In some cases vesicles and blebs may be present; in other cases the disease seriously involves the deeper parts, and is accompanied by grave constitutional symptoms. In exceptional instances sloughing takes place.

A mild, transitory, limited, and often recurrent erysipelatous condition of the outlet and immediate neighborhood of one or both nostrils is met with, taking its origin from an inflammation of the hair-follicles just inside the margin of the nose; constitutional symptoms are usually wanting. Somewhat similar, doubtless, is the erysipelatous inflammation (erysipeloid) observed on the fingers and hands of butchers, etc., starting from a wound, apparently as a result of infection from putrid meat or fish.

What is erysipelas migrans (or erysipelas ambulans)?

A variety of erysipelas which, after a few hours or days, disappears at one region and appears at another, and so continues for one or several weeks.

What is the cause of erysipelas?

The disease is due to a specific streptococcus—the streptococcus of Fehleisen. Depression of the vital forces and local abrasions are predisposing factors.

State the diagnostic points.

The character of the onset, the shining redness and swelling, the sharply-defined border, and the accompanying febrile disturbance.

What is the prognosis in erysipelas?

In most instances the disease runs a favorable course, terminating in recovery in one to three weeks. Exceptionally, in severe cases, a fatal termination ensues.

What is the treatment of erysipelas?

Internally, a purge, followed by the tincture of the chloride of iron and quinia, and stimulants if needed. Locally, one to three per cent. carbolic-acid lotion or ointment, a saturated solution of boric acid, or a ten- to twenty-per-cent. aqueous solution or ointment of ichthyol may be employed.

In some cases the spread of the disease is apparently controlled by painting the bordering healthy skin with a ring of tincture of iodine or strong solution of nitrate of silver.



Phlegmona Diffusa.

What do you understand by phlegmona diffusa?

Phlegmona diffusa is a more or less extensive inflammation of the cutaneous and subcutaneous tissues presenting symptoms partaking of the nature of both deep erysipelas and flat carbuncles, and usually attended with varying constitutional disturbance. Suppuration at several points takes place, and sloughing may ensue. Recovery usually finally results, but a fatal issue is possible.

Treatment is based upon general principles.



Furunculus. (Synonyms: Furuncle; Boil.)

Define furunculus.

Furunculus, or boil, is an acute, deep-seated, inflammatory, circumscribed, rounded or more or less acuminated, firm, painful formation, usually terminating in central suppuration.

Describe the symptoms and course.

A boil begins as a small, rounded or imperfectly defined reddish spot, or as a small, superficial pustule; it increases in size, and when well advanced appears as a pea or cherry-sized, circumscribed, reddish elevation, with more or less surrounding hyperaemia and swelling; it is painful and tender, and ends, in the course of several days or a week, in the formation of a central slough or "core," which finally involves the central overlying skin (pointing). One or several may be present, gradually maturing and disappearing. Insignificant scarring may remain.

In some cases sympathetic constitutional disturbance is noticed.

What is a blind boil?

A sluggish boil exhibiting little, if any, tendency to point or break.

What is furunculosis?

Furunculosis is that condition in which boils, singly or in crops, continue to appear, irregularly, for weeks or months.

State the etiology of furuncle.

A depraved state of the general health is often to be considered as a predisposing factor. Persistent furunculosis is not infrequent in diabetes mellitus. The immediate exciting cause is the entrance into the follicle of a microbe, the staphylococcus pyogenes aureus. It is not improbable, however, that boils may also be due to other pus-producing organisms.

Workmen in paraffin oils or other petroleum products often present numerous furuncles and cutaneous abscesses. Conditions favoring a persistent miliaria have also a causative influence, especially observed in infants and young children. In these latter, especially among the poorer classes, sluggish boils or subcutaneous abscesses about the scalp in hot weather, are not at all infrequent.

What is the pathology of furuncle?

A boil is an inflammatory formation having its starting point in a sebaceous-gland, sweat-gland, or hair-follicle. The core, or central slough, is composed of pus and of the tissue of the gland in which it had its origin.

How would you distinguish a boil from a carbuncle?

A boil is comparatively small, rounded or acuminate, and has but one point of suppuration; a carbuncle is large, flattened, intensely painful, often with grave systemic disturbance, and has, moreover, several centres of suppuration.

State the prognosis.

When occurring in crops (furunculosis) the affection is often rebellious; recovery, however, finally resulting.

