Postgrad Med J: first published as 10.1136/pgmj.4.44.127 on 1 May 1929. Downloaded from 9sTeTIHE G&ADuIITE MEDICAL JOU1NAL

VOL. IV; MAY, I929. No. 44.

CONTENTS PAGE PITFALLS IN ...... 127 By A. C. ROXBURGH, M.D., M.R.C.P. PYELO-NEPHRITIS IN CHILDREN ...... 135 By HAZEL H. CHODAK GREGORY, M.D., M.R.C.P.LOND. FIBROSIS OF LUNG IN CHILDREN ...... 140 By L. S. T. BURRELI., M.D., F.R.C.P ...... 143 SURGICAL RESURRECTIONS-IV...... 141 EDITORIAL ...... I43 copyright. POST-GRADUATE NEWS ...... 143 FELLOWSHIP 'OF MEDICINE AND POST-GRADUATE MEDICAI, ASSOCIATION.-

SPECIAL COURSES ......

PITFALLS IN the diagnosis which he is at first inclined http://pmj.bmj.com/ to make, and with the points in favour of DERMATOLOGY. each. I propose therefore to talk to you about A POST-GRADUATE LECTURE DELIVERED TO THE' 'ELLO\\'- the differential of a number of SHIP OF MEDICINE AT THE MIEDICAL SOCIETY OF ,0ONDON, diagnosis FEBRUARY 18, 1929. conditions commonly met with which are

apt to be confused one with another. You on September 29, 2021 by guest. Protected ,3y A. C. ROXBURGH. will realize, of course, that the list is far MI.D., M.R.C.P.., from complete. Physiciant - itn - Chargc of the Skinl Depalrtmenlct, St. Take first the common condition, small- Bartholomew's Hospital; Physicilan to St. .lohn's Hospital spored ringworm of the scalp. This is for Discases of the Ski,n. often confused with . The principal points to remember are, first, that IN the diagnosis and treatment of skin small-spored ringworm does not occur in disease there are many pitfalls for the un- persons over the age of I4 years. The wary, especially for those who are not next point is the character of the skin accustomed to see many skin cases in the surface. In ringworm this is scaly, and in course of their daily work. Many mistakes alopecia areata smooth and shiny. The in diagnosis arise from the unfamiliarity of third point is the character of the the physician with possible alternatives for stumps. In ringworm these are plentiful Postgrad Med J: first published as 10.1136/pgmj.4.44.127 on 1 May 1929. Downloaded from

128 PITFALLS IN DERMATOLOGY and are present all over the surface of the light, while the normal hair looks only as affected patch. In alopecia areata they are though it had been lightly dusted with flour. usually scanty and only found near the By this means even one infected hair on periphery of the patch. The stumps them- an otherwise healthy scalp can be easily selves in ringworm are dull, inelastic, often identified. bent in the middle and, if examined in infected with large-spored ringworm liq. potassa under in. objective, are seen are not nearly so easy to see, as they fluoresce to have a coating of spores in the form of less brightly and with a bluish tint. A pit- a mosaic. In alopecia areata the stumps fall in this method is that if the hairs have are shiny and elastic like normal hair, that been recently painted with iodine or silver is, they spring back to their previous niitrate, or have had chrysarobin ointment positlOio if the finger is drawn over them applied, they will not fluoresce. against the lie of the hair. They are also A form of ringworm which sometimes of the shape called " exclamation mark " (!), causes difficulty is due to a large-spored that is, they are of the normal thickness at endothrix fungus, and is known as " black- the free end and very thin and depigmented dot" ringworm. In these cases the stumps at the inserted end. are broken off level with the skin surface Remember that not all the hairs in a and appear as black dots somewhat re- patch of ringworm are infected, and it is no sembling comedones. They have to be use sending hairs to a laboratory for micro- extracted wvith a needle or a ex- scopic examination unless you are able to presser for microscopic examination. This select with the aid of a hand lens the hairs type does not die out at pubetty and maycopyright. which are probably infected. A good be found in adults. method is to rub the suspected patch well Difficulty may arise in the diagniosis with ether on a swab, to remove all grease, between alopecia areata and syphilitic and then examine with a hand lens in a alopecia. In alopecia areata there are g.ood light and look for short, dull, or usually a small number of completely bald

