility of a fatal component which has no connection with sepsis. At the other extreme are innocent cases, in all respects resembling impetigo contagiosa, which tend to appear about the navel only (periumbilical pemphigus). In certain cases this mild type becomes the starting point for the ordinary severe form. The eruption of pemphigus neonatorum in typical cases appears within the first fortnight of life, and without any regular sequence. The blebs may be few or many, and in the worst cases become con- fluent in certain localities, denuding large quantities of skin. Diagnosis This shoidd give no trouble. The usual proof is secured by culti- vation of one of the pyogenic cocci from the serum of the bullse. Treatment But little can be said under this head. The infant should be iso- lated and placed under all available hygienic conditions. The bullae should be punctured and treated with soothing antiseptic dressings. In severe cases, however, local treatment is of little avail. Too much stress cannot be laid upon the necessity for early and complete isola- tion, as the contagious nature of the disease is now fuUy recognized. Pig. 19. Model in Lesser's Clinic in Berlin {Kolhow). 34 Plate 14. Fig. 21. Dermatitis herpetiformis. Dermatitis Herpetiformis Synonyms: Duhring's disease; Hydroa herpetiforme, Pemphigus pruriginosis Pkite 13, Fig. 20; Plate 14, Fig. 21 This affection was first described as such by Duhring, but it was evidently familiar to many of his predecessors under other designa- tions. It is a highly multiform affection, and one of the commonest features of the eruption is the presence of clusters of herpes-like vesicles. It may present any ciita-uMms losinn s;ivc ulceration, and sooner or later is followed by tl'ij) pigmentation. The great possihUi-tlcs i'or dil'lVronce in type in individual cases made it a difficult disease to describe, and tliis probably accounts for the delay in its recognition as a clinical entity. In young children it may be wholly v esicular or bullous ; and in some of the worst cases in adults the lesions may consist of e^r^^jepaa- tou s patch es and papules or vesicopapules. As a rule c onsecutive at - t acks present flie same lesions as the first outbreak, so that some would divide the disease up into several distinct types. Itching is said t o be most intense during the evolution of an outbreak. According as the outbreaks succeed one another rapidly or with long pauses, the appearance of the case ^\•ill vary. In the former case it is more likely to be generalize d, as in the opposite instance many lesions will disappear. When the lesions do not proceed beyond the erythematous \ stage the eruption is said to resemble greatly erythema multiforme when that affection is generalized. The question naturally arises as to whether there are any charac- teristics which belong especially to this one disease. Is there any- thing characteristic of the individual lesions? The large vesicles and bullae show peculiar outlines. Instead of being rounded or oval they are~angular, polyhedral, elongated and in general show great irre- gularily. They are also grouped closely together and otherwise re- semble groups of herpes vesicles. The groups, however, are often 35 very large — often as large as the palm of the hand, and even occur in large sheets. Then, again, a large portion of an entire limb may be studded with more or less discrete lesions. As with pemphigus, the mucous membranes may sutler. It can hardly be claimed that there are any true localities of preference. Like those of pemphigus, its lesions may appear almost anywhere. Etiologj/ The same neurotic element is present here that we have already seen in pemphigus. Also the autotoxic and septic factors, and it is highly probable that the neurotic element may depend on the presence of a toxin in the blood. Eosinophilia isjnyariably iiresent, as well as ^ , indicanuria. (^ Histologic study throws no light on the nature of the disease. Diagnosis When first seen, and especially during the early outbreaks, a diag- nosis is often difficult, because the multiform nature causes it to simu- late so many other conditions. The diagnosis is often left open until the case can be studied thoroughly. In the erythematous and papulo- vesicular stages, the affection is readily confused with eczema or ery- thema multiforme, some authors to the contrary notwithstanding. Intense itching, refractoriness to treatment, occurrence in suQfiessive cro£s_and marked pigmentation causTsuspicion of dermatitis herpeti- formis. However, if the characteristic vesicles, bullae or pustules are ' present, the correct diagnosis is at once suggested. Prognosis This should be guarded, as the disease is essentially a chronic one. Still, many cases improve notably, doubtless as a result of general treatment. Treatment In a persistent disease like dermatitis herpetiformis, hygienic measures are of great importance. Everything possible should be done to relieve or avoid strain upon the nervous system. Best, free- dom from work and worry, and particularly a change of surroundings, are indicated. Articles of diet which are prone to cause fermentative changes in the intestines, thereby increasing autointoxication, should be interdicted. Internal medication should be directed chiefly toward improving the patient's general health. Tonics such as strychnia, 86 i)C V- quinia, phosphorus, iron and cod-liver oil, may be used. Of all remedies, however, arsenic, judiciously administered, is the most valuable. It acts almost as a specific in some cases, particularly those offi^jvesicular or bullous type. The dose should be increased grad- ually until the disease shows signs of yielding, or the well-recognized symptoms of arsenical toxemia appear. The prolonged administra- tion of arsenic is not to be endorsed, and its ability to promote epithelial growth should be kept in mind. Crocker prefers salicin to arsenic, and recommends that it be given three times a day in doses of from fifteen to thirty grains. Potassium permanganate in one- grain doses, in capsules, taken after meals, was of apparent benefit in a number of my cases. Locally, any of the antipruritic and antiphlogistic applications may render aid. For the pruritus, solutions of ichthyol, potassium permanganate, or liquor picis alkalinus are of considerable value. The following lotion is particularly serviceable in extensive eruptions ■ftdth a good deal of inflammation : IJ Acidi carbolici oi Pulv. calamine prep 3ii Zinci oxidi oiv Glycerini 5vi Aquse calcis ,^i Aqua; rosw ad oviii M. Et ft. lotio. Ointments, as a rule, are of less value, althoiigh good results are generally obtained from the use of mild sulphur ointment, as first rec- ommended by Buhring himself. Fig. 20. Model in St. Louis Hospital in Paris, No. 1352 (Baretta). Tenneson's case. Fig. 21. Model in Dcrmatological Clinic in Freiburg (Vof/dbacher). 87 Urticaria Synonyms: Hives, Nettle rash Plate 15, Fig. 22; Plate 16, Fig. 23; Plate 17, Figs. 24 and 25 This affection must be regarded in a twofold manner. First as an innate peculiarity of certain skins, in virtue of which wheals may be produced at a point of irritation. To a certain extent this is not a peculiarity, for it resides in all skins. Thus the mosquito, bedbug, body louse and other insects produce wheals in all or nearly all by their bites. In some individuals lesions are produced by contact with jelly-fish. The point of a hypodermic or of an electric epilating needle very often causes a small wheal. A high, specialized degree of this behavior is seen in urticaria factitia and dermographism. These manifestations may be produced at will in some subjects. Thus whipping with nettles will bring out a crop of wheals, and by dermo- graphism is meant that artificial wheals may be determined in lines, curves, etc., so that writing may be produced. Other skins behave in this manner only during an acute general outbreak of urticaria. Secondly, urticaria must be regarded as an acute generalized dermatosis of internal origin, of the exanthem type, characterized by the evolution of evanescent white or reddish wheals, during which there is much subjective disturbance — bitching, burning, etc. Attacks may succeed one another in crops. The entire skin and visible mu- cosae may be involved, and it is highly probable that an analogous disturbance occurs in the viscera. There are numerous types of this affection. In the simplest and most familiar form there is a single crop of wheals which comes and goes in a few hours, the lesions being of pea or bean size; or the evolution may be slower and somewhat irregular, so that wheals are in evidence for several days. In rare instances the evolution of wheals is almost continuous, although the individual lesions come and go rapidly. The condition is then called urticaria chronica. In certain eases the wheals are represented by small papules closely ag- gregated. While these manifestations are usually comprehended 88 Plate 15. Fig. 22. Urticaria. Plate 16. Fig. 23. Urticaria chronica infantum. Plate 17. Fig. 24. Urticaria rubra. Fig. 25. Urticaria pigmentosa. under urticaria factitia, they may occur spontaneously, as a result of some internal condition. They are then largely peculiar to the irri- table skins of children and may be disseminated over the liml)s. They resemble a papular eczema greatly, but their urticarial nature is sho^\^l by their evanescence. They are apt to occur over a period of several weeks. Urticaria with large wheals is not uncommon, large red or white wheals being often associated with smaller ones. Sometimes several large wheals are closely approximated, forming a large firm swelling which resembles confluent insect bites. A minute hemorrhagic point in the centre increases the illusion. Large wheals, forming edematous tumors, are kno\\Ti as giant urticaria. Urticaria may be complicated with purpura (urticaria ha^morrhagica) and there is also a bullous type of urticaria (urticaria bullosa). Urticaria pigmentosa (Fig. 25), usually regarded as a separate affection, may be mentioned here. In this affection the eruption is characterized by the usual wheals, but these do not undergo the usual involution. Instead they tend to persist indefinitely and a deposit of pigment occurs which is virtually permanent. The affection is almost peculiar to infants and children. The stains are not due to such familiar causes as hemorrhage and scratching, but seem to be part of a new formation of tissue, as an integral element in the disease, which, while it is but little affected by treatment, is usually outgrown at puberty. Etiologv Urticaria has some deep-seated connection with the vasomotor system, and has affinities with the vasomotor neuroses. The first step in the formation of a wheal is angiospasm causing an area of local anemia. This spasm is followed by sudden vaso-dilatation and effusions, which compresses the vessels from without. This causes a white wheal with an outlying hyperemic zone. The process resembles