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SAN DI6QO
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822 00502 6844
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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 Ritter's disease (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 vesicular or bullous ; and in
some of the worst cases in adults the lesions may consist of e^r^^jepaa-
tous patches and papules or vesicopapules. As a rule consecutive at-
tacks present flie same lesions as the first outbreak, so that some
would divide the disease up into several distinct types. Itching is said
to 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 generalized, 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
<L>
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
<u
N
O
LU
O
Eczema
Plates 24 to 29, Figs. 36 to 46
The conception of eczema has constantly undergone changes, some
of them radical, since the terra was lirst introduced by the Greeks.
The "boiling over," which the word signifies, does not refer to the
discharge of moist eczema, but to hot, burning pustules appearing
over the entire surface — in other words, furunculosis. Eczema meant
nothing else until the time of Willan, who applied the term to cer-
tain forms of dermatitis due to known irritants, characterized by
minute vesicles or vesicopustules, closely aggregated and diffused
over the irritated area. Thus far there was no suggestion of any-
thing but an acute affection. Biett, and especially Bayer, isolated
vesicular eczema from the artificial eruptions, and incidentally estab-
lished the fact that the former could represent a chronic condition ;
that it was not rare but extremely common, and that itching was
characteristic — an itching vesicular eruption, running chiefly a
chronic course. Bayer also regarded the affection of the face and
scalp, previously known as milk crust, as an acute phase of eczema.
After an interval of great confusion, Devergie made another advance
by retiring the vesicle as a characteristic lesion. The most essential
phenomena for him were redness, a discharge which stains and
stiffens linen, and violent itching. Hehra was the first to insist that
eczema may never reach the weeping stage, and may exhibit only
diffuse redness and desquamation or dry papulation. He isolated
five clinical types — squamous, papular, vesicular, the red weeping
type (eczema rubrum or madidans), and impetigenous eczema. This
conception of eczema has not been radically changed since, but it be-
came apparent in time that there were primary forms — erythematous,
papular, vesicular, and pustular — and secondary forms — eczema
rubrum and eczema squamosum. The condition known as eczema
seborrhoicum, added by Unna to the basic forms of the disease, is
considered elsewhere.
Eczema is a superficial inflammation of the skin, and the claim is
made that all its manifestations may bo produced experimentally, by
49
local irritation; while it may exceptionally pursue an acute course,
or occur in mild and abortive forms, it is essentially a chronic affec-
tion; while it may remain localized in the area originally involved,
its natural tendency is to spread ; the one most characteristic feature
is violent itching, with more or less .burning ; it is non-contagious ; it
never induces scarring ; it exhibits primary and secondary phases, or,
as some would call them, initial and mature phases. It occurs in any
area of the integument, and its manifestations vary greatly with the
locality involved and the degree and extent of the process. Different
lesions may occur in the same subject, and everything makes_for
polymorphism.
Once looked upon as a rare affection, eczema is now by far the
most frequent of all dermatoses. Wliether the present conception of
it will stand is uncertain. The term "the eczemas," representing a
great group disease, would in some ways be preferable to "eczema."
It could then include dermatitis and possibly other affections.
Etiology
Eczema is produced preeminently by a coincidence of predispos-
ing and exciting factors. If it could be explained by the action of the
latter "wdthout the element of predisposition, we should then rank it
as a dermatitis or perhaps a parasitic disease. If there is no evi-
dence of any external irritant we may assume the existence of some
ultramicroscopic germ, or that some acute metabolic or other auto-
toxic disorder acts as an exciting cause. Both exciting and predis-
posing factors may escape us; but in very many cases the etiology
is evident enough. These form a connecting link between eczema and
dermatitis. Here we see a single exciting cause able to set up, in
the absence of any marked predisposition, a condition which behaves
clinically as an eczema. With the removal of the exciting cause,
there shoiild be a tendency to recover permanently, although the con-
dition would perhaps require further treatment. When the evidence
of a predisposition is apparent, despite the presence of an original
exciting cause, as shown by a tendency to spread or to relapse spon-
taneously, we are forced to assume the existence of a diathesis. In
earlier times it was customary, at least in France, to accuse various
diatheses, and it is interesting to note that the idea of diathesis in
this connection has recently been revived in Germany, where it was
originally reviled. If we assume with Unna and others that a bacte-
rial factor must invariably bo present, then the term diathesis would
simply mean the sum of all the conditions which tend to make the skin
a good culture medium. It is the relative preponderance of predis-
50
posing overexciting causes, or the converse, which makes nearly every
case of eczema a law to itself, and which tends to the formation of a
great number of clinical types, which may differ as much among
themselves as if they were quite distinct diseases.
In England, where gout is prevalent, * 'gouty" eczema appears to
be common and easily recognized. To call an eczema gouty, how-
ever, does not mean, as Unna implies, that it must be set up by the
irritation of uric acid crystals. A predisposition and an excitation
may both come about from defective metabolism. This is seen dis-
tinctly in the genital eczema of diabetics, in which the irritating urine
promptly sets up vulval eczema, which is invited by the abnormal
metabolism of the patient.
All the kno^\^l metabolic affections favor the development of
eczema; and while these may occur at any age, they are practically
inevitable in advanced years, and are very largely sufficient in them-
selves to explain eczema at that period of life, which may, of course,
come about prematurely.
Equally striking is the relationship between the diet and diges-
tive organs and the peculiar types of eczema in the nursling, which
affect chiefly the face and scalp with a moist, crusting process. It
has long been noted that babies with this type of eczema, although
they may feed heartily, do not vomit or regurgitate. Countless cases
of eczema in infants can be traced to the custom of drinking beer
freely by their nursing mothers, and they generally recover as soon
as the mother's diet is supervised. So slight a correction of the diet
of a bottle-fed baby as lengthening the interval between feedings has
frequently been followed by very decided improvement even in severe
cases.
In certain local types of eczema, the dependence on a single clean-
cut cause, whether we term this predisposing or exciting, is marked
— so much so that we hesitate about calling it eczema. Here belong
the various eczemas of the legs and scrotum, the orificial eczemas due
to irritating secretions, especially those of the upper lip, nipples, and
genitals, the intertriginous eczemas, etc. Like the professional ecze-
mas so-callod, all these appear to form a link between dermatitis and
the purest forms of eczema.