whitish, bent hairs. Pull some of these out patches with sharply marked margins, and http://pmj.bmj.com/ and, if you are goinig to examine them your- possibly exclamation-mark hairs. In syphi- self, place them on a slide in liq. potassa litic alopecia there are a large number of under a cover glass. Warm over a flame irregular small patches, none completely anid then examine with - in. objective. You bald, involving most of the back and sides will see, in infected hairs, parts where the of the head and running into one aniother. hair is encased in a sheath of small, uniform- The result is to give a " moth-eaten " sized, perhaps polygonal, spores. Fat appearance. Other sigins of such on September 29, 2021 by guest. Protected dr-oplets sometimes provide a pitfall, but as adenitis, a , or mLcous patches will these are always of various sizes and never probably be present and will assist materially polygonal. in the diagnosis. In neither of these forms Examination by Wood's light in a dark of baldness is the skin scarred. There are, room is a great assistance. This is light however, a number of conditions leadinig to from a mercury-vapour lamp or other patchy baldness in which the affected areas source of ultra-violet light passed through are scarred, the skin being atrophic and the Wood's glass, the latter being a dark violet follicles absent. Some of these are as glass containing oxide of nickel. It allows follows:- certain of the long-wave ultra-violet to pass, Pseudopelade or cicatricial alopecia, a but very little else. This ultra-violet causes rare condition in which numerous small hairs infected by small-spored ringworm to atrophic bald patches occur, which coalesce fluoresce and shine brightly with a greenish to form irregular areas, generally on the Postgrad Med J: first published as 10.1136/pgmj.4.44.127 on 1 May 1929. Downloaded from

PITFALLS IN DERMATOLOGY 129 vertex. There may be a faint pink or viol'et the commonest causes of diffuse fall of hair. halo about the hairs at the periphery of the The areas affected are the vertex and frontal patches. regions. These are also the areas from erythematosus causes depressed which the hair first falls in men who have an bald scars on the scalp, generally an inch or- hereditary tendency to early loss of hair. two in diameter. The follicles have dis- In hereditary early baldness and in the oily appeared in the centre and at the periphery type of seborrhoea the prognosis is not are filled with horny plutgs. There is usually good, but in the dry scaly type a good deal some at the margini of the patch. can be done. Diagnosis is easy if typical lupus erythemina- Diffuse fall of hair in women after the tosus is present on face, ears, or hands, but m-enopause is often associated with hypo- occasionallythe disease is limited to the scalp. thyroidism, of which there will probably be Localized (morphcea) may other signs to assist in the diagnosis. also cauise depressed bald scars on the scalp, Remember that alopecia areata sometimes possibly pigmented, and perhapswith a violet- involves the whole scalp very rapidly anid coloured border, but there is nio plugginig is the commonest cause of complete of the follicles as in lupus erythematosus. baldness. When the hair has been missinlg Herpes zoster frontalis may cause scars in for six months the chances of its return the distribution of the supra-orbital branch become progressively worse. of the fifth cranial nerve, but there will Scaliness of the scalp is due usually to probably be scars on the forehead, too, one of three causes: ringworm, seborrhoea, which will assist in the diagnosis. or . Ringwor-m of the scaly type copyright. Favus may cause extensive scarring on is uinlikely to be found in adults. In the scalp of an irregular type. Some of the seborrhoea the scaliness is usually diffuse, yellow " favus cups" may still be present iln or if patchy the patches fade gradually into places, and the "mousy" odouir of the disease lhealthy skin. There may be of may be noticeable. seborrhwea corporis over the sternum and Kerion, an acute purulent inflammatory between the scapulae, or of seborrhceic http://pmj.bmj.com/ reaction to ringworm , may cause dermatitis in the flexures. bald patclhes which are occasionally per- Psoriasis of the scalp is usually patchy, manent. In the active stage the inflamma- and the patches have absolutely sharp tion is obvious and infected hairs may be margins. There is generally psoriasis on the foulnd at the periphery. Wounds and body or limbs also, which gives away the nay also leave permanently bald scars. diagnosis. Permanent baldness due to over-dosage Pustular lesionis on the scalp are not neces- on September 29, 2021 by guest. Protected with] X-rays in the treatinent of ringwormii sarily boils; they may be patches of kerion, can ustually be recogniized by the presence of that is, inflammatory ringworm. Iniflamma- other signs of ani old X-ray dermatitis, i.e., toiry ringworms of animal origin occasionally scarrinig, pigmentaticn, and telangiectases. occur oIn the scalp in adults; the diagnosis Diffuse fall of hair has several causes, and can be made by examininig hairs for fungus. it is important to distingUish- them. A few Red scaly lesions on the forehead at the weeks after an acute febr-ile illness, especially hair margin may be due to seborrhcea, influenza, the hair may begin to fall rapidly psoriasis, or secondary syphilis. Examina- all over the scalp. In such cases the tion of the scalp and of the rest of the body prognosis is good and the hair will probably will usually clear up any dotubt there may retuLrn to its previous strength and quality. be. Seborrhoeic infection of the scalp, whether A pitfall which catches maniy is the dia- of the oily or dry scaly variety, is one of ginosis between circinate contagiosa Postgrad Med J: first published as 10.1136/pgmj.4.44.127 on 1 May 1929. Downloaded from