What is the method of treatment of furunculus?

If there be but one lesion, with no tendency to the appearance of others, local treatment alone is usually employed. If, however, several or more are present, or if there is a tendency to successive development, both constitutional and local measures are demanded.

Name the internal remedies employed.

Such nutrients and tonics as cod-liver oil, malt, quinine, strychnia, iron and arsenic; in some instances calx sulphurata, one-tenth- to one-fourth-grain doses every three or four hours has been thought to be of service. Brewers' yeast has been recently again brought forward as a remedy of value.

What is the external treatment?

Local treatment consists in the beginning, with the hope of aborting the lesion, of the application of carbolic acid to the central portion, or the use of a twenty-five-per-cent. ointment of ichthyol applied as a plaster:—

[Rx] Ichthyol, ............................ [dram]j Emp. plumbi, ........................... [dram]ij Emp. resinae, ........................... [dram]j. M.

Or the injection of a five-per-cent. solution of carbolic acid into the apex of the boil may be tried if the formation is more advanced. If suppuration is fully established, evacuation of the contents, followed by antiseptic applications, constitutes the best method.

A saturated solution of boric acid or a lotion of corrosive sublimate (one to three grains to the ounce) applied to the immediate neighborhood of the boil or boils tends to prevent the formation of new lesions. Frequent washing of the parts with soap and water or tincture of green soap and water is also a preventive measure of value. In repeatedly infected areas, mild exposures to x-rays, at intervals of a few days, will often prove of curative value.



Carbunculus. (Synonyms: Anthrax; Carbuncle.)

What is carbuncle?

A carbuncle is an acute, usually egg to palm-sized, circumscribed, phlegmonous inflammation of the skin and subcutaneous structures, terminating in a slough.

At what age and upon what parts is carbuncle usually observed?

In middle and advanced life, and more commonly in men.

It is seen most frequently at the nape of the neck and upon the upper part of the back.

What are the symptoms and course of carbuncle?

There is rarely more than one lesion present. It begins, usually with preceding and accompanying malaise, chilliness and febrile disturbance, as a firm, flat, inflammatory infiltration in the deeper skin and subcutaneous tissue, spreading laterally and finally involving an area of one to several inches in diameter. The infiltration and swelling increase, the skin becomes of dark red color, and sooner or later, usually at the end of ten days or two weeks, softening and suppuration begin to take place, the skin finally giving away at several points, through which sanious pus exudes; the whole mass finally sloughs away either in portions or in its entirety, resulting in a deep ulcer, which slowly heals and leaves a permanent cicatrix.

In some cases, especially in old people, constitutional disturbance of a grave character is noted, septicaemia is developed, and a fatal result may ensue.

What is the cause of carbuncle?

The same causes are considered to be operative in carbunculus as in furuncle; general debility and depression, from whatever cause, predisposing to its formation, and the introduction of a microbe, probably the same as in furunculus, being at present looked upon as the exciting factor.

What is the pathology?

The inflammation starts simultaneously from numerous points, from the hair-follicles, sweat-glands or sebaceous glands. The inflammatory centres break down, and the pus finds its way to the surface; finally the process ends in gangrene of the whole area.

How would you distinguish carbuncle from a boil?

By its flat character, greater size, and multiple points of suppuration.

What is the prognosis of carbuncle?

Occurring in those greatly debilitated or in late life, and in those cases in which two or more lesions exist, or when seated about the head, the prognosis is always to be guarded, as a fatal result is not uncommon. In fact, in every instance the disease is to be considered of possible serious import.

What constitutional treatment is usually employed in carbuncle?

A full nutritious diet, the use of such remedies as iron, quinia, nux vomica, with malt and stimulants, if indicated. Calx sulphurata, one-tenth to one-fourth grain every two or three hours, appears, in some instances, to have a beneficial effect. If the pain is severe, morphia or chloral should be given.

What external measures are employed?

In the early part of the formation, injection of a five or ten per cent. carbolic acid solution, or covering the whole area with a twenty-five per cent. ichthyol ointment, may be employed. When it has broken down the pus may be drawn out with a cupping-glass, and carbolized glycerine or carbolized water introduced into each opening, and the ichthyol ointment superimposed. If the whole part has sloughed, it should be removed as rapidly as possible, and antiseptic dressings used. Or, if its progress is slow, and grave systemic disturbance be present, the whole part may be incised and curetted, and then treated antiseptically. Mild exposure to the x-rays is also to be commended.