Another point of contact between eczema and dermatitis of me-
chanical cause is very often conspicuous. In certain types of eczema
tlie itching is by far the most prominent sjTiiptom. The actual lesions
are barely evident as minute papules or even a mere redness, repre-
senting abortive forms. As a result of the itching, the great major-
61
ity of the lesions are artefacts, produced by scratching, rubbing, etc.
The extensive hypertrophic thickening of the skin in some cases of
clironic eczema may be due very largely to habitual irritation. So
notable is the tendency to scratch in eczema that it is often difficult
to get an idea of the actual lesions of the disease. Many are of the
opinion that if scratching could be prevented at the outset eczema
would be a disease of trifling lesions only.
Many cases of eczema occur under such circumstances of loca-
tion and form, that, in the total absence of predisposing or exciting
factors, we can think only of a parasitic origin. Here belongs espe-
cially the nummular eczema on the backs of the hands, fingers, fore-
arms, etc. The parasitic origin is even more plausible in so-called
seborrheic eczema, which is seen especially on the scalp, face, ster-
num, intrascapular region, etc., and which exceptionally occurs any-
where on the surface. The appearance and mode of spreading of all
these lesions suggests a parasitic cause.
An eczema varies considerably in its lesions according to locality.
On hairy regions it is much more inclined to form pus than on smooth
ones, because infection with pyogenic germs comes about with greater
certainty. In folds eczema has a greater tendency to become moist
than elsewhere, although the worst tj'pes of weeping eczema occur
quite independently of location. Eczema of the palms and soles is
naturally attended by much more thickening of the epidermal layers
than in other localities. "When eczema occurs in the rosacea area
of the face it is often difficult to distinguish it from the latter affec-
tion.
Acute erythematous eczema of the face may cause an unusual
amount of swelling, the eyelids becoming so edematous that they can-
not be opened.
Diagnosis
Enough has already been said of the characteristic features of
eczema, and it only remains to give the differential diagnosis. To
discriminate between acute eczema of the face and erysipelas is a
matter of vital importance, for it no doubt happens at times that
patients with the former are isolated and treated as very sick individ-
uals. The patient mth eczema is never affected constitutionally,
although very young children may present some malaise and tem-
perature. He has no toxemia, no fever or prostration. His face may
resemble greatly the erysipelas mask, but the swelling is not brawny
nor is the contour sharp and indented. In eczema the color shades
gradually into the normal tint.
52
Dry squamous eczema may greatly resemble psoriasis, but the
proper diagnosis should be made in any doubtful case after a proper
amoimt of observation.
WTiat is true of psoriasis applies to some extent to lichen planus.
When the patches first appear they may closely resemble eczema.
Study of the case will probably lead sooner or later to tlie recognition
of the peculiar primary lesion of lichen, the triangular dellated
papule ; .just as in psoriasis, the minute papule with its disproportion-
ately thick crust will reveal that affection. Pustular eczema is readily
confounded with other pustular eruptions, but as far as the secondary
pyogenic infection is concerned it is practically the same condition
throi;ghout, demanding much the same management.
Two such multiform affectidiis as syphilis and eczema nmst at
w times Simula 1 1' farli oilier. Squamous eczema sometimes bears con-
^^'^ siderable reseniblanee to i)apulosquamous syphilides, and palmar and
plantar S5i)hilides may simulate eczema. The differential tests are
the presence or absence of history of syphilis and vestiges of this
affection, the presence or absence of itching (the only sypliilidc which
itches at time? is the generaEzed ga^ular eruption, a coiniiaratively
VlaTe secondary phenomenon) ,~a"n3r finally tlie elTc .t ot anti-sypliilitic
treatment. The prefungoid eruption in granuloma fungoides is often
indistinguishable from a chronic eczema.
Treatment
If there is any evidence of faulty metabolism or any derangement
of the digestive apparatus, or if the diet of the patient is badly chosen,
he will not be likely to recover unless these conditions are first cor-
rected. It is a common experience that not only eczema but nimierous
other dermatoses, such as all forms of seborrhea and acne, pruritus,
chronic urticaria, etc., tend to improve, and become aggravated under
much the same conditions of general nutrition, digestion and diet.
The same individual may present a number of these affections at the
same time or in succession. Placed upon a restricted diet and general
hygienic regimen of exercise, hydrotherapy, etc., all these conditions
show a common tendency to improve. Some connection is often
apparent between these dermatoses and overweight. As the subject's
weight is reduced by his regimen the resistance of the skin increases.
This general therapeutic indication must always be borne in mind in
the management of eczema. The predisposition herein implied is not
deep-seated enough to be termed an inborn diatliesis, but simply the
result of malhygiene and hence preventable. Even the deep-seated
68
■^
metabolic anomalies of actual or premature senility are not neces-
sarily diathetic but are due chiefly to the fact that with advancing
years the subject continues to eat heartily while exercising progres-
sively less. The nutrition in all these subjects has become so de-
ranged that the skin may become a culture medium for ordinary
pathogenic cocci and even for others which ordinarily are harmless
saprophytes.
The limits of this article do not afford scope for a consideration of
the general management of eczema, but under etiology the various
causal factors were considered. In regard to the subject of inter-
nal medication in eczema, certain remedies are no doubt highly bene-
ficial, although the rationale may not be clear. In any case of acute
generalized eczema or acute eczema of the face large doses of acetate
of potassium have been used with success for over a century.
The belief formerly prevailed that acute eczema of internal causa-
tion was dependent in some way on acute renal insufficiency, the urine
being commonly concentrated. The diuretic action of the potash ap-
peared to be succeeded by a rapid retrogression of the eruption. It
has been pointed out that in renal disease we naturally stimulate the
skin, and that the opposite course is rational when conditions are
reversed. The extreme swelling of the eyelids in acute eczema
of the face certainly appears to yield promptly to the action of
diuretics.
The action of arsenic on chronic eczema is unmistakable and_it is
often use^ hypbdeVhlicallylo secure prompt results.
