Professor Henry C. Maisch of Philadelphia has made an elaborate series of tests of the various methods of estimating the amount of uric acid in urine, (Journal of the American Medical Association, October 1, 1898) and finds the best results from Hopkin's method of saturating the urine with ammonium chlorid and estimating the uric acid gravimetrically as ammonium urate. The estimation of uric acid is so difficult that a comparative study such as this is of great importance, and it is encouraging that the simplest method proved to be the most accurate.

Harold Frederic, the well-known novelist and correspondent died in London, October 19 of acute rheumatism. The special interest in his case was his having at the advice of friends and the insistence of a "Christian Scientist," a Mrs Mills, discharged his physicians and put himself under the care of said Mrs Mills. As might have been anticipated in case of such a disease as acute rheumatism the poor man soon died under the ministrations of the "Christian Scientists." The inquest showed that death was unnecessary. It is devoutly to be hoped that those responsible for his death will be tried for manslaughter and convicted.

Clara Barton, of Red Cross fame, is once more in the business of advertising patent medicines. This time she commits the whole Red Cross Society by saying: We have tried Dr. Green's Nervura blood and nerveremedy, and although the remedy has been in our hands but a short time we judge that the remedy has all of the merits which are claimed for it. We shall still continue its use with the expectation that we shall be able to endorse it still more highly." (Italics ours) The profession will remember that it is the same Miss Barton who presumed so freely to criticise the conduct of the Army Medical Department during the war. It must be pleasing to the physicians in the service of the Red Cross Society to have their chief publicly advertise that they are using the Electropoise and Dr Green's Nervura in their relief work. It is a pity to see Miss Barton so flippantly degrading the Red Cross in the public estimation, for the nonmedical public has grown to know just what this sort of testimonial to quack medicines means, i. c., either venality or imbecility.

On November 10. Health Officer Hess, aided by advice of other physicians declared that a case of smallpox existed on the west side of this city. The case was so mild that the diagnosis from chickenpox was very difficult, if not impossible. The newspaper statement that a bacteriologist had been employed to make a diagnosis was a little surprising, as the bacteria of neither disease have even been isolated or cultivated. A statement attributed to the Health Officer, that there was, in any event, no danger of an epidemic, because the case was so very mild, must certainly have been erroneously reported in spite of the emphasis which he is reported to have given it, as all physicians know that the mildness of an initial case of any infectious disease is never an index of the severity of the epidemic which may follow, but on the contrary is very frequently quite the reverse. The case, of course, was quarantined and it is hoped and expected that no spread of the disease will occur. It is some years since there was a good smallpox scare and it is quite probable that the great number of cases now occurring in various places in Ohio are due to the existence of a very large number of susceptible persons. Physicians should constantly bear in mind this probability and advise their patients and acquaintances not to neglect vaccination.

VOL. III

Cleveland Journal
of Medicine

DECEMBER, 1898

No. 12

IMPETIGO: ITS CLINICAL FORMS AND PRESENT STATUS, IN-. CLUDING ECTHYMA AND THE SO-CALLED

PEMPHIGUS CONTAGIOSUS

BY WILLIAM THOMAS CORLETT, M. D., L. R. C. P., LOND.

Professor of Dermatology and Syphilography in the Medical School of Western Reserve University; Physician-in-Chief for Skin Diseases, Lakeside Hospital; Dermatologist to Charity Hospital; Physician for Skin and Venereal Diseases, City Hospital, Cleveland

F

EW diseases present more difficulty in diagnosis to the general practician, offer greater incongruities to the nosologist, and withal seem to

be less definitely understood than the affection under consideration.. This is not due to any special clinical obscurity in the disease; rather is it attributable to the confusing nomenclature which, from the time of Celsus, has prevented a clear understanding of the Impetigo group. At the present time what is considered Impetigo in one country is not so regarded in another. Again Porrigo (porrigo, to extend)* and Impetigo (impeto, to attack)** aresometimes indiscriminately used to indicate the same condition. Willan1 first eliminated the scaly affections included under the term by Celsus2 and. used it to designate a pustular eruption, although some affections so denom-inated by this writer are now known to be quite distinct diseases. Willan in 1810 and Bateman3 in 1814 defined Impetigo as a humid or running tetter; while Porrigo was employed by them to indicate Ringworm, Favus and so forth. Of the five varieties of Impetigo specified by these authors, four have, through the influence of Hebra's teaching, been relegated to the eczematous group, and the fifth evidently refers either to Cancer or Lupus Vulgaris. The name alone remained, and Hebra utilized it in describing an herpetic, pustular eruption which he had observed in pregnant women, or in those who had. been recently delivered1.

IMPETIGO HERPETIFORMIS

Further observation has demonstrated that pregnancy is not an essen-tial factor in the disease, and cases have since been reported in men.

According to Willan, who used it in connection with Favus, it is derived from porrum, a leek— on account of the strong odor of the exudation and scabs.

**According to Pliny, ab impetu, impetu agens, acting with force, with severity, and implying a more active form of inflammation than was encountered in Eczema and Lichen.

Symptomatology. The important features, as given by Hebra and subsequently elaborated by Kaposi, are as follows: The disease begins with the formation of small pinhead-sized pustules, usually in the groin or on the inner surface of the thighs, from which it soon extends to the folds of the breasts and to the axillas. The contents of the pustules are opaque from the first and are situated on a reddish, slightly swollen base. Later they increase to the size of a lentil or larger, and the contents change to a deep yellow or slightly greenish color. The arrangement of the lesions is characteristic in that they are in clusters or rings, which vary from a dime to a half-dollar in size. The disease progresses by the appearance of fresh crops of pustules, usually situated about the periphery of former groups or in clusters by themselves. Those previously formed, constituting the center of the patch, often merge together and the epidermic covering either ruptures or the contents become desiccated, forming friable yellowish crusts which are easily detached. Extensive areas are thus sometimes produced, presenting a glazed, weeping surface often surrounded by two or three circles of small pustules. Ulceration has not been observed.

In the course of a few months it is not uncommon to find the whole cutaneous surface more or less involved, in which case it is made up of crusts, fissures, and excoriated surfaces, with, here and there, circles or groups of pustules which give character to the disease. In some of the cases reported the mucous membrane of the mouth, fauces, esophagus and stomach were involved (Kaposi loc. cit.)

The objective symptoms consist of fever, either continuous or intermittent, alternating with chills, dry tongue, and in fatal cases towards the close, with diarrhea, vomiting and delirium.

Pathology. The pathology and morbid anatomy of the skin have been studied by Théo. Du Mesnil and Marx, of Würzburg, who found in the region affected the blood-vessels and lymph-channels dilated and surrounded with embryonic cells and their endothelium swollen. This was especially marked around the blood-vessels. Further, these changes were most conspicuous in the superficial strata of the derma, and notably at the base of the pustules. The interpapillary prolongations were longer than nor mal, and acanthosis was here observed. In the papillary layer subjacent to the pustules the infiltration was so active that the structure of the derma could with difficulty be made out. The cells extended into and nearly replaced the mucous layer of the epidermis, thus obliterating the line of demarcation between the derma and epidermis. As the cells migrated upward through the stratum mucosum they were seen to accumulate under the stratum corneum, which they believe to account for the large number of cellular elements present which were greatly in excess of the serum. In the small pustules cleavage was seen to take place at a point where the cells of the stratum mucosum flattened horizontally; in larger pustules this cleavage took place lower and