Pustula Maligna. (Synonyms: Anthrax; Malignant Pustule.)

What is malignant pustule?

Malignant pustule is a furuncle- or carbuncle-like lesion resulting from inoculation of the virus generated in animals suffering from splenic fever, or "charbon," and is accompanied by constitutional symptoms of more or less gravity. A fatal termination is not unusual.

What is the cause of pustula maligna?

The disease is due to the presence of the bacillus anthracis.

What is the treatment of malignant pustule?

Early excision or destruction with caustic potash, with subsequent antiseptic dressings; and internally the free use of stimulants and tonics.



Post-mortem Pustule. (Synonym: Dissection Wound.)

Describe post-mortem pustule.

Post-mortem pustule develops at the point of inoculation, beginning as an itchy red spot, becoming vesico-pustular, and later pustular, with usually a broad inflammatory base, and accompanied with more or less pain and redness and not infrequently lymphangitis, erysipelatous swelling, and slight or severe sympathetic constitutional disturbance.

What is the treatment of post-mortem pustule?

Treatment consists in opening the pustule and thorough cauterization, and the subsequent use of antiseptic applications or dressings. Internally quinia and stimulants if indicated.



Framb[oe]sia. (Synonyms: Yaws; Pian.)

Describe framb[oe]sia.

Framb[oe]sia is an endemic, contagious disease met with in tropical countries, characterized by the appearance of variously-sized papules, tubercles, and tumors, which, when developed, resemble currants and small raspberries, and finally break down and ulcerate. It is accompanied by constitutional symptoms of variable severity.

Hygienic measures, good food, tonics, and antiseptic and stimulating applications are curative.

Verruga Peruana. (Synonyms: Peruvian Warts; Carrion's Disease; Oroya Fever.)

Describe verruga peruana.

A specific inoculable affection endemic in some valleys of the Western Andes, in Peru, and characterized by a prodromal febrile period and subsequent outbreak of peculiar pin-head- to pea-sized, or larger, bright reddish, rounded, wart-like elevations. The prodromal symptoms, of an irregular malarial or typhoid type, with associated rheumatic and muscular pains, may last for weeks or several months, usually abating when eruption presents. The lesions may be crowded together in great bunches. The face and limbs are favorite localities. The disease is inoculable and thought to be due to a bacillus.

The fatality varies between 10 and 20 per cent. Tonics and stimulants are prescribed.



Equinia. (Synonyms: Farcy; Glanders.)

What is equinia, or glanders?

A rare contagious specific disease of a malignant type, derived from the horse, and characterized by grave constitutional symptoms, inflammation of the nasal and respiratory passages, and a deep-seated papulo-pustular, or tubercular, nodular (farcy buds), ulcerative eruption. A fatal issue is not uncommon. It is due to a micro-organism.

Treatment, both local and constitutional, is based upon general principles.



Miliaria. (Synonyms: Prickly Heat; Heat Rash; Lichen Tropicus; Red Gum; Strophulus.)

What do you understand by miliaria?

An acute mildly inflammatory disorder of the sweat-glands, characterized by the appearance of minute, discrete but closely crowded papules, vesico-papules, and vesicles.

Describe the symptoms of miliaria.

The eruption, consisting of pin-point to millet-seed-sized papules, vesico-papules, vesicles, or a mixture of these lesions, discrete but usually numerous and closely crowded, appears suddenly, occurring upon a limited portion of the surface, or, as commonly observed, involving a greater part or the whole integument. The trunk is a favorite locality. The papular lesions are pinkish or reddish, and the vesicles whitish or yellowish, surrounded by inflammatory areola, thus giving the whole eruption a bright red appearance—miliaria rubra. Later, the areolae fade, the transparent contents of the vesicles become somewhat opaque and yellowish-white, and the eruption has a whitish or yellowish cast—miliaria alba. In long-continued cases, especially in children, boils and cutaneous abscesses sometimes develop; and it may also develop into a true eczema.

Itching, or a feeling of burning, slight or intense, is usually present.

What is the course of the eruption?

The vesicles show no disposition to rupture, but dry up in a few days or a week, disappearing by absorption and with slight subsequent desquamation; the papular lesions gradually fade away, and the affection, if the exciting cause has ceased to act, terminates.

What is the cause of miliaria?

Excessive heat. Debilitated individuals, especially children, are more prone to an attack. Being too warmly clad is often causative.