somewhat the formation of the lesions in erythema multiforme. It is evident that the actual cause of the disease is that which tends to induce this angiospasm, and this is commonly a circulating toxin absorbed from the alimentary canal. Many familiar dietetic articles can cause it, the best knowm being shellfish, mushrooms, and straw- berries. In many cases there is no evidence to point to any one substance, but simply a gastro-enteric crisis due to general dietetic abuses. In urticaria of intestinal origin, the intestinal tract may suffer as well, as a result of direct irritation from the toxic sub- 89 stance. So-called idiosjaicrasy, in which the consumption of a cer- tain drug or dietetic article is invariably followed by urticaria, is best explained by anaphylaxis — supersensitiveness to the particular substance caused by the original unpleasant experience with it. For this reason it may be very dangerous for these subjects to make use of these substances at all, for the oversensitiveness may so in- crease, that the so-called anaphylactic shock may prove fatal, espe- cially in individuals with advanced cardiac disease. Diagnosis Urticaria in 'its simpler form is readily recognizable even by the laity, who know it under such names as "hives" and "nettle rash." Chronic urticaria, on the contrary, is easily misjudged. It is neces- sary to watch for new lesions, and when these are found to be wheals the diagnosis is easy. Giant urticaria may readily be taken for some local lesion, the result of insect bites, for example; the more so because it may be limited to some one area. These cases are usually regarded as a transition between urticaria and acute circumscribed edema. Treatment If an acute attack is seen at the outset, a quickly acting purgative should be given ; usually one of the salines. Antacids are also given. This plan should be pursued whether vomiting and diarrhea are present or absent. Any other detoxicating measures available should be practised, and this plan of management should be kept up for several days. Intestinal antiseptics, colonic irrigation, and simple, bland diet are comprised in the management. Some writers advise salol in regular doses for its supposed antifermentative properties. A combination of alkaline diuretics and bromides appears to aid in controlling the disease. Johnston recommends the administration of ichthyol in five-grain capsules after meals. This he regards as the most serviceable drug for internal medication at our command. Locally the antipruritics and sedative measures used in acute dif- fuse eczema are indicated. Medicated baths frequently allay the cutaneous irritation and inflammation. An excellent formula, recommended by Bulkley, is the following : ^ Potassii carbonatis §iv Sodii carbonatis 3"i Pulveris boracis 3" M. Use in a thirty-gallon bath, with a pound or two of starch. 40 Owing to the volatile character of the lesions sediment lotions are generally inferior to ointments. In recurrent and chronic urticaria the management is summed up under rigorous intestinal disinfection, including a carefully se- lected diet, and some of the same tonic measures as are applied in dermatitis herpetiformis. Fig. 22. Model in Neisser's Clinic in Breslau {Kroener). Man, thirty years of age, suffering from chronic urticaria for one year previous to the time when the model was made. Fig. 23. Model in Neisser's Clinic in Breslau {Kroener). Fig. 24. Model in Neisser's Clinic in Breslau {Kroeiur). Fig. 25. Model in Neisser's Clinic in Breslau (Krociur). Boy, two years old, suffering also from tetany. The affection distributed over the entire body; skin reflexes exaggerated; factitious urticaria over the entire skin. 41 Dermatitis Medicamentosa Plates 18 to 22, Figs. 26 to 33 This term is employed to denote outbreaks caused by the internal administration of drugs, and is not to be confused with the various forms of dermatitis venenata caused by the external application of remedies. Drug eruptions do not differ essentially from dermatoses due to supposed autotoxications and metabolic disorders. In either case all the primary and secondary lesions may be represented, and marked polymorphism is sometimes seen. These drug rashes may also closely simulate the exanthems of acute infectious diseases. Nor are lesions due to drugs limited to mere acute efflorescences, for cer- tain medicaments can produce chronic, productive and destructive lesions like the granulomata. Arsenic can cause an overproduction of horny epithelium, sometimes resulting in a malignant growth. A very important distinction must be made between customary action, supersensitiveness, and idiosyncrasy in respect to this action of drugs on the skin. The term idiosyncrasy should not be confound- ed with supersensitiveness, for it implies something peculiar to the individual and, perhaps, his blood relatives. The idea of supersensi- tiveness has received a great impetus in recent years from the study of anaphylaxis. Supersensitiveness may, of course, be innate in a subject, but it is often the result of a poisoning on some previous occa- sion which has rendered the skin supersensitive to the substance in question. Anaphylaxis may also result locally, and the sensitiveness to poison ivy and the like is doubtless in part anaphylactic. A sub- ject supersensitive to one drug may very likely be supersensitive to others. No doubt there is a general predisposition to drug eruptions based on unusual vasomotor irritability, and hence noted chiefly in children, certain women and neurotic subjects. Defective elimination has the same significance as overdoses, and certain drug lesions ap- pear to have resulted from proved renal insufficiency in elimination. A factor of great importance is that the rash, etc., provoked by a given medicament is not always connected with its true cause, so 42 Plate 18. Fig. 26. Dermatitis Medicamentosa (Antipyrine rash). Fig. 27. Dermatitis Medicamentosa (Arsenic rasli). that the patient continues the use of the drug until a more or less serious condition results. Few drugs exert tlieir toxic action peculiarly on the skin. It must be borne in mind that otlier tissues are usually implicated, and that the offending substance leaves the body in the urine, in which it may often be detected. In some instances a drug which is eliminated by the skin may«come in contact with another locally employed. A cTiemical reaction may result, causing some local disturbance. The action of light on metal- lic salts wliich are in the circulating blood may also cause special phenomena, especially of the nature of discoloration of the skin. A question naturally arises, are drug rashes to some extent the effects of elimination by the skin ? There is little direct evidence as to the correctness of this speculation, but beyond the fact that these substances are in the circulating blood nothing is really kno^vn as to their modus operandi. A drug eruption is recognized as such only by the crucial test of exhibiting the drug on a second occasion. Its known action on the supersensitive usually gives -sufficient information. It is possible, by combining certain antagonistic drugs, to prevent many drug erup- tions, but there is hardly any special treatment, save in severe chronic cases, to be mentioned later. Following are some of the leading drugs which cause lesions and their symptoms: Aniipyrin (Fig. 26) This drug does not, as a rule, cause anaphylaxis, but the contrary, as many become immune. It causes a general outbreak, but as a rule the face and trunk bear the brunt. The rash may be morbilliform, searlatinaform or polymorphous. In rare cases bulhc, purpura, and pustules have been noted. A feature of especial significance is pig- mentation following the eruption. Arsenic (Fig. 27) This drug is believed to have an elective action on the skin, and the number and variety of its collateral phenomena are too great even to enumerate. Arsenic can cause a typical herpes zoster, keratosis of the palms and soles, gangrene of the scrotum, pigmentation, "and even epithelioma. The general pigmentation that frequently follows the continued use of arsenic is often mistaken for Addison's disease. 48 Bromine (Fig. 29) These salts affect nearly all subjects. Bromie acne is much like the ordinary form, but has a tendency to confluence, producing a sort of small carbuncle. In mild cases lesions are rather confined to the face and shoulders, as in acne proper. In bromism supervening sud- denly upon large doses the thighs are a favorite locality, and hardly any region is immune. In certain cases the papillary layer of the skin seems to be stimulated, so that fungoid outgrowths are produced without previous ulceration. Cutting off the drug may not be fol- lowed at once by improvement. Lesions may even continue to appear. Chloral Hydrate A typical drug rash not infrequently follows its use. A scarla- tinoid exanthem, implicating the mucosa?, and succeeded by desquama- tion, is well known. Various anomalous rashes also occur, as in the use of other drugs. Chlorine (Fig. 32) Workers in this gas often suffer from an acne-like affection, be- lieved, however, to result from outward exposure, at least in part. Copaiba (Fig. 28) A peculiar erythematopapular universal efflorescence is often seen in gonorrheal subjects who are using the balsam. This rash serves greatly to obscure the fact that gonorrhea itself can cause an exanthem. Iodide of Potassium (Figs. 30-31) An acne-like eruption, much like that of bromine salts, is pro- duced by this drug, and exceptionally the usual irregular outbreaks seen with drugs in general (buUaj, purpura, etc.). There is also a peculiar confluent, patchy lesion, somewhat similar to a bromine "car- buncle," but more indolent, which seems to be due to a congeries of inflamed follicles, and occurs on the legs as a rule. There is also a severe, proliferative, and destructive affection, much resembling the infectious granulomata, seen on the upper extremities and elsewhere. In this form a tendency to buUas exists, and is a leading factor. These severe forms of iodism have sometimes been brought in re- lation with renal and cardiac insufficiency, but have also been seen in apparently vigorous youthful subjects. 