130 PITFALLS IN DERMATOLOGY on the face and ringworm. It is important is very slow and takes a year or more to do to avoid this trap, because paintinig an what syphilis will do in a month. In lupus impetigo with iodine frequently makes it vulgaris the edge of the is irregular worse. The principal point for diagniosis and conitains apple-jelly nodules. The scar is that in impetigo the ring is made up of where the disease has nearly died out is the continuous edge of one big whose fairly thick and contains apple-jelly nodules. centre has disappeared. Whereas in tinea If the nose is affected it is the tip, and the circinata the ring is made up of a large cartilages of the ala which are likely to be number of small lesions, vesicles or pustules, lost. There is little or no tendetncy to set close together. In impetigo there may be spontaneous cure. elsewhere typical crusted lesions. Impetigo In tertiary syphilis of the type liable to be may also be confused with a patch of herpes confused with lupus vulgaris the progr-ess recurrens onl the face. Here again the fact is relatively rapid; the edge tenids to be made that a patch of impetigo represents one big up of segments of circles, the nodular lesions blister is helpful, for a patch .of herpes is are larger than the apple-jelly nodules of made up by the massing together of a lupus and less translucent. The cenitral scar number of tiny . It is just as well to is tlhin and may be pigmented and contains be able to distinguish these because, although no nodules. I think this latter point is often there is not much difference in the treat- of great assistance. The lesions tend to ment, the prognosis is different; impetigo is spontanieous cure in the centre while spread- not likely to recur, while herpes recurrens ing at the periphery. If the nose is affected mav become a perfect pest to the sufferer the bony bridge is more likely to be attackedcopyright. from it. than the cartil-ages. The Wasse-rmann re- Lesions on the region. Staphy- action will probably be positive, and the lococcal sycosis is familiar to all of you. effects of antisyphilitic treatment will usually Remember that ringworm can be rapid. cause a somewhat similar condition which Confusion) sometimes arises between