What is the nature of the disease?

The affection is considered to be due to sweat-obstruction, with mild inflammatory symptoms as a cause or consequence, congestion and exudation taking place about the ducts, giving rise to papules or vesicles, according to the intensity of the process.

How would you distinguish miliaria from papular and vesicular eczema, and from sudamen?

The papules of eczema are larger, more elevated, firmer, slower in their evolution, of longer duration, and are markedly itchy.

The vesicles of eczema are usually larger, tend to become confluent, and also to rupture and become crusted; there is marked itchiness, and the inflammatory action is usually severe and persistent.

In sudamen there is absence of inflammatory symptoms.

What is the prognosis of miliaria?

The affection, under favorable circumstances, disappears in a few days or weeks. If the cause persists, as for instance, in infants or young children too warmly clad, it may result in eczema.

What is the treatment of miliaria?

Removal of the cause, and in debilitated subjects the administration of tonics; together with the application of cooling and astringent lotions, as the following:—

[Rx] Aeidi carbolici, ..................... [dram]ss-[dram]j Acidi borici, ........................ [dram]iv Glycerinae, ........................... f[dram]j Alcoholis, ........................... f[Oz]ij Aquae, ................................ [Oz]xiv. M.

This is sometimes more efficient if zinc oxide, six to eight drachms, is added.

Lotions of alcohol and water or vinegar and water, and also the various lotions used in acute eczema, are often employed with relief.

Dusting-powders of starch, boric acid, lycopodium, talc, and zinc oxide are also valuable; the following combination is satisfactory:—

[Rx] Pulv. acidi borici, Pulv. talci veneti, Pulv. zinci oxidi, Pulv. amyli, .............āā.....[dram]ij. M.

Probably the best plan is to use a lotion and a dusting-powder conjointly; dabbing on the wash freely, allowing it to dry, and then dusting over with the powder.



Pompholyx. (Synonyms: Dysidrosis; Cheiro-pompholyx.)

What is pompholyx?

Pompholyx is a rare disease of the skin of a vesicular and bullous character, and limited to the hands and feet.

Describe the symptoms of pompholyx.

In most instances the hands only are affected. It begins usually with a feeling of burning, tingling or tenderness of the parts, followed rapidly by the appearance of deeply-seated vesicles, especially between the fingers and on the palmar aspect. These beginning lesions look not unlike sago grains imbedded in the skin. In some instances the disease does not extend beyond this stage, the vesicles disappearing after a few days or weeks by absorption, and usually without desquamation. Ordinarily, however, the lesions increase in size, new ones arise, become confluent, and blebs result, the skin in places appearing as if undermined with serous exudation. The parts are commonly inflamed to a slight or marked degree. The skin comes off in flakes, new lesions may appear for several days or two or three weeks, and the process then declines, recovery gradually taking place.

There are no constitutional symptoms, although it is usually noticed that the general health is below par.

What is the character of the subjective symptoms in pompholyx?

The subjective symptoms consist of a feeling of tension, burning and tenderness, and sometimes itching. Not infrequently, also there is neuralgic pain.

What is the cause of pompholyx?

The eruption is thought to be due to a depressed state of the nervous system. It is more common in women, and is met with chiefly in adult and middle life.

What is the pathology?

Opinion is divided; some considering it a disease of the sweat-glands and others an inflammatory disease independent of these structures.

State the diagnostic features of pompholyx.

The distribution and the peculiar characters and course of the eruption.

It is to be differentiated from eczema.

What is the prognosis?

For the immediate attack, favorable, recovery taking place in several weeks or a few months. Recurrences at irregular intervals are not uncommon.

What is the treatment of pompholyx?

The general health is to be looked after, and the patient placed under good hygienic conditions. Remedies of a tonic nature, directed especially toward improving the state of the nervous system, are to be prescribed. Locally, soothing and anodyne applications, such as lead-water and laudanum, boric-acid lotion, oxide-of-zinc, boric-acid and diachylon ointments, are most suitable; or the parts may be enveloped with the following:—

[Rx] Pulv. ac. salicylici, ................ gr. x Pulv. ac. borici, Pulv. amyli, .......... āā ..... [dram]ij Petrolati, ........................... [dram]iv. M.

In fact, the external treatment is similar to that employed in acute eczema.



Herpes Simplex. (Synonym: Fever Blisters.)