44 Plate 19. Fig. 28. Dermatitis Medicamentosa (Copaiba rash). Plate 20 ■a o G o bjD CI c G Q bi) Plate 21. CO l-H IS o c (U E CO -3 CO E Q CO •a o to o E CO o CO E Q en Plate 22. Fig. 33. Dermatitis Medicamentosa (Mercury rash). Mercury (Fig. 33) Erytliematous eruptions sometimes occur after the internal ad- ministration of mercury. They may be partial or general. The rash is of a deep red color and is often accompanied by swelling and pruritus. Occasionally it may be papular or scarlatiniform, and in the latter case is generally followed by desquamation. Quinia Cinchonism is sometimes expressed by eruptions of the same type as those due to antipyrin. In addition to the preceding, rashes and other manifestations have been seen after a great variety of drugs: aconite, acetanilid, alcohol (sometimes causes a desquamating erythema), antimony, ben- zoic and boric acids, calx sulphurata, cannabis Indica, chloroform, cubebs, digitalis, ergot (not including severe ergotism), opium (pru- ritus a very conmion sequence), phenacetin, rhubarb, salicylic acid and derivatives, sulphonal, turpentine, and numerous others. Fig. 26. Model in Freiburg Clinic (Johnsen). An old medical man, who, after every dose of migranin, gets circumscribed urticarial eruptions on the buttocks, legs, shoulders and mucous membranes, which disap- pear after about a fortniglit, leaving pigmentation. Fig. 27. Model in Freiburg Clinic (Johnsen). Fig. 28. Model in Neumann's Clinic in Vienna (Hennlng). An hemor- rhagic eruption after copaiba. Fig. 29. Model in Neisser's Clinic in Breslau (Kroencr). Fig. 30. Model in Lesser's Clinic in Berlin (Kolbow). Figs. 31 and 32. Models in Freiburg Clinic (Johnsen). Fig. 33. Model in Neisser's Clinic in Breslau (Kroener). 46 Lichen Simplex Chronicus Vidal Synonym : Neurodermatitis Plate 23, Fig. 34 This affection, unlike true lichen, is an extremely chronic one. It attacks by preference the neck, the inner surface of the upper parts of the thighs, and the flexor folds of the knees and elbows. Excep- tionally the abdomen may be affected. The lesions are papules of the simple lichen type, equivalent to those often seen in eczema. They are naturally discrete but readily become confluent. Well marked cases show a central area of lichenification of a grayish-brown color, which is surrounded by a brighter zone in which are present small, slightly scaly lichenoid papules. Vidal claimed that the disease is essentially a pruritus and that the cutaneous manifestations are due entirely to the results of scratching — hence an artefact, or form of dermatitis, confined largely to the pilous follicles. The deep red, angry look of the papules, if not the lesions themselves, he ascribed to rubbing and scratching. Etiology The disease affects only neurotic individuals and is more frequent in women than in men. Diagnosis This should not be difficult in a fully developed case. It is dis- tinguished from other similar conditions by the duration, localization, and absence of marked inflammatory phenomena. Prognosis The condition is chronic in the sense that new outbreaks constantly occur. Treatment General measures directed to the relief of the pruritus are, of course, indicated. The local treatment is essentially that of chronic eczema. In severe cases chrysarobin ointment is often of considerable benefit. Solutions of oil of cade are also useful. Fig. 84. Model in Neisser's Clinic in Breslau (Kroener). 46 Plate 23. Fig. 34. Lichen simplex chronicus (Vidal). Fig. 35. Pityriasis rubra pilaris. Pityriasis Rubra Pilaris Plate 23, Fio. 35 This affection appears to be a dermatitis involving the hair-fol- licles. It is extremely persistent and has no particular secondary tendencies. Unlike types of folliculitis, it may involve the entire sys- tem of hair-follicles of the smooth as well as the hairy skin, producing large sheets of inflamed integument and becoming practically univer- sal in certain cases. The separate papules, however, can always be distinguished. Considerable fine desquamation is present, hence the use of the term pityriasis. General scaling, however, does not occur. An incipient case naturally presents a different picture from one well advanced, for, as a rule, the disease begins in a limited area, and sometimes remains there. Such areas are the scalp, and the palms and soles. In the latter localities there may be only callous thickenings, while in the scalp ordinary or seborrheic eczema may be simulated. Lesions then appear in various other localities — as the fingers, forearms, trunk, etc., where their development may be readily studied. The papules may be red or they may have a brownish or grayish color. Each follicle may be the seat of a smaU hard central plug as well as a hair-stump. As they become confluent the corium shows participation. It becomes thicker and less supple, and may crack slightly at the natural folds. "Wlien the entire face is involved there may be some retraction about the orifices. Alopecia does not result, but the nails may become brittle. It is one of the few der- matoses able to implicate practically the entire integument. The thickening of the skin gives the latter a coarsely granular appearance. Etiology The affection is rare, and its nosologic position has been much de- bated. It was once believed to be the same disease as lichen ruber acuminatus. A stumbling-block was the high mortality of the latter as described. But at Vienna, where fatal liclien ruber was first noted, no fatalities or even cases of marked severity are now recorded, nor has any fatal type been seen for years. For a time it was believed 47 that lives were saved only by the heroic use of arsenic, but this was doubtless a misapprehension, and it is not improbable that some of the recorded deaths resulted from the misuse of .this drug. Arsenic now seems to have little or no power over the disease. Nothing whatever is known as to its causal elements. It may be- gin in childhood, and is an affection of early life. It shows no familial incidence, and occurs in the sound and vigorous. As a hy- perkeratosis, which it appears to be, with inflammatory phenomena purely secondary, it shows an affinity with psoriasis. The reaction of the corium to the epidermal process is similar. The very participa- tion of the entire follicular system seems to coimect it with some fun- damental error of development. Diagnosis At the very outset lichen rubra pilaris might be suggested, or ordi- nary dandruff and callosities. As the disease develops there shoidd be no further trouble in identifying it until it becomes universal. The papules are usually seen in a typical state on the backs of the fingers. Since the affection has been made a congener of lichen planus, it is evident that the two could be confused, especially as in lichen planus the papules are not invariably flattened. The initial lesions, however, are so typical in each affection that confusion should hardly occur. When the eruption becomes universal, psoriasis and eczema may be simulated, but the elementary lesions, and especially the evolution of the disease, should prevent confusion. Prognosis Arrest, spontaneous cure, cure by treatment, all occur. Recur- rence also occurs, and in many cases the tendency is progressive from first to last. The general health is but seldom affected. Treatment Of treatment in the ordinary sense, with a view of a cure, there is none. The management comprises, in a general way, that of eczema, psoriasis, and ichthyosis. Alkaline baths, subsequent inunctions, and salicylic acid ointment tend to remove the overproduction of corneous matter and hence to check the inflammation. This must be persisted in, and thus conditions are made favorable for improvement and recovery. Fig. 35. Model of Dr. Bayet in Brussels. 48 Plate 24. Fig. 36. liczema acutuni cum pigmentatioue. i ig. 37. liczema folliculare. Plate 25. / Plate 26. X 05 03 E (U IM U d CQ s e 5 U5 3 N U tu CO Plate 27. Fig. 41. Lczema orbiculare oris. Fig. 42. Eczema e prolessioiie. Plate 28. Fig. 43. Eczema chronicum squamosum. Fig. 44. Eczema chronicum corneum. Plate 29. 3 o E 3 o c o u J3 i5hilitic arteritis, the crippling of the peripheral cir- culation being practically the same. Arteritis of some sort is no doubt responsible for a certain per cent, of cases. A Wassermann test should be made as a matter of routine. Prognosis This is good for life, but rather poor for recovery. The gangre- nous tissues separate in time, and the exposed surfaces heal slowly. Amputation is seldom required. The disease may reappear in other fingers, so that we may see the different aspects side by side. Treatment This includes all measures which may favorably modify the cir- culation, including general regimen. Hydrotherapy, massage, galvan- ism and faradism have all been used extensively. In the later stages strict asepsis is required, as infection from without readily occurs and fatal sepsis has been known to result. Fig. 68. Model in Neisser's Clinic in Breslau (Kroener). See Transac- tions of Demiatol. Congress in Breslau, 1901. 74 Plate 43. Fig. 69. Gangrena diabetica. Diabetic Gangrene Plate 43, Fig. 69 Localized cutaneous gangrene frequently occurs in cases of ad- vanced diabetes mellitus. The extremities are generally affected, par- ticularly the toes and fingers. Occasionally the penis is involved. Although the gangrene may be of any familiar type, Kaposi has described a form believed to be peculiar to this affection. It is seen only in advanced cases, and consists of a serpiginous grouping of bul- lae occurring on the limbs in successive crops. A black scab then forms, which is surrounded by a ring of new bullae. The corium is involved, and after all scabs have come away, a portion of it sloughs. This, in turn, being thrown off, leaves a granulating surface. Prognosis This should always be guarded, as the gangrene occurs only in individuals suffering from advanced diabetes. Treatment This has never been very satisfactory. For the underlying condi- tion, general medical and dietetic measures are of course indicated. When gangrene is established its advance is often controlled by the frequent application of warm antiseptic dressings. In beginning dia- betic gangrene of the fingers good results have recently been reported following the employment of Schaeffer's hot air method of treatment. The intense heat is said to force new blood into the stagnating blood- vessels and by re-establishing the circulation aborts the process. Fig. 69. Model in Neisser's Clinic in Breslau (Kroener)- 75 Ecthyma Gangrenosum Synonym: Dermatitis gangrenosa infantum Plate 44, Fig. 70 This affection, while peculiar to young children, corresponds to multiple spontaneous gangrene in adults. A study of the literature conveys a strong impression that a distinct disease as described by some authors does not really exist. If we state that in certain cachec- tic infants nearly any eruption may become gangrenous under certain unknown conditions, there is not much to add. Hutchinson first described the condition as a sequel of varicella, under the name varicella gangrenosa. A similar termination was noted in vaccinia. Other cases were described as pemphigus gan- grenosus. French authors regard it simply as ecthyma with a ne- crotic tendency, and term it terebrant or boring ecthyma, rather than gangrenous ; for in gangrene we naturally expect to see more lateral extension. The term rupia escharotica conveys the impression of firmly adherent crusts, beneath which necrosis occurs, either from pressure or through the action of anerobic bacteria. The chief interest lies in the purely spontaneous cases, which are said to begin as small papulopustules or vesicles about the buttocks. In a case described a few years ago by Welander, in a young infant, the head was the seat of the lesions, although the statement has been made that the head is never attacked. The disease may run a rela- tively mild or a severe and fatal course, and there may be only a few lesions or many. It has been shown to be independent of tuberculosis and also of syphilis. No evidence of pathogenic germs constantly present has been adduced, nor is it even known whether such germs are inoculated from without or gain the surface from within. In fatal sepsis a few small necrotic pustules have been seen in the skin as if produced by emboli of germs, but they bear no clinical relation to this affection. From the fact that the lesions are usually seen about the region of 70 Plate 44. Fig. 70. Ecthyma gangrenosum. the buttocks, it has beon thought that they have resulted from inocula- tion from feces or other outward source. They have, however, been seen to cover the abdomen and limbs, also, as above stated, the head. To sum up, when the affection is not secondary to some well- knowTi eruption, like varicella, it appears to begin as papulopustules or vesicopustules, which lead to crust-formation. Destruction of tis- sue takes place beneath and around the crusts and an ecthymatous lesion is produced, i.e., a large pustule with a hard, inflamed base. The crusts come away, leaving ulcers, which, if the lesions are close enough together, may become confluent, but no diffuse gangrene results. Permanent scars naturally result. Treatment This is carried out by ordinary antiseptic dressings, with tonics and good nursing. Fig. 70. Model in Kaposi's Clinic in Vienna (Hennmg). 