requires different tr-eatment. Ringworm anid vulgaris, the more so as http://pmj.bmj.com/ infections on1 this area tend to be much more the two conditions may be present together. nodular, and sometimes cause the formation Acne vulgaris is typically a disease of the of quite large purplish lumps. It may be young from 14 to 30 years. Rosacea, of the difficult to find the fungus, as the heavily middle-aged, from 30 to 5O. The essential infected hairs fall out owing to the jeature of acne vulgaris is the blackhead or of their follicles. comedon. Any redness there may be is the A localized rinigworm of the beard has result of infection of follicles and tends to on September 29, 2021 by guest. Protected to be distinguished also from a form of be localized. In rosacea the r-edness is the tertiary syphilide, which is not uncommon primary feature, and is diffuse, affecting the and is called frambcesiform. This is a warty forehead, cheeks, nose, and chinl. The plaque on the cenitre of the chin or about chr-onic paralytic distension of the small the angles of the mouth or nose which is vessels of the skin in these regions leads easy to recognize wheni you hiave seen one sometimes to hypertrophy of the sebaceous or two. The absence of fungus and the glands and secondary suppuration, but never presence of a positive Wassermann reaction to the formation of blackheads. (usually), and the effect of antisyphilitic It is important to distinguish the two con- treattnent, will clear up the diagnosis. ditions, because in rosacea it is essential to A differential diagniosis sometimes has to treat the indigestion which is usually present, be made between lupus vulgaris and tertiary while in acne vulgaris the digestion is seldom syphilis of the tubero-serpiginious type. The at fault. principal points to r-emember are that lupus Rosacea may be confused also with Jupus Postgrad Med J: first published as 10.1136/pgmj.4.44.127 on 1 May 1929. Downloaded from

PI'I'FALLS IN DERMATOLOGY 131 PIFAL INDRAOLG.3 erythematosus, in cases where the latter has To come to the trunk, an important dia- caused sym-metrical red patches on the cheeks. gnosis-sometimes has to be made between A close examination with a lens will probably scarlet fever and recurrenit scarlatiniform reveal, in parts of the lupus erythematosus erythema. This, may be very difficult, but patches, a fine stippling, produced by the the chief points to rely on are: in scarlet plugging of the openings of the follicles and fever the onset is more acute, the throat the sweat-ducts with little, horniy plugs. more painful, and there may be vomiting. There may be otlher evidence of lupus The temperature is higher (IO4° F.). The erythematosus on finigers or ears, or depressed pulse mnore frequent (I40-I60). There scars on the scalp. are often enlarged lymphatic glands. The The diagnosis of small tumours. on the tongue in scarlet fever is furred, with red face provides a niumber of possible pitfalls. papillx projecting through the fur, anid Remember that the possibilities are when the fur clears the papillae are still squamous-celled carciinoma, basal-celled large, making the tongue rough. In scarlet carcinoma (rodent ), molluscum con- fever the rash begins on the second day on tagiosum, sebaceous , mole, , and the face, neck, or chest; it fades after six to , besides a few rarities with which I will seven days and peeling of the " perforative " not trouble you. type begins after the rash has faded. There The squamous carcinoma is very rapid in may be some albuminuria and second its growth, and in a matter of weeks will attacks are rare. reach a size that a basal-celled carcinoma In scarlatiniform erythiema there may be would take years to attain. The squamiiouis a history of previous attacks, the onset is copyright. carcin-oma also is more opaque than the less acute, the throat less sore, there is no basal, and may have a little scaly patch iri vomiting, the temperature is lower (ioo° to the centre. The basal-celled carcinoma is IoI° F.), and the pulse less frequent. There very slow in its growth, relatively translucent, are no enlarged glands. The tongue is at and the centre has a tendenicy to be depressed. first futrred, later smooth and bare, but never