Internal remedies — sedatives and hypnotics — have some influence
over the itching, enough to aid the patient in getting his sleep. Gel-
semium has been recommended in desperate cases. More recently the
various synthetic analgesics — phenacetin, antipyrin, etc. — have been
used for this purpose.
Locally, the principal indication is to subdue the itching, for in
many cases this represents almost the whole of the disease, the lesions
being principally those arising from constant scratching and rubbing.
It is never advisable to dissuade the patient from scratching, as this
is often beyond his power. No one substance has any constant superi-
ority as an antipriiritic. Phenol, menthol, chloral, camphor, corrosive
sublimate are some of the more powerful remedies used, but milder
substances, like boric and salicylic acid and thymol, may be sub-
stituted.
In acute eczema the antipruritic may be combined with anti-
phlogistic remedies when these are indicated. The ointment or the
sodimont in tlio lotions also serves the purpose of excluding the
air, which intensifies the itching. The substances used to form the
sediment are usually zinc or bismuth compounds, which have an anti-
phlogistic action, and are also added to the ointments. A good oint-
ment may be made wth cold cream as a base and should contain
calamine, zinc oxide or bismuth subnitrate with the addition of phe-
nol, menthol or camphor. A corresponding lotion should have as a
vehicle weak lime water, and contain the same ingredients. Oint-
ments give the best results when they can be applied with a fixed
dressing, but lotions are preferred for all exposed localities for their
cosmetic possibilities. Whenever the inflammatory reaction is con-
siderable, ichthyol is indicated, and in some cases may be combined
with the remedies already mentioned.
Most acute cases should recover promptly if the dressiogs could
be made permanent and changed only once a day. In practice, how-
ever, this is seldom practicable, as patients do not wish to be inval-
ided. Hence a compromise treatment must be devised. The patient
must forego washing his skin or disturbing it in any way, excepting
with a special technique. Since ointments cannot be used freely in
ambulatory cases during the day, it is the custom to use lotions at that
period and ointments at night. This necessitates removing the oint-
ment in the morning, which is done preferably with suds of tar
soap. The skin is then dried by simply blotting it with gauze and
the lotion applied thickly. If the locality is such that the sediment
wears away it must be repeated over and over. The parts are thus
kept constantly protected from the air and in contact w'ith antipruritic
and sedative substances.
If a large area of integument is involved, the patient should take
a medicated bath on retiring, A pound each of starch and soda may
be placed in the bathtub and allowed to dry upon the skin of the pa-
tient. If the surface involved is large, ointments and lotions cannot
be applied thickly. A thin layer of carbolized vaseline will answer,
for the skin has already received a coating of soda and starch.
Dusting powders are also serviceable when there is a large area of
skin involved, and they may also be applied over the lotions. They
may be applied in all exudative cases, but possess no advantage over
sediment lotions made with the same substances save for the extreme
facility with which they may be applied. They are useful in hospital
and dispensary practice.
^Vhile ointments cannot well be used over weeping surfaces in the
ordinary state, they may be combined with starch, casein, zinc oxide,
65
etc., in special percentages — generally equal parts of vaseline and
powder. If these pastes so-called are applied firmly with fixed dress-
ings, the fluid is absorbed.
Fig. 36. Model in Neisser's Clinic in Breslau (Kroener).
Fig. 37. Model in Freiburg Clinic {Johnsen).
Fig. 38. Model in Freiburg Clinic (Voffelbaclier).
Fig. 39. Model in Polyclinic of Prof. M. Joseph in Berlin {Kolbotc).
Fig. 40. ]\IodeI in Freiburg Clinic {Jolmsen). Weeping and scabbing
eczema of the armpits in a very fat, sweaty man, in whom the genitals
and surrounding parts, the anal and the umbilical regions were also
eczematous.
Fig. 41. Model in St. Louis Hospital in Paris, No. 295 (Baretta).
LaiUer's case.
Fig. 42. Model in Neisser's Clinic in Breslau {Kroener).
Fig. 43. Model in Neisser's Clinic in Breslau {Kroener) .
Fig. 44. Model in St. Louis Hospital in Paris, No. 591 {Buret ta).
Foumier's case.
Fig. 45. Model in Freiburg Clinic {Johnsen).
Fig. 46. Model in St. Louis Hospital in Paris, No. 770 {Baretta)
Foumier's case.
56
Plate 30.
Fig. 47. 48. Prurigo.
Prurigo
Plate 30, Figs. 47 and 48
This affection is comparatively rare in the United States and the
cases encountered are generally observed in iimnigrants from Central
I'^urope. All attempts to connect it nostologically with papular and
itching affections seen in this country are futile. Wliile it may occur
sporadically in the very poor and desolate in any country, this fact in
no wise accounts for its cumulation in Austria-Hungary.
While prurigo may begin with the simple itching of an intact skin,
or one with urticaria papulosa, the most intense and persistent
scratching in other dermatoses does not commonly transform them
into true prurigo. Even the so-called mild form of the latter retains
its indi%aduality and is not chronic urticaria.
Prurigo no doubt begins as wheals, especially in nurslings, and
to a progressively less extent as the age increases. Cases are now
alleged to begin in adults. Adhering chiefly to the original descrip-
tion of the Vienna dermatologists, it persists until the early part of
the second year as a mere association of urticarial papules and
wheals and scratch marks. These are at once supplanted by papules
which are of the color of normal integument and represent inflanmia-
tory formations. The latter no doubt represent old urticarial pap-
ules. In the meantime itching reaches a maximum, so that sleeping
becomes difficult. A scratch dermatitis develops, but not in excess
of what may be seen in other pruriginous dermatoses. The prurigo
papules are not of this origin, although doubtless intensified thereby.
The disease may reach an acme of severity before the third year
is passed. The papules occupy chiefly the exterior surfaces of the
extremities, especially the lower. The ocular appearance is some-
times deceptive, so that the sense of touch is indispensable for diag-
nosis. The lesions project slightly above the skin level, so that a
papule very often exhibits a dot of dried blood on its summit from
scratching. Trophic disturbances seem in evidence, as the skin is
unnaturally dry and rough, the hair dry, etc. Further changes due
67
to protracted scratching are thickening of the skin, pigmentation, and
at times areas of simple dermatitis not comiected with the disease.