What is herpes simplex?

An acute inflammatory disease, characterized by the formation of pin-head to pea-sized vesicles, arranged in groups, and occurring for the most part about the face and genitalia.

Describe the symptoms of herpes simplex.

In severe cases, malaise and pyrexia may precede the eruption, but usually it appears without any precursory or constitutional symptoms. A feeling of heat and burning in the parts is often complained of. The vesicles, which are commonly pin-head in size, are usually upon a hyperaemic or inflammatory base, and tend to occur in groups or clusters. Their contents are usually clear, subsequently becoming more or less milky or puriform. There is no tendency to spontaneous rupture, but should they be broken a superficial excoriation results. In a short time they dry to crusts which soon fall off, leaving no permanent trace.

Is the eruption in herpes simplex abundant?

No. As a rule not more than one or two clusters or groups are observed.

Upon what parts does the eruption occur?

Usually about the face (herpes facialis), and most frequently about the lips (herpes labialis); on the genitalia (herpes progenitalis), the lesions are commonly found on the prepuce (herpes praeputialis) in the male, and on the labia minora and labia majora in the female.

State the causes of herpes simplex.

Herpes facialis is often observed in association with colds and febrile and lung diseases. Malaria, digestive disturbance, and nervous disorders are not infrequently predisposing factors. Herpes progenitalis is said to occur more frequently in those who have previously had some venereal disease, especially gonorrh[oe]a, but this is questionable. It is probably often purely neurotic.

What are the diagnostic points?

The appearance of one or several vesicular groups or clusters about the face, and especially about the lips, is usually sufficiently characteristic. The same holds true ordinarily when the eruption is seen on the prepuce or other parts of the genitalia; it is only when the vesicles become rubbed or abraded and irritated that it might be mistaken for a venereal sore, but the history, course and duration will usually serve to differentiate.

Give the prognosis.

The eruption will usually disappear in several days or one or two weeks without treatment. Remedial applications, however, exert a favorable influence. Herpes progenitalis exhibits a strong disposition to recurrence.

What is the treatment of herpes facialis?

Anointing the parts with camphorated cold cream, with spirits of camphor or similar evaporating and stimulating applications will at times afford relief to the burning, and shorten the course.

What is the treatment of herpes progenitalis?

In herpes about the genitalia cleanliness is of first importance. A saturated solution of boric acid, a dusting-powder of calomel or oxide of zinc, and the following lotion, containing calamine and oxide of zinc, are valuable:—

[Rx] Zinci oxidi, Calaminae, .......... āā ........ gr. v Glycerinae, Alcoholis, ......... āā ........ [minim]vj Aquae, ................................ [Oz]j M.

In obstinate recurrent cases, frequent applications of a mild galvanic current will have a favorable influence.



Hydroa Vacciniforme. (Synonyms: Recurrent Summer Eruption; Hydroa Puerorum; Hydroa Aestivale.)

Describe hydroa vacciniforme.

It is a rare vesicular disease usually seen in boys (only two or three exceptions), occurring upon uncovered parts, especially the nose, cheeks, and ears. The lesions begin as red spots, discrete or in groups, rapidly exhibit vesiculation, and later umbilication; the contents become milky, dry to crusts, which fall off and leave small pit-like scars. Fresh outbreaks may take place almost continuously, and the process go on indefinitely, at least up to youth or manhood, when the tendency subsides. Its activity is usually limited to the warm season. Arthritic symptoms and general disturbance are sometimes noted in severe cases.

It is doubtless a vasomotor neurosis. Exposure to sun and wind is an important, if not essential, etiological factor. Primarily the lesion begins in the rete middle layers, and is purely vesicular in character; later, necrosis of the rete and extending deep in the corium is observed.

Treatment so far has only been palliative, consisting of the applications employed in similar conditions. Constitutional medication is based upon general principles. The patient should avoid exposure to the sun, strong wind and excessive artificial heat.



Epidermolysis Bullosa.

Describe epidermolysis bullosa.

This is a rare, usually hereditary, disease or condition, characterized by the formation of vesicles and blebs on any part subjected to slight rubbing or irritation. No scarring is left, and no pigmentation noted. The predisposition to these lesions persists indefinitely. The general health is not involved. The nature of the disease is obscure.

Treatment has no influence in modifying or lessening this tendency. The vulnerable parts should so far as possible be protected from knocks and undue friction.



Dermatitis Repens.