77 Ulcer from Roentgen Rays Plate 45, Fig. 71 The Roentgen rays cause various degrees of injury to the skin and subjacent tissues, as a result either of oversensitiveness or ex- cessive dosage, the latter being largely preventable, as should also be the results of accidental exposure. The changes caused somewhat resemble the different degrees of sunburn, and there are also trophic alterations, such as shedding of the hair. After a period of latency, occupying in some cases several days, the characteristic erythema or dermatitis supervenes. The mildest degree is much like the erythema due to the solar rays and likewise tends to leave pigmentation. With repeated or severe exposures or undue sensitiveness a vesicular der- matitis results. Unlike sunburn, a deeper degree of injury sometimes occurs in which superficial necrosis develops, leaving a large raw sur- face covered perhaps with an adherent false membrane. These are not only extremely painful but show little or no tendency to cicatrize. There is also, so to speak, a fourth degree of injury, in which the subcutaneous tissues — muscles, bone, etc. — may also slough, leaving deep losses of substance. Hence the two severe degrees of X-ray injury are not unlike burns of the third and fourth degrees. They appear to be due primarily to injury to the blood-vessels. Those who work continually ■\\ath the rays also suffer from atrophy of the skin of the hands and forearms, and the development of epithelioma is not infrequent. Treaimeni The milder degrees of injury are managed like dermatitis and acute eczema. The ulcers are often very painful and anodjmes are frequently indicated, orthof orm being the most useful. In deep ulcers excision followed by skin grafting may be practiced but owing to the peculiar pathological change that has taken place in the tissue sur- rounding the ulcer the surgical results are often disappoiiating. Fig. 71. Model in Freiburg Clinic {Vogelbacher). 78 Plate 45. Tig. 71. Ulcer from Roentgen Rays. Plate 46. Fig. 72. Pellagra. Plate 47. Fig. 73. Pellagra. Pellagra Plates 46 and 47, Figs. 72 and 73 Pellagra is a general disease with important and characteristic cutaneous manifestations which serve for its recognition. It was at first thought to be peculiar to certain countries in southern Europe, in which it is endemic, notably parts of Spain and Italy. In compara- tively recent times it has been seen both sporadically and epidemically in various localities in both hemispheres. It is clearly not peculiar to warm climates, although practically confined to them. The earliest cases seen in the United States were in native subjects, and confined to the insane. They are known as, or presumed to have been, pellagra from the records of institutions, although not recognized at the time. In quite recent years a few imported cases have been noted in the United States. The great bulk of American cases, however, have appeared within the last decade, and in the Southern States, where pellagra now prevails to an alarming extent. It has recently been asserted that the disease may be found described in the annals of Spanish America at a date much earlier than the oldest European records. Owing to its severe constitutional symptoms, chiefly manifested in the nervous system and gastro-enteric tract, pellagra is relatively un- important as a dermatosis. A large proportion of cases find their way to insane asylums. The eruption of pellagrins is confined to a desquamating erythema of the face and backs of the hands and wrists, which extends for a variable distance up the forearms; this is a chronic condition which in time shows a slight degree of thicken- ing and deposition of pigment. A certain amount of atrophy may remain. The patient seems at first to suffer from spring lassitude along with disordered digestion. The latter may involve almost the entire digestive tract — stomatitis, epigastric pain, anorexia, and diarrhea. The patient becomes weak and easily fatigued. After several weeks of these prodromes, the parts exposed to the weather — face, portions of the upper extremity already mentioned, and the tops of the feet and ankles, in those exposed, assimie a deep red hue with a tendency to become brown. That the sun and wind are only predisposing 79 causes, as in the case of freckles, is apparent from the fact that in rare instances the erythema has been seen on non-exposed regions. The process may be very superficial or deeper, and in the latter case results in more or less thickening. Peeling, pigmentation and atro- phy, these sequelae of the inflammatory process, are often seen side by side, forming a picture which could not be mistaken for any other affection. The skin, thinned and wrinkled, and deeply pigmented, sometimes shows diminished sensibility. The amount of cutaneous participation is no index of the general severity of the disease. In the more acute forms the patient may die before erythema develops. The course of the skin lesions follows the seasons, improving or dis- appearing in the fall, probably to reappear in the spring. The peeling is an integral part of the disease and not a mere sequel of the erythema. Even when the skin has become atrophic the epidermis comes away in large flakes. Several years are required for the com- bined cycle of changes in the skin. The patients are doomed to disability and very often to early death. There are, however, degrees of severity and in the mildest the patient may live for many years and sometimes recover. In a virgin community the disease is more severe and few survive. Etiology Of this absolutely nothing is known. It is probable that two fac- tors act in association. One is a living cause, and the other a vehicle which is probably articles of diet. The spoiled Indian meal so often accused cannot cause all the cases. We know now tliat the prosperous and well-fed may become affected. It is believed that solar rays are somehow responsible, in that they may liberate a poisonous principle in the tissues. As a pseudo-pellagra has been caused by various agencies — alcoholism, and perhaps ergotism — it has been held that pellagra is a mere syndrome. The actual lesions which cause death seem to be intracranial — pachymeningitis and cerebral sclerosis. Diagnosis Only in the early stage could any confusion arise. The disease while it may attack all ages is not a child's malady, but inclines to affect matured people exposed to the weather. No one should con- fuse pellagra with sunburn, for it appears in the spring and not at the beginning of summer. We sometimes find a crude simulation of pellagra in wretched cachectic and alcoholic subjects. Treatment On the first appearance of the disease when the type is mild, vigor- ous constitutional treatment with change of diet and surroundings 80 ought to benefit the patient. Arsenic and thyroid substance are two remedies which are believed to have some specific virtues. That a severe blood dyscrasia is present seems to follow from the favorable results of transfusion in severe cases. Local treatment is hardly mentioned by authors; but as considerable itching is present the management of acute eczema ought to be transferable to pellagra. Figs. 72 and 73. Model in the Dcrmatological Clinic of the University in Innsbruck (Henning). The reproduction of tiiis model, wiiich was first published in a Monograph by Prof. Merck, "Skin Manifestations m Pellagra," was kindly permitted by the author. 81 Variola Synonym: Smallpox Plate 48, Fig. 75 ; Plate 49, Fig. 76 Variola is an acute infectious disease of unknown causation: a protozoon has been described but has not been definitely proven to be the causative agent. Among those unprotected by vaccination, variola is the most viru- lent of all contagious diseases. The period of incubation, when the disease is inoculated, is eight to nine days ; when it is transmitted by contagion, it is ten to fourteen days, and occasionally longer. All persons exposed should be kept under observation for at least three weeks. Onset is sudden with severe chills, high fever, temperature 103° to 105° F., intense backache and pains in the legs, vomiting, frequently delirium and in children convulsions. Prodromal eruptions, when they occur, appear usually on the sec- ond day. They may be morbilliform or erythematous in character and may be hemorrhagic, and are most marked on the lower part of the abdomen, inner surface of the thighs, the axillae or lateral thoracic region; occasionally they occur on the extensor surfaces, especially of the knees and elbows. The erythematous type limited to the lower part of the abdomen and inner surface of the thighs is seen especially in pregnant women. The characteristic eruption appears on the fourth day, first on the forehead and face, and spreads rapidly over the whole body, in- volving the mucous membranes of the eyes, mouth, and throat; but it is always most marked on the face and hands. The eruption con- sists at first of hard, small, shotlike papules which rapidly increase in size and gradually, usually by the end of the second or third day, become vesicular. These vesicles are always umbilicated, and after another two or three days their contents become purulent. As the pustules develop, the temperature, which had gone dowoi with the 82 Plate 48. _o > c > bJO development of the papules, rises again. The pustules begin to dry up and crust in about ton days. At