One of the most characteristic symptoms is the chronic inguinal bubo
commonly present in fully developed cases. Patients with chronic
prurigo generally show failure of nutrition.
Etiology
Age has already been mentioned. Prurigo is never inlierited,
never congenital. Some familial predisposition is seen at times.
There seems no doubt that it develops on an urticarial basis. As a
rule urticaria of childliood has no sequelae, and even the worst cases
of prurigo are sometimes outgrown at an early period. The unknown
X is involved in the problem of the transition of an urticaria into
prurigo. The evidence of a dystrophic skin as the cause is not suffi-
cient, and at present we have no clue to this factor.
Diagnosis
This is made first by the location and history of early develop-
ment ; the characteristic papules and inguinal buboes ; the dry skin ;
and further by exclusion of eczema (especially in a dry skin) ; para-
sitic diseases and other forms of itching affections.
Prognosis
This should be guarded as to the duration of the disease.
Treatment
Hygienic and nutritive management represents the first line of
treatment. A course of quiet with liberal feeding is rationally
indicated. Pilocarpin antagonizes the dry skin. The itching and
irritation require warm alkaline baths, followed by inunctions with
ointments containing phenol, naphthol, tar, etc.
Figs. 47 and 48. Models in Neisser's Clinic in Breslau (Kroener).
.58
Plate 31.
Fig. 4Q. Lichen planus.
Fig. 50. Lichen planus atiophicus.
Plate 32.
Fig. 51. Lichen planus verrucosus.
Plate 33.
3
C
en
bfi
re
3
3
c
in
to
Lichen Planus
Plate 31, Figs. 49 and 50; Plate 32, Fig. 51; Plate 33,
Figs. 52 and 53
This is a unique affection, the characteristic lesion of which is a
small papule, flat and triangular or polyhedral, having a minute
central depression ; the color is deep red or livid and a peculiar waxy
lustre is evident. These papules, naturally isolated, readily coalesce
to form patches and sometimes rings. In a patch it is usually possi-
ble to recognize the original papules, whose borders and depressions
still persist. The patches show a slight degree of sealing. As a rule
the papules are extremely persistent and are liable to come out in
successive crops. There is some tendency to pale out and undergo a
sort of atrophy. The typical papule is less than an eighth of an inch
in diameter. In some subjects they leave deep pigmentation.
The disease is naturally disposed to a general distribution but has
certain areas of preference as the flexor surface of the forearms and
lower portion of the legs. The papules are sparsely distributed at
first and later become more dense, but do not tend to appear at the
outset in isolated groups. Exceptions occur, however. As already
stated small rings of papules sometimes form or the latter may be
arranged in chains. When the disease attacks the glans and foreskin
or the inside of the cheeks, the papules appear closelj' grouped and
in fact may be confined to one or both of these situations. Exception-
ally they are seen on the female genitals, and the tongue. On all
these mucous surfaces the papules have a whitish appearance, save
in persons with exposed glans where the eruption resembles that on
the skin.
Lichen often assumes a chronic form and presents a notable degree
of itching, so that the effects of prolonged scratching are sometimes
apparent.
Etiology
The causation of lichen planus is still a matter of conjecture. It
is generally regarded as being dependent on some form of nerve dis-
order, and in patients presenting acute general eruptions, with intense
pruritus, it is seldom difficult to obtain evidence tending to support
this theory. They are often either apprehensive or depressed, and
the history of recent shock or fright is occasionally obtained. LUce
59
many another affection, lichen planus often develops in subjects
whose resistance has been diminished by poor nutrition, overwork
and nervous insufficiency, but there seems to be no warrant for mak-
ing it a neurosis. It may occur in young and apparently vigorous
subjects. Some authorities now regard the disease as an infective
granuloma. The lesions appear to represent an inflammatory infiltra-
tion in the outer portion of the corium, involving some thickening of
the rete and horny layer, and hypertrophy of the papillae.
Diagnosis
Wliile numerous other affections produce papules none of these
resembles in the slightest the lesion of lichen planus. Once seen, the
latter could hardly be forgotten. Wlien, however, the lesions become
grouped, the patches readily simulate chronic squamous affections.
This is especially prone to occiar when large patches are formed in
some unusual locality, as over the knees. Lichen may also show a
special tendency to form multiple scaling patches. When rings are
formed showing various stages of development it may be necessary
to exclude the other ringed affections, as syphilis, ringworm, etc.
Confusion with lichen ruber of Hehra is doubtless due to the fact that
atypical forms of each may simulate the other. Typical cases show
no parallelism.
Prognosis
The affection is naturally chronic and sometimes progressive. In
many cases, however, there seems to be a natural tendency to recov-
ery. With proper treatment the outlook for recovery is always good.
Treatment
This is influenced largely by the stage of the disease and the type
of eruption presented. In the acute hyperemic, disseminated variety
the internal treatment should at first consist only of alkaline mix-
tures. The following are good examples :
IJ Potassii citrat 3vl
Tr. nucis vomicae 5ii
Aqui-E ad 'iii
M. et ft. Sig. — Teaspoonful in water after meals.
1^ Potassii acetat oiii
Potassii bicarbonat 3iii
Tinct. gent, comp 3vi
Syr. auranti dulc 5'
AqusB ad 3'ii
M. et ft. Sig. — Teaspoonful in water after meals.
60
Mild laxativos are also indicated, the diet should be restricted and
alcoliol prohibited. The discontinuance of tobacco is not always
advisable, as it often seems to increase the nervous irritability. As
soon as the acute stage begins to subside, mercurial treatment should
be instituted, for there is now but little doubt as to the superiority of
mercury over all other drugs in the treatment of this disease. In
many cases its effect is almost specific. The results, however, are not
always uniform. It should be administered in increasing doses until
either improvement in the eruption occurs, or beginning mercurial-
ism is noticed. A fairly accurate method of administration is in the
form of one-grain tablets of hydrargynmi cum creta. From six to
twelve of these may be taken daily, according to the effect produced.
