HERPES SIMPLEX¹

Synonyms.—Herpes, Fever blisters; Fr., Herpès vulgaire; Ger., Bläschenflechte.

Definition.—An acute inflammatory affection characterized by
the formation of pin-head­ to small pea-sized vesicles, grouped, and
occurring about the face or genitalia.

Symptoms.—The eruption is commonly foreshadowed by a feel­
ing of heat and burning in the part. It generally consists of but one
or two groups, which may be small or large; or several or more clusters
may present. The vesicles, which are usually seated upon a hyper-
emic or mildly inflammatory base, are pin-head or slightly larger in size,
often crowded close together so that sometimes it may be somewhat
difficult to make out their individuality; this is especially so on the lips,
but on other parts of the face the lesions, while grouped, are quite clearly
discrete. They are distinctly vesicular, with clear contents, subsequently

¹ Knowles, “Herpes Simplex,” New York Med. Jour., Aug. 7, 1909 (full review of
the subject).

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becoming more or less milky, and may exceptionally change to a seropuru-
lent or purulent character. They show no tendency to spontaneous
rupture, but should they be broken open, a superficial abrasion or excori­
ation results, crusts over, the crust subsequently falling off. As a rule,
however, they remain unbroken throughout, and gradually dry to thin
crusts of a yellowish or brownish color, which finally drop off and leave
no trace. In some cases in which the lesions may be few and the conse­
quent group small and insignificant, the contents may be reabsorbed, and
the disease be shortened or aborted. There are, as a rule, no systemic
disturbances; never in the cases in which the eruption is upon the
genitalia, probably for the reason that it is always scanty; on the face,
when the eruption is somewhat extensive, there may be, in severe cases,
more or less malaise, pyrexia, and chilliness preceding and accompanying
the early part of the outbreak.

Fig. 81.—Herpes simplex of somewhat extensive development in a girl of ten years,
of four days’ duration. Outbreak preceded by slight, evanescent febrile action. Char­
acteristic grouping and coalescence; crusting stage already reached on the lips.

While the facial and progenital region are the usual seats of herpes
simplex, yet instances are not rare in which the eruption (usually a
single patch) occurs on other parts. In occasional instances there is not
only a tendency to recurrence, but to recurrence on the same spot;¹
the lips, chin, cheek, and buttock are favorite localities for this recurrent
type. I have seen several children in whom a patch had so presented on
the cheek once or twice yearly for several years or more.

Herpes Facialis.—The herpetic clusters—one or several—may be
limited to the lips (herpes labialis); or appear on the skin near the mouth,
chin, under or near the ala of the nose, or on the cheek, or elsewhere

¹ Dubreuilh, “De l‘herpes récidivant de la face chez les enfants,” Jour, de Méd. de
Bordeaux” Aug. 11, 1907, records several such instances and refers to several other
papers of his own and others recording cases in which the recurrence was in the same
place; Adamson, Brit. Jour. Derm., 1909, p. 321, records 4 cases of a patch of herpes
recurring on the fingers, in 2 of which had been previous attacks in the same place;
and adds to these and reviews subject, with bibliography, ibid., 1911, p. 322, “Recur­
rent Herpes of the Buttocks.”

HERPES SIMPLEX

345

on the face. Occasionally the seat of the patch or patches is the ear,
commonly the auricle. When on other parts than the lips or mucous
membrane, the eruption is occasionally quite abundant. The skin is
hyperemic or slightly inflamed. The malady is also seen in the mouth,
and shows two, several, or more vesicular lesions crowded close together.
At first small, the lesions often increase in the course of some hours or
one or two days to the size of a small French pea. There is heat or burn­
ing and, rarely, itching.

After several days, or earlier in slight cases, they begin to dry up,
and form a thin crust, which in the course of two or three days drops
off. Sometimes one or two of the vesicles are broken and the patch
is then excoriated at these points, serum oozes out, which dries to a
thin yellowish crust. In some instances, especially on other parts
than the lips, the lesions may coalesce and form a small bleb; as a rule,
however, this does not take place. Unless irritated, the crust formed
drops off in from several to ten days after the disease has first presented.
When near or at an angle of the mouth, from the act of opening and
shutting the mouth, slight fissuring is sometimes noticed, and the con­
stant irritation of the food and saliva may keep the part macerated and
sore for one or two weeks or longer. In some instances of considerable
eruption slight febrile action precedes. A form of “herpetic fever” has
been recorded from time to time, occurring epidemically (Savage, Sea-
ton),¹ usually preceded by a rigor or distinct chill and other symptoms
of general disturbance; the outbreak is generally limited to the lips and
region of the mouth, in some cases involving also the ears.