What do you understand by dermatitis repens?

It is a rare spreading dermatitis starting from an injury, extending by a serous undermining of the epidermis, and usually occurring upon the upper extremities.

It usually begins shortly after an injury, and, as a rule, presents itself by redness and serous exudation. The overlying epidermis breaks, and the area of disease gradually progresses by an extension of the serous undermining process, the denuded part looking red and raw, with usually an oozing surface. As the disease spreads the oldest part becomes dry and heals, the new epidermal covering being thin and atrophic in appearance. Its most usual beginning is on some part of the hand, and from here it may spread up the arm and involve considerable area.

The injury from which it starts may be extremely insignificant, apparently affording an opening for the introduction of the causative factor, doubtless parasitic. Beyond a feeling of soreness there seem to be no special subjective symptoms.

Give the prognosis and treatment.

The malady shows but little tendency to spontaneous cure. The frequent or constant application of a mild antiseptic lotion, such as boric acid and resorcin, or of a mild parasiticide ointment will generally bring the disease gradually to an end.



Herpes Zoster. (Synonyms: Zoster; Zona; Shingles.)

Give a definition of herpes zoster.

Herpes zoster is an acute, self-limited, inflammatory disease, characterized by groups of vesicles upon inflammatory bases, situated over or along a nerve tract.

Upon what parts of the body may the eruption appear?

It may appear upon any part, following the course of a nerve; it is therefore always limited in extent, and confined to one side of the body. It is probably most common about the intercostal, lumbar and supra-orbital regions. In rare instances the eruption has been observed to be bilateral.

Are there any subjective or constitutional symptoms?

Yes; there is, as a rule, neuralgic pain preceding, during and following the eruption; and in some cases, also, there may be in the beginning mild febrile disturbance. There is also a variable degree of tenderness and pain.

What are the characters of the eruption?

Several or more hyperaemic or inflammatory patches over a nerve course appear, upon which are seated vesico-papules irregularly grouped; these vesico-papules become distinct vesicles, of size from a pin-head to a pea, and soon dry and give rise to thin, yellowish or brownish crusts, which drop off, leaving in most instances no permanent trace, in others more or less scarring. In some cases the lesions may become pustular and, on the other hand, the eruption may be abortive, stopping short of full vesiculation.

What is known in regard to the nature of the disease?

An inflamed and irritable state of the spinal ganglia, nerve tract, or peripheral branches is directly responsible for the eruption, and this state may be due to atmospheric changes, cold, nerve-injuries and similar influences. The view has also been advanced that the disease is of specific and infectious character.

Give the chief diagnostic features of herpes zoster.

The prodromic neuralgic pain, the appearance of grouped vesicles upon inflammatory bases following the course of a nerve tract, and the limitation of the eruption to one side of the body.

What is the prognosis?

Favorable; the symptoms usually disappearing in two to four weeks. In some instances, however, the neuralgic pains may be persistent, and in zoster of the supra-orbital region the eye may suffer permanent damage.

How would you treat herpes zoster?

Constitutional treatment, usually tonic in character, is to be based upon general principles; moderate doses of quinia, with one-sixth grain of zinc phosphide, four or five times daily, appear in some cases to have a special value. The accompanying neuralgic pain may be so intense as to require anodynes. Local treatment should be of a soothing and protective character. A dusting-powder of oxide of zinc and starch (to the ounce of which twenty to thirty grains of camphor may be added) proves useful; and over this, in order that the parts be further protected, a bandage or a layer of cotton batting. Oxide-of-zinc ointment, and in those cases in which there is much pain, ointments containing powdered opium or belladonna, or orthoform, may be used. A mild galvanic current applied daily to the parts is often of great advantage, both in its influence upon the course of the eruption and upon the neuralgic pain. The plan, so often advised, of painting the parts with flexible collodion is not to be commended.



Dermatitis Herpetiformis. (Synonyms: Hydroa Herpetiforme (Tilbury Fox); Herpes Gestationis (Bulkley); Pemphigus Prurigiuosus; Duhring's Disease.)

Give a definition of dermatitis herpetiformis.

Dermatitis herpetiformis is a somewhat rare inflammatory disease, characterized by an eruption of an erythematous, papular, vesicular, pustular, bullous or mixed type, with a decided disposition toward grouping, accompanied by itching and burning sensations, with, as a rule, more or less consequent pigmentation, and pursuing usually a chronic course with remissions.