Mercury can also be advantageously given in the form of bichloride,
Hz to H2 of a grain three times a day. This is best given in a
mixture, but in certain selected cases it may be administered
intravenously.
Should the treatment with mercury be unsatisfactory, recourse
may be had to arsenic, which must also be given in full doses, but
never in the acute stage. It can be administered in the form of
Fowler's or Pearson's solutions, in doses of from five to twelve
minims three times per day. A more convenient method of adminis-
tering arsenic is in the form of tablets or pills. A tablet containing
^^0 of a grain of sodium arseniate may be taken after each meal, and
the dose increased by one every three days until three are taken after
each meal, then return is made to the first dosage. Occasionally the
Asiatic pill, which contains Ho of a grain of arsenious acid, is useful.
Intramuscular injections of cacodylate of sodium have been recom-
mended, and recently there have been a few favorable reports from
the use of salvarsan intravenously administered.
In acute cases, where arsenic is contraindicated, Pringle recom-
mends the wine of antimony in fifteen-minim doses, three times a day.
The same writer has reported rapid subsidence of inflammation and
complete cessation of itching in an acute case after the use of antipy-
rin in ten-grain doses given three times a day. Bulkley uses chlorate
of potassa, five to ten grains in water, after meals, followed half an
hour later by two to five drops of strong nitric acid, well diluted.
Eartzell has had favorable results from the salicylate of soda. Con-
stitutional treatment should be continued for some time after the
eruption has disappeared. The nervous exhaustion that not infre-
quently follows a severe attack of lichen planus is best overcome by
the use of strychnine. Tablets of strychnia nitrate of Ho of a grain
may be given three times a day. The glycerophosphates of lime and
61
soda are also useful, and the following formula, in which they are
combined with strychnia, is an excellent one:
IJ Strychnia nitrat gr. %4
Calcii glyceropliosph.,
Sodii glyceropliosph aa gr. iiss.
M. et ft. cap. Sig. — One capsule three times a day before meals.
Local treatment in the acute stage should be soothing, and consists
in the main of cooling lotions, such as the calamine and zinc lotion, or :
IJ Pulv. boracis oii
Tr. camphoras 3iii
Glycerine 3ii
Aquas aurantii florum ad §viii
M. et ft. lotio.
Alkaline and bran baths are cooling and generally grateful.
As soon as the acute symptoms subside, mildly antiseptic oint-
ments, such as ammoniated mercury 2i^% or salicylic acid 5%, can
be used. Tar, in the form of lotion, ointment or paste, is useful. In
the chronic type the following ointment, recommended by Unna, may
be applied :
J^ Hydrargyri bichlorid gr. iv
Acid, carbolici 9 i
Ungt. diachyli §i
M. et ft.
In the hypertrophic, verrucous variety, appearing most frequently
on the legs, the treatment should be stimulating ; a ten to twenty per
cent, salicylic acid and rubber plaster acts very well.
The following collodion paint is also useful:
^ Acidi carbolici gr. x
Hydrargyri bichlorid gr. iii
Creosote HK iii
Collodion §i
M. et ft.
A mercurial plaster is sometimes of benefit. In particularly in-
tractable cases the X-rays are occasionally of service.
Figs. 49 and 52. Model in St. Louis Hospital in Paris, Nos. 1398 and
1554! {Baretta). Hallopeau's case.
Fig. 50. Model in Neisser's Clinic in Breslau {Kroener).
Fig. 51. Model in Freiburg Clinic {Vogelbacher).
Fig. 53. Model in Municipal Hospital in Cologne. Prof. Zinsser.
62
Plate 34.
Fig. 54. Psoriasis gyrata et serpiginosa.
Plate 35.
Fig. 55. Psoriasis vulgaris guttata et ostracea. Fig. 56. Psoriasis vulgaris.
Plate 36.
Fig. 57. 58. Psoriasis vulgaris.
Plate 37.
«
o
o
o
CSS
in
Plate 38.
Fig. 61. Psoriasis vulgaris unguium.
Fig. 62. Psoriasis vulgaris rupioides.
Psoriasis
Plate 34, Fig, 54; Plate 35, Figs. 55 and 56; Plate 36, Figs. 57 and
58; Plate 37, Figs. 59 and 60; Plate 38, Figs. 61 and 62
This affection, because of its characteristic, scaly, white spots, and
its intractable character, is believed to have been comprised in the
original conception of leprosy, and perhaps to have made up much of
biblical leprosy. The superstitions which have come down to us at-
tached to the scaliness of leprosy and the contagious nature of the
scabs are hardly reconcilable with what we know of leprosy to-day.
On the other hand, the affection known to the Greeks as "alphos" ap-
plies in a measure to vitiligo, a white but not a scaly dermatosis. The
very word lepra implies a scale, and it must be remembered that the
Greek word for true leprosy was elephantiasis. Psoriasis may there-
fore have been the lepra of the Greeks, but this was not true leprosy.
The dissimilarity between these affections is very marked, and the
confusion is due entirely to ancient etymological misconceptions.
Psoriasis in its inception is a sharply individualized disease. The
first lesion to appear is a small red papule the size of a pin-head or
point. This is surmounted by a fine silvery scale. "Wlien tliis minute
scale is picked off a hyperemic base is disclosed. This has been aptly
termed the pathological unit, for from it all the other lesions of the
disease are derived. There is no other dermatosis whicli, beginning
as a mere point in the skin, presents at the same time a definite scale.
After a large area of psoriasis has once been formed the scaling is not
so much in evidence. We see a congested and slightly infiltrated area,
surmounted by scales, but not differentiated sharply from other red,
squamous affections. The spots with which psoriasis begins vary
much in size and in thickness of scale with the individual case ; but
generally speaking, the size of the scale is out of all proportion to the
degree of subjacent disturbance. A thick, adherent crustlike scale
may be seated on an area of skin but slightly compromised. Histo-
logically, as might be expected, psoriasis proves to be an affection of
68
the epidermis. Tlie papillary layer of the corium is only secondarily
involved, from a tendency of the rete to grow inward.