Transitional forms are often miiet with, how- of the " strawberry " type. The rash begins http://pmj.bmj.com/ ever, in which the diagniosis canl only be after a few days of preliminary symptoms made by sectioni. Molluscum conitagiosLIM and usually starts on the limbs or trunk. is usually multiple, and the little pearly trans- The rash rnay last for weeks or months, but lucent tumours have each a dull spot in peeling begins on the second or third day the centre through which the caseous mass while the skin is still bright red. This is can be extruded by pressure. They seem to perhaps the most important diagnostic lie upon, rather than in the skin. Sebaceotus point. The peeling is of the " branny " on September 29, 2021 by guest. Protected are yellowish white and opaque in type. There is no albuminuria anid the appearance, and the contents can be ex- disease has a tendency to recur. pressed through a puncture. A mole has Of the maculo-papular on the usually a long history and it may be either trunk, two which are ofteni confused are soft or hard, and pigmented or hairy, or and the mactular secondary both. svphilide or roseola. A wart can usually be recognized by its Pityriasis rosea usually beginls with a rough warty surface, and ther-e may be "herald patch," which is slightly red and others, but sometimes a single wart of recent slightly scaly and lasts for a week or so and rapid growth is very difficult to tell from before the general eruption begins. This, a squamous epithelioma. when it appears, comes out rapidly on the A boil is of course usually easily recog- neck, trunk and upper parts of the linbs, the nized, but a small infected epithelioma may so-called " vest and drawers" area. The be mistaken for one. characteristic lesion of pityriasis rosea is a Postgrad Med J: first published as 10.1136/pgmj.4.44.127 on 1 May 1929. Downloaded from

132 12PITFALLS IN DERMATOLOGY pink, oval, macule tending, on the trunk, to Lichen urticatus may have to be diagnosed have its long diameter parallel with the ribs. also from , as both are extremely itchy It soon becomes fawn-coloured and wrinkly and lead to scratching and secondary inifec- in the centre, and then begins to peel from tioIn, so that the final picture may be much the centre outwards, so that a collar of scales alike. Here let me remind you that the first is visible with its free edge towards the centre, thing to do when confronited with any and its attached edge at the periphery. One itching eruptioni in any patient, of any age or or two typical lesions can often be found on station in life, is to exclude scabies. Many a the flank, if the majority of the lesions do case of scabies is missed because the doctor not show these characters. There is no did Inot think of it as likely in a patient in adenitis or sore throat and the patient feels such good circumstances. I remember a well. The eruption mav itch quite lady who had been itching for eighteen considerably, or not at all. months and had been treated by all sorts of The macular secondary syphilide occurs methods, including a prolonged stay in a chiefly on the trunk. The macules tend to nursing home on a strict diet, and yet got no be round and evenly spaced. The follicles better but rather worse; and all because no on them may be rather prominent. Some of one had apparently realized thai the trouble the macules may be becoming papular and was scabies ! rather brownish and infiltrated. Other In scabies there are two types of lesion, the signs of syphilis canl usually be found if well-known " buirrows " and also a red, folli- looked for. Such are headache, alopecia, cular i-ash on the trunk, which is presumably

adenitis, mucous patches in the mouth, sore toxic. The sites where one is most likelycopyright. throat and, possibly, a primary sore and to find burrows are the ulnar borders of the moist on the scrotum or at the hanids, the front of the wrists, betweeni the anus. There is no itching. The Wasser- finigers, the anterior axillary folds, the manni reaction also will be positive. buttocks, the inner sides of the feet and Another pitfall is provided by the dia- ankles, around the nipples in women and on