Herpes Progenitalis.—Herpes about the glans and prepuce in the
male, and the vulva in the female, is also not uncommon. It may
consist variously of one or several groups, but it is rarely seen in such
abundance as frequently observed on the face. Slight burning and itch­
ing are usually first noted, rapidly followed by the appearance of a slightly
red, and sometimes a little puffy inflamed area, upon which are soon seen
several or more minute vesicular points, which slowly increase to the size
of a pin-head, sometimes larger. They dry up, or the contents are ab­
sorbed; slight crusting ensues, and the disease, under favorable circum­
stances, in the course of several days or so disappears. Or the lesions may
be rubbed or chafed, rupturing taking place, giving rise to one confluent
excoriated surface or several excoriated points; and then the duration is
usually much longer, inasmuch as the surface is continually irritated by
the secretions and probably occasionally by the urine, and resulting in a
slight abrasion or even superficial ulceration, which may give rise to con­
fusion with a soft chancre. The eruption may be seated upon the outer
prepuce or inner prepuce (herpes præputialis) or the glans in the male; and
on the labia minora or labia majora in the female; in the former, too, a
patch is sometimes observed further down on the sheath of the organ, and
in women just beyond the labia majora.

Etiology and Pathology.—Herpes facialis is often observed in
association with other diseases, such as colds (cold sores), fevers (herpes

¹ Savage, Lancet, Jan. 20, 1883; Jour. Cutan. Dis., 1883, p. 253; Seaton, Trans.
Clin. Soc, London, 1886, p. 26.

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febrilis, fever sores), lung disease, malaria, and digestive disturbances.¹
In some individuals an attack of indigestion will lead to an outbreak.
Long exposure to the sun, more especially when on the water, is some­
times provocative. An irritable or decayed tooth seems in some instances
of recurrent cases the exciting factor.

Herpes progenitalis is believed, in the male subject at least, to be
much more common in those who have previously had some venereal
disease (Greenough, Diday and Doyon, Fournier, and others),² more
especially gonorrhea; while this is unquestionably true, doubtless this
apparent overwhelming frequency may, in part, be explained by the
fact that individuals addicted to sexual indiscretions are readily alarmed
by the appearance of any lesion on this part, and thus come more fre­
quently under the eyes of the physician than those who have no reason
to be suspicious. A long prepuce predisposes to it, and coitus is also
often the exciting factor; in some instances an attack follows each in­
dulgence. Bergh³ found that in women an outbreak is concomitant
with, precedes, or follows menstruation, and that in women it is not a
“professional” (prostitute) disease, although Unna's⁴ experience does not
agree with this. As to relative frequency in the two sexes, it is the
general opinion that it is much more common in the male, although
Unna‘s and Bergh‘s statistics do not bear this out, the last named, in
fact, believing it more common in women.

Herpes is certainly neurotic It is possible that it may depend
upon reflex irritation of the neighboring sympathetic ganglia, due to
local or internal irritation. In fact, the disease is considered by some
to be an abortive or irregular zoster, a view scarcely to be accepted.
Kopytowski⁵ found considerable histologic analogy between herpes
progenitalis and zoster.

Ravaut and Darre,⁶ from their experimental study of 26 cases (7
men, 19 women) of lumbar puncture in genital herpes, found that all
cases accompanied by any nerve symptoms (as well as many without
such symptoms) presented some modification in the cephalorachidian

¹E. F. Wells, “Pneumonic Fever—Its Symptomatology,” Jour. Amer. Med. Assoc,
May 26, 1894; statistics of his own cases and those of others quoted show that herpes is
observed in a large proportion; Arthur Powell, “Prognostic Value of Herpes in Malarial
Fevers,” Brit. Jour. Derm., 1897, p. 354 (always favorable); Schamberg, “The
Nature of Herpes Simplex and the Diagnostic and Prognostic Significance in Various
Infectious Diseases,” Jour. Amer. Med. Assoc, 1907, vol. xlviii, p. 746 (with refer­
ences); Rolleston, “Herpes Facialis in Diphtheria,” Brit. Jour. Derm., 1907, p. 375
(in 4.2 per cent, of his cases; with brief review and references); Knowles, “Herpes
Simplex,” New York Med. Jour., Aug. 7, 1909 (with bibliography); Rolleston, “Herpes
Facialis in Scarlet Fever,” Brit. Jour. Derm., 1910, p. 309 (in 6.5 per cent, of his cases;
bibliography).

² Greenough, “Herpes Progenitales,” Arch. Derm., 1881,p. 1; Diday and Doyon,
Les hérpès genitaux, Paris, 1886; Fournier, Gaz. med. de Paris, 1896, Jan. to May.

³ Bergh, “Ueber Herpes menstrualis,” Monatshefte, 1890, vol. x, p. 1 (a complete
review with many references).

⁴Unna, “Herpes Progenitalis, Especially in Women,” Jour. Cutan. Dis., 1883,
p. 321. This paper, and the several preceding, all on genital herpes, are full and
exhaustive and give many literature references.