this time the temperature falls and there is a general improve- ment of all sjTiiptoms. The crusts usually come off and leave com- pletely healed lesions by the twenty-first day. In addition to the above or regular tj^De we have hemorrhagic smallpox, which occurs in two forms: first — purpura variolosa: in this form at the end of the second or on the third day an ervthematous rash appears, especially in the groins, with small punctiform hemor- rhages; the rash extends, rapidly becoming more and more hemor- rhagic, ecchymoses appearing in the conjunctiva — and hemorrhages from mucous membranes. This tj-pe is rapidly fatal — death occur- ring on the third to fifth day. Second form or variola hemorrhagica pustulosa: in this form hemorrhages occur when the rash reaches the vesicular or pustular stage. Bleeding from mucous membranes is common and the mortality is high — death occurring on the seventh to ninth day. Occasionally cases are seen where bleeding takes place into the lesions in the vesicular stage, followed by rapid abortion of the rash and speedy recovery. Varioloid, modified smallpox, seen in persons who have been suc- cessfully vaccinated, sets in abruptly like the regular type, but the sjTnptoms are usually milder, the number of the lesions are very much less and may be limited entirely to the face and hands; the temperature drops rapidly, the lesions soon dry up and there is no secondary fever. Diagnosis The prodromal rashes are to be differentiated, first, from measles by the severity of the constitutional sjTnptoms, the absence of Koplik's spots, the absence of lacrjination and coryza, and by the early appearance of the rash on the trunk instead of on the face and neck as in measles. Secondly, from scarlatina by the initial symptoms and the absence of the angina and scarlet tongue. The regular rash must be differentiated chiefiy from varicella. This is done by the severity of the onset, the duration of the prodro- mal SjTnptoms, the site where the rash first appears — in varicella the rash first appears on the trunk — and the indi\'idual characteristics of the lesions. The papules in variola are always hard and shotty and last about two days ; in varicella the papules are not indurated and be- come vesicular in a few hours. The vesicles of variola are always umbilicated and do not collapse when ruptured ; in varicella they may 83 be umbilicated, but they are superficial and do collapse when rup- tured. The most characteristic and important point, however, is that the lesions in variola are all in the same stage on the same site, while in varicella the lesions come out in crops, and we find papules, ves- icles, pustules and crusts intermingled in the same region. The lesions in variola are comparatively most numerous on the face and hands — in varicella they are comparatively most numerous on the back. From pustular syphilis it is diagnosed by the history of the onset, the history of the development of the rash — the absence of mucous patches and condylomata. A negative Wassennann would also be of great aid in the diagnosis. Prognosis In the hemorrhagic types it is very bad. In the regular type it varies directly with the severity of the disease, from bad in the con- fluent form to favorable in the discrete form. In varioloid it is very good. Prophylaxis Everyone should be vaccinated regularly every three or four years, and if exposed to the disease revaccination is imperative. To prevent the spread of the disease, all cases occurring in cities or thickly settled communities should be isolated in suitable hospitals. All persons exposed should be inspected daily for at least twenty- one days. All bedding and clothing that has come in contact with the patient should be thoroughly disinfected either by boiling or steam steriliza- tion. If this cannot be done, it should be burned. The premises from which a case has been removed should be fumigated with either sul- phur or formaldehyde, using four pounds of sulphur for every 1,000 cu. ft. of air space and eight hours' exposure or six ounces of formalin per 1,000 cu. ft. of air space and five hours' exposure. After fumiga- tion the premises should be washed with a 1 to 1000 solution of bichloride of mercury. All excreta should be sterilized with a 5% solution of phenol or a 1 to 1000 solution of bichloride of mercury. In case of death the body should be wrapped in a sheet saturated ■with a 1 to 1000 bichloride solution and interred in a metal lined coffin. Treatment Absolute rest in bed from the beginning until the secondary fever lias subsided. The diet during this period should be liquid. 84 For the intense headache and backache morphia by hypodermic injection gives the best result and should be given early. Dover's powder is occasionally satisfactory in relieving the insonmia. The temperature can be best controlled by hydrotherapy. The eyes must be kept scrupulously clean by repeated Avashings with boric acid solution. For the nose and throat a dilute Dohell's solution or a 2% boric acid solution is useful. Scrupulous cleanliness is absolutely necessary during the whole course of the disease and the patient should receive daily baths, tak- ing care not to rupture the vesicles or pustules on the face. The red light treatment has received considerable attention re- cently; to be of any value it must be carried out absolutely, making it necessary to have only red glass in all -windows and lighting fix- tures, and a vestibule with double doors so that not a single ray of white light can enter the room or ward. The red light is very trying on the eyes of both patients and attendants, and the results hardly justify the inconvenience it causes. The prevention of scarring is practically impossible, but carbol- ized ointments or lotions should be applied to the face to relieve the intense pruritus. During the stage of pustulation, stimulants are almost always necessary: the best are whiskey and strychnine; to an adult half an ounce of whiskey and strj'chnia sulphate gr. Ho can be given every four hours. The delirium is best treated by bromides and morphia. The crusts, which are usually ready to come off in twenty-one days, should be completely removed before the patient is discharged ; but care must be taken to see that no moist or raw spots exist and that all crusts have been removed from the palms and soles and from under the edges of toe and finger nails. Complications Purulent conjunctivitis is frequent and is to be avoided by fre- quent and careful cleansing of the eyes. "WTien it develops it is to be treated the same as conjunctivitis from any other cause — cold com- presses — ^boric acid washings sufficiently frequent to keep the eyes clean. Solution of argyrol (20%) every four hours or a 1% to 2% solution of silver nitrate painted over the conjunctiva once or twice a day. If a keratitis sliould develop the cold compresses should be changed to hot ones — the pupils must be kept dilated with a 1% solution of atropine sulphate. The cleansing with the boric acid solu- 85 tion is to be continued, and if corneal ulcers develop it may be neces- sary to cauterize them with tincture of iodine or the galvano cautery. Laryngitis is frequent and may cause necrosis of the cartilages and be followed by broncho-pneumonia, or may cause edema of the glottis, necessitating tracheotomy; intubation is not satisfactory in these cases. The throat complications are best avoided and treated by spraying or gargling with aUcaline solutions or with a hot normal salt solution. In beginning edema of the glottis an ice collar is frequently of service, at other times hot poultices seem to give better results. Otitis media sometimes occurs. As soon as the drum membrane is red and bulging it should be incised and the ear irrigated with hot boric acid solution sufficiently often to keep it clean. If tenderness develops over the mastoid it should be opened at once, the mastoid cells completely removed and the antrum drained. Albuminuria is frequent, but a true nephritis is rare ; if it occurs, however, the patient should be given plenty of pure water and placed on a milk diet; diuretics are seldom necessary. If suppression of urine develops, hot packs and high saline irrigations are indicated. In robust patients bleeding is often of considerable benefit. Multiple abscesses are frequently seen and are at times extremely troublesome. They should be opened as soon as fluctuation is de- tected, drained, and packed. The characteristic pitting that is often such a disfiguring sequelae to the disease, is always permanent. Treatment is most unsatisfac- tory. Fibrolysin and thiosinanim are useless and massage and electrical applications of but little, if any, benefit. Fig. 75. Model by Kolbow, of Berlin. Fig. 76. Model by M. Trammond, Paris {Jumelin). 86 Plate 49. Fig. 76. Variola. Fig. 77. Varicella in adult. Plate 50. Fig. 78. Varicella. Varicella Synonym : Chicken-pox Plate 48, Fig. 74; Plate 49, Fig. 77; Plate 50, Fig. 78 This is an acute contagious disease of unknown causation, having a period of incubation from ten to fifteen days. Although generally regarded as an affection of childhood, its occurrence in adults is not as rare as is commonly supposed. The prodromal symptoms are of short duration, lasting as a rule but a few hours. They consist of slight fever, chilliness, nausea, with occasional vomiting, pain in the back and legs, and very rarely convulsions. The eruption generally appears first on the back or chest, although frequently first seen upon the face. It consists of small superficial papules which rapidly become vesicles, and at the end of about thirty- six hours after the first appearance of the rash the contents of these vesicles have become purulent. The vesicles are often ovoid in shape, very superficial, and the skin around them is neither infiltrated nor hyperemic. Occasionally some of the vesicles are found to be um- bilicated. During the third and fourth day the lesions dry up and are covered wdth a browmish crust which soon falls off, and as a rule leaves no scar. Fresh crops of papules continue to develop during the first three days, giving the characteristic picture of intermingled papules, vesicles, pustules and crusts. The lesions are most numerous on the trunk, but the extremities, face, and scalp are also affected. They are seldom seen on the palms and soles, although they occur here in severe cases. The lips and mucous membranes are sometimes involved as illustrated in Fig. 74. Occasionally the vesicles become very large and develop into bul- lae (varicella bullosa) and in certain severe cases cutaneous ecchy- moses and bleeding from the mucous membranes occur (varicella hemorrhagica). In delicate and especially in tubercular children the lesions may become gangrenous and large areas of skin may be destroyed. The 87 gangrenous spots are usually circular in shape, and as a rule they vary from a quarter to three-quarters of an inch in diameter. They have clear cut vertical edges and appear as