ginosis, in children, between varicella and the peinis in men . An itchy rash distributed http://pmj.bmj.com/ lichen urticatus (or papulai- urticaria). of on these areas, or several of them, is gener- the vesicular type. This may be extremely ally worth treating as scabies, even if no difficult. In varicella there is generally some actual burrows can be identified. fever, the rash usually begins on the upper Another pitfall is provided by pediculosis trunk and spreads downwards, lesions may corpor-is, for this is surprisingly common in be found on the scalp, and on the mucous elderly people, even in good social circum- membranes of the mouth and vulva. stances. The primary lesions are red pin- on September 29, 2021 by guest. Protected Itching is slight or absent. One attack point macules with pink halos, which usually protects. There may a history of represent the bites of the insect, but the association with other cases or with a case most striking ones are the severelinear scratch of herpes zoster. marks which the patient makes on the backs In lichen urticatus there is no fever, and of his shoulders. It may be possible to find the rash may appear anywhere on the trunk the parasite by examining the neck or or limbs. It seldom affects the scalp and seams of the underwear or shirt, but often never the mucous membranes. The one has to rely on the scratch marks for a itching is very pronounced but ceases probable diagnosis. The pediculus, as when the top of the lesion has been Norman Walker remarks, spends its leisure scratched off. The eruption may go on on the clothes-and onily adjourns to the skin for weeks or months, and there may be a for its meals, so that it tenids to bite places history of previous attacks. where the clothes make good contact with Postgrad Med J: first published as 10.1136/pgmj.4.44.127 on 1 May 1929. Downloaded from PITFALLS IN DERMATOLOGY 133 the skin, such as the shoulders and the again, an inspection of the toes may be of upper part of the buttocks. use. Dermatitis her-petiformis is another itching OIn the feet, plantar and corns are disease which may be widespread and tends often confused, and it may be helpful to to recur. The lesions may be erythemato)us remember that most lesionis of this sort on blotches, grouped vesicles, or bulke, some of the plantar surface are warts, not corns. which are generally scratched and scabbed. Warts usually have a somewhat uneven or Sites of old lesions are shown by scars and " warty" surface, and there is usually at the patches of pigment. A typical case does edge of each a sulcus into which a small not suggest scabies particularly, but during blunt instrument can be inserted. Corns the war most cases occurring in the troops have a smooth, domed surface with no were diagnosed as scabies, until, upon the sulcus at the edge. failure of treatment, they were seen by a On the arms papulo-necrotic tuberculides dermatologist. may be mistaken for boils. The tuberculides I will not deal here with the differential are indolent, compared with boils, being diagnosis betweeni primary syphilitic and more purple, less red, and less tender. They other penile sores, for although the subject leave characteristic depressed, oval, white is one of the first importance it is thorouighly scars, especially about the elbows and dealt witlh in many textbooks. shoulders. There may be a history, or Let us now take the diagnosis of red, evidence, of tuberculous glands to assist in moist, irritating lesions in the flexures such the diagnosis. as the groins, perinetum and axillze. These On the hands, again, papulo-inecrotic may be duLe to seborrhlceic dermatitis, ring- tuberculides may be takeni for broken chil- copyright. worm, intertrigo, or flexural psoriasis. blains, the more so as they are apt to occur In seboirrhcic dermatitis the patch is in persons with a " chilblain-circulation," scaly with a definite, or sometimes a rather and to be worse in the winter. The tuber- indefinite edge, and outlying red follicular culides ar-e smaller, more indolent ancd pain- papules, and the patient nearly always has less, and leave their characteristic scars, seborrhcea of the scalp. while chilblains are larger, more inflamed and http://pmj.bmj.com/ In ringworm the edge is sharply marked painful, and their scars are irregular in type. and the lesionis are most active near the A simple eczema of the nipple is not un1- edge. Fungus can usually be found ill commonl, and should not be mistaken for scales, anid if the toes are examinied it is very Paget's disease. The principal points are likely that white soddeni skinl containing that the eczema may occur at any age, and fungus will be found between the fourth and is often bilateral. It tends to get better and on September 29, 2021 by guest. Protected fifth toe on one or both feet. worse. The edge may be ill-defined, the Initertrigo, i.e., an infection of the 'Moist surface is less bright red than in Paget's of a flexure with streptococci, or disease, there is no induration, and the possibly yeast fungi, has a less definite edge nipple is not altered in shape. Paget's and is less scaly thani ringworm. disease usually occurs after 40, and is uni- Flexural psoriasis is-usually of a uniform lateral. Its progress is slow but constant. red coloUIr vitli a sharp edge, anid there may The edge is well-defined, the surface is be recognlizable psoriasis elsewhere. bright red, and there is pronouniced indura- Remember that it is generally worth tion, which is described as feelinig like a examining the sodden peri-anal skin of a penny wrapped in flannel. The nipple is case of pruritus ani for ringworm fungus, flattened or retracted, and a biopsy or since, if you find it you will be able to cure examination of scrapings will show the the prurituLs without muich difficulty. Here, characteristic "round bodies." Postgrad Med J: first published as 10.1136/pgmj.4.44.127 on 1 May 1929. Downloaded from 134 PITFALLS IN DERMATOLOGY