⁵ Kopytowski, Archiv, 1904, vol. lxviii, pp. 55 and 387 (clinical and pathologic
study of 24 cases of herpes progenitalis).

⁶ Ravaut and Darre, “Les réactions nerveuses au cours des herpès génitaux,”
Annales, 1904, p. 480.

HERPES SIMPLEX

347

fluid—numerous cell elements (lymphocytes); they consider their re­
search is strong evidence that the central nervous system plays an
important rôle in genital herpes. A microbic origin has also been sus­
pected in herpes, but, while possible, it does not seem probable.

Diagnosis.—Herpes facialis is, as a rule, readily recognized, espe­
cially when on the lip. On neighboring skin there is also rarely any
difficulty. It can scarcely be confused with vesicular eczema, as this
latter disease is made up of closely crowded small vesicles, which tend
to coalesce, but with no tendency to form distinct groups; is slow,
as a rule, in its appearance, usually presents some inflammatory thick­
ening, the vesicles are smaller and rupture spontaneously and give
rise to gummy exudation. The crusted patch of herpes and that of
impetigo often look closely alike, but the scattered patches of impetigo
and the history of its appearance and course are distinctive; moreover,
impetigo rarely is seen on the lip; herpes, commonly.

Herpes of the genitalia presents similar features to that of the face;
the presence of several or more small vesicles on a red or inflamed base
scarcely permits of error. When abraded and irritated by the moisture
or secretions of the part, or cauterized by some overzealous physician,
there is sometimes great difficulty to distinguish it from a soft sore and
possibly from hard chancre. The absence of glandular enlargement in
herpes or, at the most, of slight transitory swelling is a differential point
of value. Chancroids are usually multiple, with distinct ulceration.
In doubtful cases, when a hurried opinion is necessary, auto-inoculation
experiments can be made. Ordinarily the beginning induration of a
syphilitic chancre will serve to differentiate, together with the history of
its appearance. In some instances it must be acknowledged it is not
possible to give a definite opinion at once, but the application of the
appropriate treatment for herpes will soon heal this disease, whereas much
time is necessary for both chancroid or chancre to bring about such result;
for the latter an examination for spirochætæ would settle the matter.

Prognosis and Treatment.—The disease, both on face and
genitalia, soon subsides, usually in five to ten days, but there is often a
distinct tendency to recurrence, more especially in herpes progenitalis.
Herpes labialis in fevers, lung disease, etc., is not now thought to be of
any prognostic importance.

Ordinary herpes occurring about the lips or other parts of the face
rarely requires more than external applications; in persistent and oft-
recurring cases, however, the general health of the patient must be looked
after, special attention being given to the state of the digestive tract and
to possible malarial conditions. Ordinarily the application, several times
daily, of spirits of camphor, cologne-water, a lotion of zinc sulphate, from
1 to 5 grains (0.065-0.33) to the ounce (32.) of water or water and alco­
hol, will be sufficient to bring about a disappearance of the lesions; the
first two named, if frequently applied in the earliest stage, will occasionally
abort the outbreaks, more particularly the spirits of camphor. Painting
over the affected part tincture of benzoin is also useful, and it is especially
valuable when the lesions are seated at the mouth angle, showing a
tendency to fissuring; the mouth is slowly and carefully opened as widely

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as possible, and the benzoin tincture painted over two or three times, and
allowed to dry, while the mouth remains open; it is repeated two or three
times daily. When the crusting stage is reached, ointments, such as
cold cream, camphor ice, etc., can be used, the crusts usually separating
more quickly under such applications.

Occurring about the genitalia, the treatment is somewhat different.
Cleanliness is of the first importance, not only in promoting the dis­
appearance of an attack, but in preventing new outbreaks; the parts
should be gently washed two or three times daily. Various powders
are useful here, such as boric acid, alone or with from 1 to 5 grains
(0.065-0.33) of zinc sulphate to the ounce (32.); or zinc oxid, with or
without from 5 to 10 per cent, of calomel. Lotions are also valuable, the
most efficient being a saturated solution of boric acid, and one containing
from 5 to 10 grains (0.33-0.65) each of calamin and zinc oxid and from
½ to 1 dram (2.-4.) of alcohol in each ounce (32.) of saturated solution
of boric acid. A layer of lint or borated cotton should be placed over the
part.

In obstinate and recurring genital cases daily applications of the gal­
vanic current will prove of value; the positive electrode is placed over
the lower lumbar region, and the negative over the affected part, the
current being mild—½ to 2 milliampères. A mustard plaster over the
lower spine, daily or every few days, is sometimes useful in this class
of cases. The same may be said of the administration of arsenic, both
in herpes facialis and herpes progenitalis. In markedly recurrent cases
of the latter in the male circumcision is advisable.

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