Psoriasis is eminently a general dermatosis, despite the fact that
it may sometimes be located for the time in narrow areas. As a rule
it appears widespread, and lesions may occur in any locality. As an
eminently disseminated affection, it may appear simultaneously in a
number of localities, although most prominently in some one area.
There may be a thick crop over the small of the back and buttocks
with more sparse lesions elsewhere. Much depends upon the course.
The more acute the outbreak the greater may be the range of localities
involved. The more chronic, conversely, the more the affection may
favor certain localities — for example, the scalp, elbows and knees.
In an outbreak of psoriasis, as with other dermatoses, two ele-
ments enter. First, the localities originally attacked ; and second, the
course of the affection in these original localities. Suppose the latter
to be any one of the favorite seats of the disease. There may be no
spread of the affection from the primary focus ; in fact, after a sta-
tionary period, there may be spontaneous involution. This, however,
is exceptional. All large, figurate lesions in psoriasis, wherever or
however produced, come about from changes in elementary lesions.
Psoriasis is a disease naturally macular or maculopapular in char-
acter. The mere surface points or droplets with which the affection
begins may increase to the size of a large coin, but seldom beyond this.
"Whenever this or any considerable size is reached, the patch tends to
clear up in the centre, leaving a ring ; while the fusion of annular seg-
ments produces a gyrate pattern. The original nummular patches
may fuse together, with the production of wide, diffuse areas. Psor-
iasis, then, begins as a point and may increase to the size of a pea or
to that of any of the coins. At any stage its growth may become
arrested. The individual lesions may be thickly grouped, and fusion
may occur at any stage. But at any time one of the larger lesions
may clear up in its centre, leaving a ring ; and coalescence of these
partially involved lesions may give rise to peculiar figurate patterns.
The more rapid the evolution of a psoriasis, the greater the dis-
semination and the less in evidence the scaling. Such cases suggest
a rash, and may even burn and itch. In some cases it seems hardly
conceivable that such eruptions are really psoriasis. It is of course
possible that some ordinary rash can incite the appearance of a
psoriasis in one disposed to it. That local conditions shape the dis-
tribution is well shoA\Ti by the occasional appearance of the disease in
recent cuts, scratches and burns.
64
In the consideration of psoriasis, we must know how the affection
originates ; for once it is in full evolution it can hardly be reduced to
sjnnptomatology. Aside from a few localities, like the elbows, knees
and scalp, psoriasis presents no particular local types. It affects the
extensor more than the flexor surfaces, and usually spares the palms
and soles, save in the generalized cases. The face, especially the more
central portion, is seldom attacked. In certain cases it may affect the
entire integument, causing general exfoliative dermatitis. It seldom
influences the texture of the skin, so that pigmentation and cicatriza-
tion do not occur.
Etiology
"We know but little about the nature of psoriasis; attempts to
connect it with causal elements produce different results in different
countries. There is no doubt that the disease is aggravated by what-
ever influences that make for rheumatism and arthritism so-called,
such as cold weather, inactivity, overeating, etc., but this influence can
only be an indirect one. Its occurrence in members of the same
families has never been worked out satisfactorily. We do not know
positively that the disease is truly a familial one, for it is possible
that it is mildly contagious. All attempts to discover and isolate a
parasite have failed, yet the course of the lesions sometimes resemble
strongly that of known parasitic diseases.
A neuropathic element, often markedly in evidence, is probably
only a predisposing factor. As already stated, the affection is pri-
marily one of the epidermis — the rete. The participation of the
blood-vessels and the papillary layer of the corium appears to be
secondary.
Diagnosis
The initial lesions, already described, are unmistakable; and a
highly developed case, with its universal distribution affecting most
markedly the extensor surfaces with its peculiar scaliness and con-
figuration, is likewise unmistakable. Confusion is most likely to occur
in isolated patches, say those on the scalp, about the ears, on the
elbows and knees, etc., for eczema may attack the same localities and
present much the same appearance. Exceptionally localized psoriasis
has been seen in eczema areas, and differentiation is so difficult that
hybrid types are spoken of. Whenever scaly, dry eczema, or sebor-
rhoic dermatitis appears to be especially resistant to treatment, and
to return promptly and without manifest cause, it is well to study the
66
case closely for evidences of psoriasis. In these cases the characteris-
tic initial lesions may be detected.
A treated psoriasis is often impossible of recognition at first. The
previous treatment may have removed the scales, so that we see only
hyperemic macules, and rings. The condition may be readily mis-
taken for a papular syphilide. It is often well to leave such cases
without local treatment for a few days, when the peculiar crustlike
scales will form. In some cases, however, scaling is naturally slight
and here, of course, diagnosis may be difficult. Psoriasis may develop
in a subject with syphilis. Hence the Wassermann reaction may be
misleading.
Prognosis
Psoriasis is one of the most inveterate of all affections, but it
responds to treatment to a notable extent, and months, often years,
may elapse between outbreaks. The affection is not progressive with
years, and leads to no serious consequences of any sort. Much de-
pends on the appearance of new lesions, for in some subjects these
appear almost continually, and little or nothing can be done to arrest
them, unless the process is relatively slow and local, when if put on
a thorough regimen it may be possible to check the outbreak. Much
also depends on the tendency of lesions to enlarge and form patches
of size, for in many cases the spots do not pass beyond the guttate
stage. It is the combination of these two factors which causes the
most severe cases. The more vigorously the disease is combated
the better should be the prognosis; but there are exceptions, for
too vigorous treatment sometimes seems to inmiunize the skin to
the favorable action of the remedies, and it is also possible for a case
to advance steadily despite the most careful treatment.
Treatment
On a carefully selected diet and regimen, such as benefit eczema
and acne, psoriasis also improves. Lesions clear up when training
for athletic events and also upon low plans of diet. This kind of man-
agement naturally renders the skin a more unfavorable culture me-
dium for germs of all kinds, but does not justify the claim that
psoriasis is due to a germ. No matter what the state of the individual,
attempts should be made to render all his functions normal, whether
he is to be built up or reduced. Going bare in the outdoor air and
sunlight is believed by Piffard to have a natural curative tendency.