Describe the erythematous type of dermatitis herpetiformis.

The character of the eruption in the erythematous type resembles closely that of erythema multiforme and of urticaria, especially the former. The efflorescences usually make their appearance in crops, and are more or less persistent; fading sooner or later, however, and giving place to new outbreaks. Vesicles are often intermingled, developing from erythematous and erythemato-papular lesions or arising from apparently normal skin.

It may continue in the same type, or change to the vesicular, bullous or other variety.

Describe the papular type of dermatitis herpetiformis.

This is rarely seen as consisting purely of papular lesions, but is commonly associated with the erythematous and vesicular varieties. In a measure it resembles the papular manifestations of erythema multiforme, with a distinct disposition toward group formation. The papules tend, sooner or later, to develop into vesicles, new papular outbreaks occurring from time to time; or the whole eruption changes to the vesicular or other type of the disease. It is not a common type.

Describe the vesicular type of dermatitis herpetiformis.

This is the common clinical type of the disease, and is characterized by pin-head to pea-sized, rounded or irregularly-shaped, distended or flattened and stellate vesicles, occurring, for the most part, in irregular and segmental groups of three or more lesions, seated either upon apparently normal integument or upon hyperaemic or inflammatory skin. They exhibit no tendency to spontaneous rupture, but after remaining a shorter or longer time, are broken or disappear by absorption. The lesions tend to appear in crops. It may, as it not infrequently does, continue in the same type, or it may become more or less erythematous or bullous in character. In not a few instances pustules, few or in numbers, are at times intermingled.

Describe the pustular type of dermatitis herpetiformis.

This is rare. It is similar in its clinical characters to the vesicular type, except that the lesions are pustular. It is met with, as a rule, in association with the vesicular and bullous varieties of the disease.

Describe the bullous type of dermatitis herpetiformis.

The bullous expression of the disease is usually of a markedly inflammatory nature, often innumerable blebs, small and large, appearing almost continuously, and in some instances involving the greater part of the surface. The lesions arise from erythematous skin, from preexisting vesicles or vesicular groups, or from apparently normal integument. There is a marked disposition to appear in clusters. A change of type to the erythematous or vesicular varieties is not unusual.

Describe the mixed type of dermatitis herpetiformis.

In this type the eruption is made up of erythematous patches, vesicles, bullae, and often with pustules intermingled, appearing irregularly or in crops, and with a tendency to patch or group formation.

Describe the characters of the vesicles, pustules and blebs.

As a rule, these several lesions, especially the vesicles and blebs, are somewhat peculiar: they are usually of a strikingly irregular outline, oblong, stellate, quadrate, and when drying are apt to have a puckered appearance. They are herpetic in that they show little disposition to spontaneous rupture, occur in groups, and are usually seated upon erythematous or inflammatory skin—in some respects similar to the groups of simple herpes and herpes zoster.

What is to be said in regard to the subjective symptoms?

The subjective symptoms are usually the most troublesome feature of the disease, consisting of intense and persistent itching and a feeling of heat and burning.

Are there any constitutional symptoms in dermatitis herpetiformis?

As a rule, not, excepting the distress and depression necessarily consequent upon the intense itchiness and loss of sleep. In the pustular and bullous varieties there may be mild or grave systemic symptoms, but even in these types the constitutional involvement is, in most instances, slight in comparison to the intensity of the cutaneous disturbance.

What is the course of dermatitis herpetiformis?

Extremely chronic, in most instances lasting, with remissions, indefinitely. The skin is rarely entirely free. From time to time the type of the disease may undergo change. From the continued irritation and scratching more or less pigmentation results.

What is to be said in regard to the etiology?

The disease is in many instances essentially neurotic, and in exceptional instances septicaemic. Pregnancy and the parturient state are factors in some instances (so-called herpes gestationis). It is possible in some instances that the eruption may be an expression of a mild toxemia of gastro-intestinal origin. In some cases no cause can be assigned. In the majority of patients the general health, considering the violence of the eruptive phenomena, remains comparatively undisturbed.

Nervous shock and mental worry are factors in some cases. Polyuria, with sugar in the urine, has occasionally been noted. Eosinophile cells have been found both in the vesicles and the blood. In some instances—exceptionally, it is true—the disease has appeared shortly after vaccination.

Mention the diagnostic features of dermatitis herpetiformis.

