ERYTHEMA EXUDATIVUM MULTIFORME (Hebra) The pathologic picture first described by Hebra under the name of erythema exudativuni multiforme is mentioned by other authors under names which are partly still in force to-day: erythema polymorphe (Kaposi), erythema hydroa (Bazin), erythema centrifugurn, erythema. marginatum, etc.
The general clinical picture is usually typieal and uniform, appearing first at the dorsal surface of the hands and feet, then at the lower arm and leg in the shape of single raised spots which arc at first the size of a lentil and become gradually larger. Their color is vivid, light red to brick red. After twenty-four hours at the most the centre of these spots sinks in and becomes cyanotic, while the vivid red remains only at the periphery in the shape of a circle. Gradually the number of these spots, or circles, increases (erythema iris), two or more of these circles rtIll illt0 each other, and the result is figures which are designated as erythema gyratum and erythema annulare. Beside these there may be occasional pimples or nodules resembling urticaria, or there may be raised spots resembling vesicles (erythema vesiculosum), there may be a circle of vesicles at the periphery, making the entire spot appear as if ornated by pearls (herpes iris). In rare cases they are discolored by transudation of blood which constitutes the luemorrhagic form of the affection.
Course.—Gradually the affection heals and fades, leaving a pig mentation behind, after having passed through the usual scale of colors. Normally the affection comes to a favorable termination at the end of from two to six weeks.
Fever does not ne.cessarily occur in this affection, the erythema causing only a slight feeling of discomfort, but morning temperatures of 37.5° C. (9S.6° F.) and evening temperatures up to 38.5° C. MI° F.) may occur. At the same time there may be pains in the limbs, and articular swellings. The knee- and ankle-joints particularly are often attacked. Itching or burning occurs only rarely, but more frequently there arc pains in the joints. The spots may also spread to the nnicous membrane and extend to the lips, cheeks, tonsils, epiglottis and even vulva. Various forms of conjunctivitis have been described by Lipp, von During and Fuchs. The involvement of the conjunctiva sets in
symmetrically in the form of small spots with a grayish white or yellow surface. They appear slightly raised and extend to the cornea over which they may spread. Renal and intestinal complications (Mematuria, intestinal luemorrhages) have likewise been described. Whether endo carditic manifestations have anything to do with this affection, has not yet been proved. In severe eases there may be spasmodic relapses which would protract the course. of the disease. Generally, however, severe cases in children are rare, and usually the affection with only slight prodromal manifestations (feeling of lassitude, headache, ete.), reaches its crisis within twenty-four hours, after which gradual recovery sets in.
Anatomy.—The pathologico-anatomical findings consist according to Neisser in a dilatation of the vessels with considerable involvement of the veins, in cedematous swelling of the papillary body and moderate inflammatory migration of leucocytes. The epithelium shows (edema tous swellings which are frequently present before the actual formation of vesicles has begun.
IInna, too, looks upon eiTthema as an affection which has its seat in the papillary body and leads to an cedematous thickening of the same. In consequence of the vascular dilatation there is migration and accumu lation of white blood corpuscles around the vessels of the subepithelial network.
pointed out the frequent occurrence of this disease at certain seasons of the year and indicate:3 particularly October and November, April and May. On the occasion of en epidemic among the army in Constantinople, During designated January, March and April as the most favorable times for this disease. Personally I have observed its occurrence most frequently in the spring and fall, although I have never seen epidemics of such magnitude as Herxheimer has described. The frequent occurrence at certain seasons of the year and the clinical course of the disease, rouse the suspicion of its being of an infectious nature, and accordingly the majority of investigators have now expressed themselves in favor of the opinion that erythema exudativum multiforme is of au infectious nature. Neisser believes in miasmatic climatic influences.