66
K any well-marked affection is present it should be treated in the
hope that the general state will improve. This applies especially to
anemia, rheumatism and gout. Arsenical preparations, including
mineral waters which contain arsenic, frequently give surprising re-
sults, but it is often best to save this resource and not place a fresh
case upon it, for the patient quickly becomes tolerant to it. When
there is urgent need that a patient be cleared up for the time being,
arsenic pushed to the limit, combined with vigorous local treatment,
may effect the desired result. It may be months before the patient
Avill again respond to arsenic. Generally speaking, the local treat-
ment of chronic eczema may always be essayed in psoriasis. Many
insist that alkalies have a distinct ability to control the disease ; this
might be true of paroxysms, but alkalies are not suitable remedies to
give for months. The benefit ascribed to iodide of potassium may be
due to the alkali and not the iodine. The effect of alkalies may be
secured by a diet made up largely of fruits and vegetables, by alkaline
waters, etc. Alkalies and arsenic given simultaneously may prove
more efficacious than either one alone. They may be pushed together
or alternately.
Local treatment is all-important and must be applied with refer-
ence to every detail. Some of the agents in conunon use stain the
hair, clothing and bedding. It is not well to use the best ammunition
in incipient or mild cases, for the skin soon acquires a tolerance to
remedies. As a rule, scales must be removed in connection with the
treatment, so that the affected epidermis may be directly acted upon.
To insure this result, bathing, oils and salicylic acid ointment cooper-
ate. If a considerable area is involved, a general alkaline-starch bath
may be used. Oil inunctions also serve to loosen the scales. The
mere removal of the scales sometimes gives the impression of great
benefit, and salicylic acid is valuable in preventing the reappearance
of scales. For circumscribed patches on the knees and elbows, an
ointment of white precipitate may be sufficient for a cure ; and it is
better at the outset to use minerals, and especially tarry preparations,
saving those to be named later for emergencies. In fact, any of the
remedies found useful in chronic eczema should be of use in psoriasis,
although the latter will prove much more refractory.
The so-called specifics, chrysarobin and pjTogallol, ■will liave
plenty of opportunity for full testing. Either of these in ointment
form will cause the disappearance of psoriatic patches, but must not
be used too often, lest the effect be lost. Remedies like these cannot
b'e used in rotation very long, as both soon lose their effect. It is
67
well, as soon as a good impression is made with these, to go back
to tar and mercurials. Betanaphthol is said by some to be nearly as
good as the two remedies mentioned.
Fig. 54. Model in Leaser's Clinic in Berlin (Kolbow).
Fig. 55. Model in Neisser's Clinic in Breslau {Kroener).
Fig. 56. Model in Neisser's Clinic in Breslau {Kroener).
Fig. 57. Model in Freiburg Clinic (Vogelbacher).
Fig. 58. Model in Neisser's Clinic in Breslau (Kroener). A man, thirty-
five years of age, who, in the course of a rather extensive eruption, had
manifestations on the palms and soles.
Figs. 59 and 60. Models in Neisser's Clinic in Breslau {Kroener).
Figs. 61 and 62. Models in Neisser's Clinic in Breslau {Kroener). ,
68
Plate 39.
E
3
o
'3
X3
o
J3
E
N
O
en
Plate 40.
E
3
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J3
o
INl
u
in
m
Eczema Seborrhoicum
Synonyms: Dermatitis seborrhoica, Seborrheic eczema
Plate 39, Fig. 63; Plate 40, Figs. 64 and 65; Plate 41, Fig. 66
This affection comprised originally no more than the so-called
"inflamed seborrhea" — salmon-colored disklike areas covered with
a greasy scale and occurring on the head and face, sternal and intra-
scapular regions. Exceptionally this eruption had a general distri-
bution and bore a more or less striking likeness to a disseminated
guttate psoriasis. Upon this substratum Unna proceeded to erect
a superstructure of disease termed by him seborrheic eczema, which
could be so stretched as to include a great deal of what is usually
classed as ordinary eczema. Much of ordinary dandruff belongs
here, the mere production of the fatty scales being held to be sufficient
evidence of the disease even in the absence of sensibly inflamed
scalp. A large part of the ordinary eczema of the scalp is also
placed here, even if it be typical. In some of these cases the presence
of ordinary inflamed seborrhea of older authors is present and fre-
quently extends from the hairy scalp upon the smooth skin for a
short distance. The middle of the face — sides of the nose chiefly —
is a common site of inflamed seborrhea, the skin being oily, the
sebaceous glands patulous and often occluded with sebum, \\dth
maculopapular lesions of pale hue and surmounted by scales or fatty
crusts. These lesions have affinities with acne rosacea and lupus
erythematosus, and in fact the same lesion may be common to all un-
der certain conditions. The obstinate eczema of the vermilion border
of the lip is also claimed as seborrhoic, when it is associated with
seborrhea of the scalp or nose.
The peculiar lesions over the sternum and between the scapulae
have usually passed for eminently characteristic local eruptions, quite
peculiar to the localities affected. They are of common occurrence,
and when we see them we may usually take it for granted that the
subject has dandruff and seborrhea of the face.
Patches are also not uncommon in the armpits and genitocrural
region. While in some cases the discrete, pale-red lesions are in evi-
dence, there are others in which the eruption resembles an ordinary
eczema or intertrigo. A diagnosis can only be made through col-
lateral evidences of seborrheic dermatitis elsewhere.
As already stated, a diffuse, generalized case, where guttate le-
sions are found over the limbs as well as the trunk, bears a striking
resemblance to a psoriasis, which is either less scaly than common
or has been benefited by treatment. In some of these cases, however,
diagnosis is easy, for there are principal lesions in the favorite
localities of seborrhoic dermatitis ; the lesions have a peculiar salmon
color, and the scales are greasy. Eczema seborrhoicum of the scalp
is a fertile cause of premature alopecia.
Etiology
It was long held that in ordinary functional seborrhea the
process might culminate in a sort of adenitis of the sebaceous glands ;
in the same manner, perhaps, as congestion of the sweat-glands
leads to prickly heat. This view was succeeded by one involving in-
fection of the glands from without, and resulting dermatitis. The
suggestion of parasitism is much stronger here than in ordinary
eczema. The claim has been advanced that the sweat-glands are also
involved. Numerous microorganisms have been accused of causing
this affection. No progress has been made of recent years in our
knowledge of the latter, which for the present is very defective.