though a piece of skin had been removed by a small cutaneous punch. The disease may recur, as many as three attacks having been reported in the same individual. Diagnosis This, in typical cases, occurring in children, presents but few diffi- culties, but in severe cases in adults it is likely to be mistaken for variola or varioloid. The principal differential points are the short- ness and comparative mildness of the prodromal symptoms, the rela- tively larger number of lesions on the trunk, especially on the back, the absence of infiltration In the lesions, their sui^erficial character, the rapid development of the lesions from papules to pustules, their development in crops, and lastly, the intermingling of papules, ves- icles, pustules, and crusts on the same area. Prognosis This is always favorable even in severe cases in adults. Treatment Entirely symptomatic. If there is much elevation of temperature, the patient should be put on liquid diet and kept in bed for a few days. A single good dose of castor oil or repeated small doses of calo- mel with sodium bicarbonate may be given. If there are many vesi- cles on the face, efforts should be employed to prevent subsequent pitting. External applications of alcohol may be used for its drying effect on the papules and protective dressings similar to those recommended in variola may be used to prevent the scratching and the secondary infection which is invariably the cause of the pits. Fig. 74. Model in the Cliildren's Clinic of Gehcimrat Heubner in Berlin {Kolbow). Fig. 77. Model in Neisser's Clinic in Breslau (Kroener). The patient, forty-three years of age, was taken ill five days previously, with high temperature and severe general symptoms. The case was established as genuine by the fact of the attending physician being attacked by typical chickenpox. Fig. 78. Model in Lesser's Clinic in Berlin (Kolbow). 88 Plate 51. .5 'B 'o u > O 00 Vaccinia Plate 51, Figs. 79 and 80 This is the term applied to the exanthem produced by the inocula- tion of bovine virus. On the second, third or fourth day after vac- cination there appears at the site of inoculation a slightly elevated papule, surrounded by a reddish zone. This papule becomes vesicular on the fifth or sixth day, and reaches its maximum size on the eighth day when it is a large, tense, umbilicated vesicle one fourth to one half of an inch in diameter with a hard and prominent margin, filled with a limpid fluid and surrounded by a wide inflammatory areola. Its development is accompanied by general malaise, fever, tempera- ture, 101° to 104° F., which usually lasts four or five days, and swell- ing and soreness of adjacent lymphatic glands. After the tenth day the vesicle begins to desiccate and by the fourteenth day is covered by a thick, firm crust, which falls off after a period of from one to three weeks, leaving a sharply defined pitted or honeycombed scar. Constitutional sjTnptoms are less severe in children under one month than in those of five or six months ; and infants should be vaccinated as soon as nutrition is established, usually in the first three months. As a rule it should be avoided during dentition. Generalized vaccinia may be either local or constitutional. The former is due to repeated inoculations, the vaccination repeating it- self at each point of inoculation. It is seen especially on the face and genitals ; and sometimes there is an outbreak of lesions over the whole body, accompanied by severe constitutional s>inptoms. This type is usually seen in the second or third week. In constitutional general- ized vaccinia, vesicles are frequently seen in the neighborhood of the primary sore, but the true generalized vaccinia of systemic origin, with lesions developing on different parts of the body, is rare. The lesions are most numerous on the vaccinated limb ; they may be few or many. Each lesion pursues the course of the typical primary vac- cination. The vesicles usually develop from the eighth to the tenth day, and they may continue to develop in crops for five or six weeks 89 after vaccination. Generalized vaccinia has occurred in children fol- lowing the ingestion of powdered crusts from a vaccination lesion. Diagnosis The history of a recent vaccination should render the diagnosis easy even in complicated cases. Prognosis Constitutional symptoms associated with generalized vaccinia in children may be very severe, and deaths have been reported, but ordi- narily the prognosis is favorable. Prophylaxis Delicate children and infants in poor health should not be vac- cinated until their general condition has been improved and children suffering from itchy skin diseases as eczema, urticaria or scabies should not be vaccinated until the eruption is quite cured. Vaccina- tion pustules should be covered by a dressing or shield so that the child is unable to scratch or pick it. Treatment There are seldom any indications for internal medication. The affected areas should be covered with wet compresses. Solutions of boric acid or acetate of aluminum are the ones most generally rec- ommended. As the condition improves a weak ichthyol ointment may be substituted for the wet dressings. Fig. 79. Model in the K. K. Vaccine Institute in Vienna (Henning). Fig. 80. Model in Finger's Clinic in Vienna {Henning). 90 Plate 52. J3 O 00 00 Morbilli Synonyms: Measles, Rubeola Plate 52, Figs. 81 and 82 Tliis is an acute contagious eruptive fever of unknowTi causation. The period of incubation is from ten to fourteen days, but may be as long as eighteen or twenty days. The disease begins with catarrhal symptoms — sneezing, coughing, injection of the conjunctiva, lacryma- tion and rise of temperature to about 103° F. On the second day usually there appear on the buccal mucous mem- brane and inside of the lips small irregular spots of a bright red color. In the centre of each spot is a minute bluish white speck. They lose their characteristic appearance, however, as the eruption on the skin develops. These are the Koplik spots and are of considerable diagnostic value. As a rule on the fourth day the eruption appears — first on fore- head and cheeks in the form of small red maculo-papules which increase in size and spread — the whole body being covered in twenty- four to forty-eight hours. The rash when fully developed consists of roundish, slightly elevated maculo-papules which vary in size from a pinhead to a finger nail, varying in color from a dark red to a purplish hue. They are frequently confluent on both the face and body, and have often been erroneously diagnosed as a mixed infection of scarlatina and morbilli. Hemorrhages into tlie lesions, especially on the lower part of the abdomen and thighs, are seen fairly fre- quently but do not add as much to the gravity of the disease as when seen in variola or scarlatina. Wliere the rash is confluent there is considerable swelling of the skin. The eruption begins to fade after two or three days, leaving brown pigmentation at the site of the lesions, especially on the trunk and limbs. The temperature, which reaches its greatest height with the full development of the rash, falls rapidly with the fading of the rash, to- gether with a subsidence of the catarrhal symptoms. 91 The amount of desquamation varies with the intensity of the rash and may not be seen at all in mild cases. It usually occurs in fine branny scales and is completed in from fourteen to twenty-one days after the appearance of the eruption. Prognosis This is favorable unless some serious complication develops. Prophylaxis AU cases should be properly isolated until desquamation is finished, and children in a family where a case exists should be excluded from school until the case has terminated. Bedding, carpets, etc., should be disinfected and the premises fumigated in a manner similar to that described under variola. Diagnosis In a well developed case this is very easy. It is diagnosed from rubella by the severity of the onset, its longer duration, the presence of Koplik's spots, coryza and conjunctivitis. The lesions of morbilli are larger and deeper in color than tliose of rubella, and the consti- tutional symptoms are always more severe. From scarlatina it is diagnosed by the character of the onset, its longer duration, the presence of Koplik's spots, the absence of severe angina and particularly by the character of the eruption, that of scarlatina being a punctate erythema. Treatment Kest in bed in a well ventilated room and liquid diet should be insisted upon as long as the temperature is elevated and the rash is present. The room should be darkened to protect the eyes. Baths are generally agreeable and should be given during the stage of eruption. The temperature is self -limited and usually requires no treatment beyond the baths. The eyes should be kept clean with a boric acid solution. If the cough is very troublesome a few small doses of heroin or codein may be given. Severe cases with cyanosis, high fever and cold extremities should have stimulants — whiskey and strychnia. An ice cap applied to the head is very agreeable, and hot mustard baths are often valuable in relieving pulmonary congestion. 92 Edema of the glottis occurs fairly often and may necessitate in- tubation or tracheotomj'. Membranous pharyngitis or laryngitis should be treated like other cases of pseudo-diphtheria. If the diphtheria bacillus is pres- ent, diphtheria antitoxin should be used the same as in a simple case of diphtheria. After recovery tonics as iron, quinia and strychnia are indicated and to delicate children cod-liver oil should be given during the fol- lowing cold season. The most serious sequela is tuberculosis either of the lungs or cervical glands and this unfortunately is seen quite frequently. A number of cases of lupus vulgaris have been reported as developing shortly after an attack of morbilli. Fig. 81. Model in Schlossmann's Home for Infants, Dresden (Kolbou) Fig. 82. Model in Neisser's Clinic in Breslau (Kroener). 93 Rubella Synonyms: German measles, Rotheln Plate 53, Fig. 83 Eubella is an acute contagious eruptive fever with an incubation period of from ten to twenty-one days. The period of invasion is very short, usually lasting only a few hours ; and in ntiany cases no prodro- mal symptoms at all occur. When they are present they consist of malaise, slight fever, and very mild catarrhal symptoms ; but there may, very rarely, be vomiting, convulsions, delirium, epistaxis, rigors and headache. The eruption appears first on the face and, spreading rapidly, covers the whole body in less than a day. Occasionally it comes out first on the back, or the whole body may be covered almost at once. In many cases the whole body is not covered, but the rash is seen most constantly on the face. The character of the eruption is quite variable. It is most fre- quently composed of small pinkish maculo-papules from a pinhead to a pea in size, frequently confluent on the face, forming large irregular blotches. On the trunk it is usually discrete, but there may be a uniform red blush, still the characteristic maculo-papules can be found on the forehead, wrists or fingers. The degree of elevation of the lesions is variable from being almost imperceptible to being so marked as to give the skin a distinctly shotty feel. The color also may vary from pink to a dark red and very rarely the rash may be hemorrhagic. Minute bright red points may be seen on the uvula and soft palate during the first twenty-four hours. The temperature is highest with the full development of the rash, and is 101° F. or less, but in the very rare severe cases it may be 103° F. The rash is generally of two or three days' duration and is usually accompanied by moderate itching. The post cervical glands are always enlarged. They subside slowly without suppuration. 