There are two bullous eruptions in infants affected areas are r-ed, not brownish, and which it is important to distinguish, viz., may become excoriated to for-m shallow bullous impetigo ( neonatorum), ulcers. There may be a similar patch on anid the rare btillous syphilide. Bullous each heel where this has been in conitact itnpetigo is never present at birth. It in- with the outside of the wet napkin. The volves chiefly the trunk and may cover baby is otherwise healthy and shows no large areas. It does not occur on the palms eruption about the mouth. or soles. It is not symmetrical. The baby Two other eruptions on this area may is well-nourished and- shows no evidence cause trouble in diagtnosis, as they both of syphilis. The mother or nurse may show extend into the flexures about the buttocks the lesions of ordinary impetigo. and thighs, viz., impetigo and seborrhceic The rare bullous syphilide, on the other dermatitis. Impetigo appears as bright red, hand, is present at birth or appears within shiny, moist, or excoriated areas with three to five days; it is symmetrical, chiefly phlyctenular margins, chiefly in the flexures, onl the wrists and ankles- and on the palms with outlying smaller areas and, possibly, and soles. The lesions dry up into reddish typical impetigo elsewhere. Seborr-hceic brown scabs, the baby is wizened and shows dermatitis forms sharp-edged red sheets, other signs of syphilis, such as papular covered with greasv-looking scales involving eruptions about the mouth, enlarged liver the flexures or the whole of the napkin area. and spleen, &c. Spirochceta pallida can be It may be present also in the axillae and on found in large numbers in the fluid from the the face and neck. The mother or nurse bullae. probably will be found to have seborrhoea There are two other eruptions in babies of the scalp. copyright. whose provides a pit Disorders of pigmentation sometimes into which it is easy to fall; these are con- cause difficulty. You are probably all genital syphilitic eruptions on the buttocks, familiar with chloasma uterinum, the and napkin rashes, sometimes called ery- brownish patches which appear on the themas of Jacquet. Typical cases of each forehead and cheeks, especially of brunettes, are easy to distinguish, but sometimes cases during pregnancy, anid do not always fade http://pmj.bmj.com/ are not clear cut and are very difficult to away completely afterwards. Pigment also decide about. The poinlts to which you appears in the areola of the nipples and the should attend are these. The syphilitic middle line of the abdomen. eruption is essentially a papular one, the In Addison's disease, pigment, varying papules are brownish red, and about 1 to from light yellow' to deep brown, and