Diagnosis
The diagnostic features have already been enumerated in part.
The disease, wherever else present, may always be found in the
scalp; it begins there, and may not appear elsewhere. It seems to
extend downward, for its next most conspicuous place is the face and
about the ears, then the breast, axillae and back, and so on. The soil
in which the disease develops is much like that in acne, the sebaceous
glands evidently being strongly disposed to inflame. The inflamma-
tion is mild in degree, focal, and produces greasy crusts. Itching is
not extreme, and scratch-marks are seldom seen. Wlien it does
closely simulate ordinary eczema, the locality and soil may be suffi-
cient to exclude the latter.
A most important source of confusion may arise in the case of an
early syphilide, because the latter produces a very similar appear-
ance in the scalp. A generalized case may also resemble a syphilitic
outbreak. Syphilis, psoriasis, and a partially cured ringworm may
70
all simulate seborrhea, since all may form annular lesions. A good
diagnostic resource is response to treatment, which should be much
more prompt in seborrhea.
Prognosis
A tendencj' to recurrence after the disappearance of the lesions
suggests a reinfection, and renders the course uncertain and chronic.
Treatment
Sulphur locally is regarded as a specific, although not much used
in the scalp. The principle upon which sulphur is used is its effi-
cacy in acne. Other valuable remedies are salicylic acid and resorcin.
The general health should receive attention. Some individuals can-
not use alcoholics without greatly aggravating seborrhea of the scalp.
If the disease proves obstinate, any of the measures used in obsti-
nate cases of eczema and psoriasis may be used, and the same is true
of the treatment of the acnes, which may also be employed wdth the
idea of rendering the sebaceous glands less disposed to inflame.
Fig. 63. Model in Freiburg Clinic (Johnsen).
Figs. 64 and 65. Models in Neisser's Clinic in Brcslau (Kroener).
Fig. 66. Half-ton^, Dr. Kingsbury, New York.
71
Pernio
Synonyms: Chilblains, Erythema pernio
Plate 42, Fig. 67
Chilblains, unless severe, do not claim much attention, since they
are an almost universal consequence of the seasons — the beginning
and duration of the cold weather, at the close of which they subside of
themselves. But conditions strongly suggestive of chilblains, since
they involve the chilblain area, and also much influenced by cold
weather, begin like ordinary chilblains. We refer here to Raynaud's
disease and lupus pernio. The chilblain area comprises the extremi-
ties of the body — the fingers, toes, heel, nose and ears. It is usually
taken for granted that a person who suffers much from chilblains has
a poor circulation and is anemic ; and doubtless the truth of this claim
might be readily demonstrated. As a matter of fact, however, one of
the most if not the most striking factor in keeping up the condition
of chilblains is the sudden warming of chilled or damp feet by placing
them before a tire or standing on registers. If there is a predisposi-
tion, whether due to defective circulation or anemia, a slight degree of
chilling may start up the affection. It is claimed by some authorities
that chilblains are to a certain extent a familial affection.
The skin in the chilblain area is cold to the touch, red or livid and
edematous. Itching is intense, and increased by warm rooms, contact
with bedding, etc. The impaired vitality of the tissues is shown by
the readiness with which they form abrasions, blisters and ulcers,
which heal with difficulty.
Treatment
Chilblains may be prevented by treatment instituted before the
cold weather begins. Tonics should be given, and an attempt made to
harden the tissues with cold bathing. Itching should be controlled by
ordinary antipruritics. Anything which antagonizes the condition of
stasis should be of value.
Fig. 67. Model in Neisser's Clinic in Breslau (Kroener).
72
Plate 42.
CI
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Oh
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Raynaud's Disease
Plate 42, Fig. 68
This affection is a vasomotor neurosis which is described at great
length in works on neurology and in special monographs. It belongs
to the so-called acroneuroses and is therefore limited to the extremi-
ties— fingers, toes, ears, and exceptionally the tip of the nose. It is
believed to result from a persistent angiospasm of the terminal arter-
ies and veins, although the same condition may be produced by an
actual arteritis. It stands in a certain definite relationship to the so-
called chilblain area, and appears to attack individuals with a sluggish
terminal circulation who are predisposed to cold extremities and chil-
blains. The persistent vascular disturbances tend to terminate in
extensive trophic alterations, the most significant of which is dry gan-
grene, Avhence the sjaionym "symmetrical gangrene." One or more
digits may be involved on each hand or foot.
The early sjonptoms vary considerably, due no doubt to the rela-
tive part played by the arterioles and venules, and also to the fact that
the initial spasm of the vessels may be followed by paresis. Further,
the affection develops in a series of exacerbations with quiescent in-
tervals between. The fingers are often seen to be white and cold, this
phase of the process indicating intense local anemia from angiospasm
of the arterioles. This stage is by no means necessarily present, and
the malady may begin witli what is termed the second stage. It is
impossible to state to what extent this is due to venous angiospasm.
The fingers become red and congested, as if from the cold, the color
usually deepening as the disease advances. Even in the early period
the extremities may have an intense cyanotic hue. The statement
that angiospasm is necessarily followed by a condition of vascular
relaxation does not seem reasonable, for the vascular changes must
be essentially obstructive in order to cause gangrene. The latter is
not a necessary development, for the condition may never progress
thus far. The gangrene may also be very sliglit and superficial or, in-
stead of necrosis, trophic ulcers or atrophy may develop. It must
never be forgotten that Raynaud's disease is not infrequently com-
bined with one of the other acroneuroses, notably scleroderma, ery-
thromelalgia, and perhaps acroparesthesia. These complications
naturally give rise to atypical cases. The uncomplicated disease is
not characterized by much subjective disturbance.
Diagnosis
It is often difficult to distinguish Raynaud's disease at its outset
from the other acroneuroses. As already stated, transition forms
occur, and the different affections really form a group disease. There
is considerable resemblance at times to the lesions of syringomyelia.
It has been said that Raynaud's disease cannot possibly be distin-
guished from s>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
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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.
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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
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