94 Plate 5: Fig. 83. Rubeola. Desquamation may be entirely wanting but usually occurs in the form of fine scales. Diagnosis Rubella is diagnosed from morbilli by its longer period of incuba- tion — shorter period of invasion — absence of Koplik's spots and its milder catarrhal and constitutional sjTnptoms. From scarlatina, by the absence of severe prodromal symptoms — the absence of angina — the presence of the typical maculo-papules on the forehead, wrists or fingers — and its longer period of incubation. In all cases, unless the disease is epidemic, it is not safe to make the diagnosis of rubella until the case has been under observation for some time. Treatment This is entirely symptomatic. A dose of calomel or castor oU at the beginning of the attack is practically all the medication re- quired. The patient should be isolated for about a week. Fig. 83. Model in Neisser's Clinic in Breslau {Kroener). 95 Scarlatina Synonym: Scarlet fever Plate 54, Fig. 84; Plate 55, Fig. 85 Scarlatina is an acute contagious disease of unknown causation. It has been claimed that a streptococcus is the causative agent, but while this is associated with the complications, it is probably but a secondary or accompanying infection. The disease most frequently attacks children between two and ten years of age. Adults are less susceptible than children. Scarlatina is not as contagious as measles. Frequently only one child in a family where there are several children will contract the disease, while with measles practically all children exposed, unless protected by a previous attack, contract the disease. The period of incubation is usually from two to six days, but it may be as short as six hours or as long as two weeks; over seven days, however, is extremely rare. The onset is sudden, with a rise of temperature from 101° to 105° F., vomiting, sore throat and frequently in children, convulsions and delirium, the intensity of the symptoms varying with the severity of the attack. The vomiting is frequently persistent and without nausea. The throat symptoms may be so mild that they are only detected by examination, but in most cases there is a uniform redness of the whole pharynx, and small red points are seen on the hard palate and the patient complains of soreness and pain on swallowing. The tip and edges of the tongue are red and the centre is covered with a thick fur, through which the enlarged papillae project, giving it the so-called strawberry appear- ance. In severe cases the tonsils and fauces are markedly swollen and may be covered by a pseudo-membrane, which may extend from the posterior wall into the mouth or up into the nostrils and occasionally may involve the larynx, trachea and bronchi. The cervical glands are frequently enlarged and tender. The eruption usually appears on the second day, but it may develop within twelve hours, or it may be delayed until the fourth or fifth day. It appears first on the neck and chest and spreads rapidly, 96 Plate 54 Fig. 84. Scarlatina. involving the entire skin, in from fonr to twenty-four hours. It has a vivid scarlet hue and is conii)()sed of innumerable minute red points upon an erytliematous ground. Although seen upon the face there is a peculiar pallor around the mouth. Occasionally all of the skin is not involved, the rash occurring in patches, or the rash may not develop on the face, or it may be present only on certain parts, usually the groins, axilla;, flexures of the elbows, or upon the buttocks and posterior surface of the thighs. In some cases it is so slight and evanescent that it entirely escapes observation, or it may be entirely absent both in mild cases and in those with severe angina, and even in malignant cases it may never develop. Miliary vesicles are frequently seen, especially upon the chest and abdomen. Petechias are occasionally seen and in malignant cases they become very exten- sive. At the height of the eruption, the skin of the face and hands may be considerably swollen. Pruritus is variable, and at times may be quite marked. The rash may last from a few hours to about six days. The temperature is highest with the full development of the rash and in fatal cases may rise to 108° or even 109° F. The pulse varies from 120 to 150 or higher. In favorable cases it continues high for two to five days and falls by lysis. The vomiting usually stops with the development of the rash. The urine shows febrile characters and albuminuria is frequent. The tongue desquamates in a few days and is clean by the time the rash begins to fade. The desquamation of the skin is characteristic. It begins after the rash has faded, usually on the eighth to twelfth day, but may be delayed until the twenty-first day. It begins on the neck and chest and is flaky in character. On the hands and feet, where the epidermis is thickest, it is finislied last, and here the flakes are quite large, frequently the epidermis being shed almost entirely in a glovelike cast. It is usually completed at the end of thirty-five days, but may continue for seven or eight weeks. Diagnosis Typical cases present no difficulty; but in the mild and atypical ones the diagnosis is extremely difficult and at times impossible until the characteristic desquamation appears. The principal diagnostic symptoms are the vomiting associated with sore throat, and a punc- tate rash on the hard palate. The pulse-temperature ratio in mild cases is also a valuable aid. The pulse is practically always increased out of proportion to the temperature. The groins, axilla and anterior surfaces of clhows should be carefully examined for a punctate rash. 97 From morbilli, scarlatina is differentiated by its shorter prodro- mal period, the absence of coryza and conjunctivitis and especially by the absence of Koplik's spots. From rubella it is distinguished by the comparatively mild symp- toms of rubella, even with a widely distributed and well marked rash ; such a rash in scarlatina invariably causing a temperature of 102° to 103° F. The scarlatina type of rashes produced by belladonna, quinia and occasionally antipyrine are not associated with intense constitutional symptoms — the temperature is not much elevated if at all — and the scarlet angina is lacking. In erythema scarlatiniforme the fauces, though red, are not swol- len, the strawberry tongue is absent and the rash is frequently localized. Desquamation begins about the third or fourth day and is usually quite profuse while the rash is still present. Prognosis The "mortality of scarlatina varies in different epidemics; it is highest in children under five years of age. The general average of all ages is about twelve to fourteen per cent. In individual cases, even in the mild ones, a guarded prognosis must be given on account of the serious complications which may develop during the course of the disease. Treatment All cases, even the mildest, must be kept in bed for at least three weeks, and during this period the diet should consist entirely of milk. The temperature usually needs no special care, but if hyperpyrexia exists, hydrotherapy gives the best results. For the relief of the rest- lessness, an ice bag to the head and an occasional dose of phenacetin are usually satisfactory. The sore throat is frequently very annoying. Irrigations with hot normal salt solution or spraying with equal parts of hydrogen per- oxide and lime water affords considerable relief. An ice collar around the neck is often very agreeable to the patient. Careful watch must be kept upon the ears, as frequently an otitis or even mastoiditis may develop without being accompanied by pain. The drum membrane should be incised as soon as it is found to be congested and bulging. When the symptoms of mastoid involvement develop an early operation is advisable. The heart also must be watched carefully and as soon as the pulse 98 is rapid or irregular or the first sound of the heart is altered, stimu- lants should be used, such as digitalis, strophanthus, strychnia and whiskey. Whiskey is especially indicated in septic cases Avith severe angina and adenitis. The patient should be kept in bed until the pulse rate is practically normal. The urine should be examined frequently during the first three weeks. To prevent the development of nephritis the diet should be milk for at least three weeks; the patient should be encouraged to drink plenty of water — weak lemon or orangeades are very agree- able and can be allowed. The bowels should be kept open -wdth salines and an occasional dose of calomel or gray powder. If nephritis develops it should be treated as a nephritis from any other cause. As soon as desquamation begins, the patient should be given daily baths to assist the process. If oils are used they should not be carbolized, owing to the danger of absorption. Adenitis should be treated by ice bags or strong iehthyol oint- ments. As soon as pus is detected, it should be evacuated. For the arthritis immobilization of the affected joints, with aspirin or salicin internally. If pus forms, the joints must be freely opened. The treatment of this complication with a mixed streptococcus vac- cine has not been very satisfactory, but recently good results have been reported from the emploATnent of a serum prepared from dif- ferent strains of streptococci. The secondary anemia calls for tonics, especially iron and digi- talis. Basham's Mixture is a pleasant and efficient form of iron. Fig. 84. Model in Neisser's Clinic in Breslau (Kroener). Fig. 85. Model in Schlossmann's Home for Infants, Dresden {Kolbow). 