i in. across. They extend into the flexures generally diffuse, appears, chiefly on the ex- on September 29, 2021 by guest. Protected and may be most marked there. There posed parts, suich as the face anid hands, and are probably other signs of syphilis on areas normally pigmented, such as the present, e.g., the -baby is wizened, has a nipples and genitalia. Also where the skin hoarse feeble cry, snuffles, and a maculo- is habitually compressed or irritated, e.g., papular eruption about the mouth and nose, round the waist, and on the mucous mem- and probably an enlarged liver and spleen. branes of the mouth, conjunctiva, and vagina. The napkin rash, on the other hand, is a There may be spots of deeper pigmentation traumatic dermatitis duie to wet and dirty on the diffusely pigmented areas. The low napkins remaining in contact with the skinl. blood-pressure and asthenia will generally It is therefore most marked on the convex give the clue to the diagnosis. surfaces of the folds about the baby's AIrsen1ical pigmentation is found in those buttocks and -thighs which get rubbed by who have ingested arsenic over long periods, the napkin, while the flexures escape. The either medicinally or by accident. It occurs Postgrad Med J: first published as 10.1136/pgmj.4.44.127 on 1 May 1929. Downloaded from PYELO.NEPHRITIS IN CHILDREN 135 chiefly on the trunk and is diffuse, but or tar, usually on the peiiis, scrotum, and deepest on areas normally pigmented. A arms, while bromides and iodides can pro- characteristic feature is that the brown area duce pustular lesions resembling acne, but is dappled over with lighter spots, as though without comedones, on the face and back. it had been rained upon, the so-called " rain- Iodides may produce also fleshy masses drop pigmentation." Arsenical pigmenta- resembling gummata or sarcomata on the tion is usually accompanied by keratoses on face, forearms, and hands, and if these are mis- the palms and soles and possibly by other taken for gummata the iodide mnay be pushed signs of arsenical poisoning. and the condition aggravated. Bromides There are two types of depigmentation may produce papillomatous masses covered which should not cause difficulty in dia- with numerous points exuding , espe- gnosis,viz., and syphilitic leucoderma. cially on the legs. These may persist for Vitiligo occurs anywhere, often on the hands, some time after the ingestion of the drug face and neck. The areas are irregular, often has been stopped, and so lead to difficulty large, thl-e margins of the patches are sharp, in diagnosis. and there is often around the patches. When the areas involved are large, sometimes it is difficullt to decide which is the normal skin, the white or the PYELO-NEPHRITIS IN dark. The convex edges of the white patches CHILDREN. enable one to recognize that it is the white which is abnormal, while the dark is normal. ay HAZEL H. CHODAK GREGORY, Syphilitic leucoderma is almost confined M.D., M.R.C.P.LOND. copyright. to the sides of the neck; the areas are small, oval, and of uniform size. They fade THE term " pyelitis" lhas been used so widely gradually into the darker areas, giving a very and for so long that few pause to ask characteristic dappled effect. themselves whether there- are, or ever have Dermatitis artefacta is generally easy but been, any anatomical grounds for that name. sometimes difficult to diagnose. It always It has been assumed, and is generally. http://pmj.bmj.com/ occurs on places which can be reached by taught, that an/infection may arise in the the patient. The appearances are usually urinary passages, either starting below as a odd and not like any known skin disease. result of urethral invasion, or above as a They may be produced in various ways, e.g., result of blood infection, and concentrate by applying lysol or carbolic acid to the itself on the pelvis of the kidney which thus and skin, or merely by rubbing with a wet finger. becomes the main focus of inflammation on September 29, 2021 by guest. Protected The patients are usually women and often pus formation. Variationls of the term, such show evidence of h'steria, e.g., anaestllesia as pyelo-nephritis, pyelo-cystitis, indicate an of the bulbar conjunctiva and soft palate, extension of the inflammatory process up- and suggestion anaesthcsia to pin pricks. wat-ds or downwards, but the assumption is They often seem really to be unaware that that the pelvis is, the actual site of disease. they produce the lesions themselves, and it It is interesting to read in medical text- is generally impossible to persuade the books circumstantial descriptions of the sympathetic relatives, and sometimes even appearance of the renal pelvis at various the family doctor, that the lesions are stages of so-called pyelitis, although it is artificial ! probably true that, in children at least, no I will close with a word about drug etrup- one has ever seen a simple pyelitis in the tions. Remember that acneiform lesions post-mortem room, and any pyelitis observed with comedones can be produced bychlorine in the operating theatre will have been a