99 Erysipelas Synonym: St. Anthony's Fire Plate 55, Fig. 86 Erysipelas is an acute inflammatory disease of the skin and sub-cutaneous tissues caused by the streptococcus (erysipelatous) pyogenes. After prodromal symptoms of from four to forty-eight hours' duration, consisting of malaise, chills, moderate fever and occasionally anorexia and vomiting, there appear at the site of infection one or more erythematous spots. These spots rapidly increase in size, forming a large, tense, red, shining patch, the tem- perature of which is higher than that of the normal skin. Its outline is usually irregular, but it is very sharply defined and its border is raised. Its size may be limited to a patch only a few inches in diam- eter, or it may involve large areas of the skin. As the process devel- ops the color becomes a dark, angry red, the swelling increases and vesicles and buUge, filled with a clear yellow serum, may develop. The amount of swelling depends on the intensity of the inflammatory process and on the structure of the subcutaneous tissues ; where there is much loose areolar tissue, it is often very considerable. Subjective symptoms are moderate pruritus, burning, tenderness and more or less pain. The rash reaches its height in about a week, remains stationary for a day or so and gradually subsides, together with a gradual improvement in the constitutional symptoms, which have consisted of those of an acute febrile disturbance from tox- aemia — temperature 103° to 105° F., headache, pain in the limbs, loss of appetite, coated tongue and nausea and vomiting, etc. The whole process may be very mild — the skin showing only an erythematous area with very little swelling and no vesicles or bullfp, accompanied by mild constitutional symptoms. Occasionally in severe cases the vesicles and bullae may be hemorrhagic. In some people who are peculiarly susceptible, erysipelas may recur fre- quently for a long period of time and by obstruction of the lymphatics 100 a. 3-. o U) TO CI C/5 in 00 ti) lead to elophantiasis. The hair is usually lost after erysipelas of the head and the alopecia resembles that of syphilis. Complications Secondary infection by staphylococci may cause extensive sup- purative cellulitis. Superficial abscesses occur frequently during convalescence. The most serious complications arise from the spreading of the disease to the mucous membrane of nose, mouth, pharjnix, larynx, rectum or vagina. Prognosis This should always be guarded. In extensive cases in the very young or in those debilitated by alcoholic excesses and exposure, the outlook is not favorable. A sudden rise of the temperature, after it has once subsided, means either another outbreak, or the develop- ment of a serious complication. Diagnosis An erythematous eczema is not accompanied by so much swelling, and never has the characteristic shining appearance of erysipelas. The line of demarcation between the affected and unaffected portions of the skin is usually ill defined in eczema. AVhen occurring upon the face, the scalp is usually spared, while an erysipelas tends to involve the scalp. Erysipeloid of Rosenhach, which as a rule occurs only on the fingers and hands, is characterized by much milder local reaction and the almost entire absence of constitutional symptoms. From the so-called pseudo-erysipelas that is secondary to intra- nasal inflammation erysipelas is distinguished by the severity of its constitutional symptoms, its tendency to spread widely beyond the nose and its adjacent tissues and the absence of history of a long continued nasal trouble. Angioneurotic edema does not present the glazed shiny surface of erysipelas and is not accompanied by symptoms of toxemia. It occurs in successive and recurrent attacks and is often accompanied by rheumatoid pains. Treatment Best in bed during the whole course of the disease. Isolation as in scarlatina or measles. The diet should be liquid and supporting. 101 Stimulants are frequently necessary. It has long been the custom to prescribe large and frequently repeated doses of the tincture of iron, but it is doubtful if this treatment is of much value. Quinia and antipyrine are sometimes of service in lowering the general tempera- ture. The treatment by antistreptococcus serums has not been very satisfactory in practice although theoretically it seemed quite prom- ising. The affected areas should be covered Avith wet dressings of alcohol, aluminum acetate, lead and opium wash, or ichthyol in a twenty to fifty per cent, aqueous solution. A favorite application formerly much used at the New York City Hospital was the saturated solution of magnesium sulphate. Sdbouraud} recommends colloidal silver as a local application. ' Sabouraud: Regional Dermatology. Rebman Company, 141-145 West Thirty-sixth Street, New York. New Edition, $3.00. Fig. 86. Model in Riehl's Clinic in Vienna (^Herming). 102 Plate 56. o 3 II CO 00 CO ca o X UJ 00 ti Exfoliatio Areata Linguae Synonyms: Pityriasis linguae, Transitory bonign plaques of the tongue. Geographical tongue. Plate 56, Fig. 87 This affection is a peculiar arrangement of the normal coating of the tongue which has received various designations and has been explained in many ways. It has been looked upon in some quarters as a glossitis, even of an ulcerated kind ; in others as a simple desquama- tion or exfoliation. It has been regarded as a manifestation of syph- ilis. Since it has been seen in nurslings, several causal factors are thereby eliminated, as for example dependence on dentition. The pediatrist Czerny has perhaps thrown some light upon the condition by making it an expression of the exudative diathesis. This makes it hereditary, at least in its predisposition. It may also be looked upon as a permanent peculiarity dependent for its manifesta- tions on accidents — dietetic peculiarities. It often improves under a strict, bland diet. The geographical tongue, in other words, is made much worse by the same dietetic factors which cause acute indigestion and diarrhea. But aside from the exudative diathesis and improper or excessive eating, numerous other factors may be isolated, as neuropathy, climate, mechanical irritation. The appearance of a geographical tongue is quite characteristic. The tongue is the seat of plaques of a lively red color, varying much in size and shape. They are chiefly rounded, however, and very slightly prominent. The papillae in these areas appear enlarged. At the border of the plaques is a narrow, gray, stippled areola. In some instances the border has a distinct double contour. The stippling is simply the filiform papillae, rendered conspicuous because broadened and surmounted by thickened epidermis. These papillae are also uni- formly enlarged in other parts of the tongue, which present thereby a grain leather appearance. Although the condition is spoken of as a permanent one, individual plaques show great volatility. Even be- 108 fore the end of tliirty-six hours they may have run through their cycle and vanished, as new plaques appear. The process has therefore been likened to the alteration of patterns in a kaleidoscope. Diagnosis The affection has no doubt been confounded with Mdller's glos- sitis and mucous patches of syphilis. The greatest confusion would be likely to arise if some other affection acted as an exciting cause to geographical tongue — syphilis, for example. Treatment There is no treatment to be actually directed against this condi- tion per se. The individual may be treated to restore him to physio- logic equilibrium, and the various local applications used in mild stomatitis seem to be indicated on general principles. Fig. 87. Model in St. Louis Hospital in Paris, No. 2235 (Baretta). Meureman and Ramond's case. 104 Leukoplakia Plate 56, Fig. 88 Clmieally, leukoplakia is represented by smooth, milk-wliite spots which at first are of a pale rose tint and not well differentiated from the outlying mucosa. They become pure white, and sometimes even- tually bluish or pearly. Eventually they become shariily differen- tiated at the borders, the more so because often surrounded by a bright-red areola. The thickened epidermis, becoming harder with time, is eventually detached, and when they come away leave a shal- low or deep fissure. That an ulcer does not develop is due to the peculiar narrow shape of the original lesion. The white color may become dark — yellowish or brownish — from minute hemorrhages. Some of the lesions have almost a cartilaginous hardness and thick- ness. The mucous membrane beneath these thickenings is rich in blood-vessels, which are permeated with leucocytes. The papilla are elongated and increased in number. In a tjT)ical case we encounter a number of lesions on the anterior portion of the dorsum of the tongue ; and if the case is chronic we may see side by side spots in all stages of development with fissures left by former spots. The tip and borders are involved in the affected area. The most favorite locality is the inner aspect of the cheeks. where a triangular area is implicated. Fissures seem to be almost peculiar to the tongue. An extraordinary feature, when we bear in mind the amount of discomfort caused by various kinds of sore mouth, is the relative absence of subjective symptoms in a large percentage of cases. It often happens that the presence of leukoplakia is discovered by mere accident. The subjective sensations may consist of nothing beyond a numb or foreign body sensation — the latter due in part to the thick- ened areas in the act of separation. Etiology The affection is extremely chronic and confined almost entirely to males, who are seldom attacked before the age of forty. It ap- 105 pears to result from the cooperation of a number of causes. The most common association is antecedent syphilis and tobacco-smoking, but these only furnish a predisposition. Diagnosis There is a notable resemblance to the mucous patches of syphilis, which are first white and then succeeded by raw surfaces. As a rule, leukoplakia spots are much more numerous and prominent. Mucous patches are usually seen at the sides, tip and under surface of the tongue. They come and go within a short interval, while leukoplakia is extremely chronic, lasting for years, and having little tendency to recovery. The fissures which result might be confused with later syphilitic disease. The crucial test is the result of treatment, which is principally negative in leukoplakia. Prognosis This is not particularly good for recovery and the affection must be looked upon as a serious one when we consider that it is a not un- common forerunner of cancer. Treatment All sources of irritation must be removed. Sharp teeth which rub against lesions should be filed do\\Ti and all carious teeth either filled or extracted. Tobacco and all pungent food articles and the taking of hot foods and drinks must be proscribed. For inveterate smokers a very moderate indulgence may be permitted. Mouth washes must be used freely and may be alternated. Hydrogen peroxide seems to be the best suited, an(^ any mild astringent solution may be employed. For actual treatment to produce permanent results various mild caus- tics are used, the strength to be gradually increased. The very number of these in use goes to show the lack of a dependable remedy — silver nitrate, chromic acid, lactic acid, salicylic acid, etc., etc. Occasionally cases are benefited by injections of salvarsan. Some surgeons recommend the removal of the entire epithelial coating with curette or cautery, but it is not certain that the results warrant such measures. Fig. 88. Model in St. Louis Hospital in Paris, No. 1573 (Baretta). Fournier's case. 106 -L'TV D 000 827 553 9