The multiformity of the eruption, the characters of the lesions, the disposition to grouping, the absence of tendency to form solid sheets of eruption (as in eczema), the intense itching, history, chronicity and course. In doubtful cases, an observation of several weeks will always suffice to distinguish it from eczema, erythema multiforme, herpes iris and pemphigus, diseases to which it at times bears strong resemblance.

Give the prognosis of dermatitis herpetiformis.

An opinion as to the outcome of the disease should be guarded. It is exceedingly rebellious to treatment, and relapses are the rule. Exceptionally the bullous and pustular varieties prove eventually fatal. The erythematous and vesicular varieties are the most favorable.

State the treatment to be advised.

There are no special remedies. Constitutional treatment must be conducted upon general principles. A free action of the bowels is to be maintained. In occasional instances arsenic in progressive doses seems of value. Externally protective and antipruritic applications, such as are employed in the treatment of eczema and pemphigus, are to be employed:—

[Rx] Ac. carbolici, ....................... [dram]j-[dram]ij Thymol, .............................. gr. xvj. Glycerinae, ........................... [Oz]ss-[Oz]j Alcoholis, ........................... f[Oz]ij Aquae, q.s., ......... ad ............. Oj. M.

Other valuable applications are: lotions of carbolic acid, of liquor carbonis detergens, of boric acid; alkaline baths, mild sulphur ointment and carbolized oxide-of-zinc ointment, and dusting-powders of starch, zinc oxide, talc and boric acid. A two- to ten-per-cent. ichthyol lotion or ointment is sometimes of advantage; thiol employed in the same manner has also been commended.



Psoriasis.

Give a definition of psoriasis.

Psoriasis is a chronic, inflammatory disease, characterized by dry, reddish, variously-sized, rounded, sharply-defined, more or less infiltrated, scaly patches.



At what age does psoriasis usually first make its appearance?

Most commonly between the ages of fifteen and thirty. It is rarely seen before the tenth year, and a first attack is uncommon after the age of forty.

Has psoriasis any special parts of predilection?

The extensor surfaces of the limbs, especially the elbows and knees, are favorite localities, and even when the eruption is more or less general, these regions are usually most conspicuously involved. The face often escapes, and the palms and soles, likewise the nails, are rarely involved. In exceptional instances, the eruption is limited almost exclusively to the scalp.

Are there any constitutional or subjective symptoms in psoriasis?

There is no systemic disturbance; but a variable amount of itching may be present, although, as a rule, it is not a troublesome symptom.

Describe the clinical appearances of a typical, well developed case.

Twenty or a hundred or more lesions, varying in size from a pin-head to a silver dollar, are usually present. They are sharply defined against the sound skin, are reddish, slightly elevated and infiltrated, and more or less abundantly covered with whitish, grayish or mother-of-pearl colored scales. The patches are usually scattered over the general surface, but are frequently more numerous on the extensor surfaces of the arms and legs, especially about the elbows and knees. Several closely-lying lesions may coalesce and a large, irregular patch be formed; some of the patches, also, may be more or less circinate, the central portion having, in a measure or completely, disappeared.

Give the development and history of a single lesion.

Every single patch of psoriasis begins as a pin-point or pin-head-sized, hyperaemic, scaly, slightly-elevated lesion; it increases gradually, and in the course of several days or weeks usually reaches the size of a dime or larger, and then may remain stationary; or involution begins to take place, usually by a disappearance, partially or completely, of the central portion, and finally of the whole patch.

Describe the so-called clinical varieties of psoriasis.

As clinically met with, the patches present are, as a rule, in all stages of development. In some instances, however, the lesions, or the most of them, progress no further than pin-head in size, and then remain stationary, constituting psoriasis punctata; in other cases, they may stop short after having reached the size of drops—psoriasis guttata; in others (and this is the usual clinical type) the patches develop to the size of coins—psoriasis nummularis. In some cases there is a strong tendency for the central part of the lesions to disappear, and the process then remain stationary, the patches being ring-shaped—psoriasis circinata; and occasionally several such rings coalesce, the coalescing portions disappearing and the eruption be more or less serpentine—psoriasis gyrata. Or, in other instances, several large contiguous lesions may coalesce and a diffused, infiltrated patch covering considerable surface results—psoriasis diffusa, psoriasis inveterata.



Is the eruption of psoriasis always dry?

Yes.

What course does psoriasis pursue?

As a rule, eminently chronic. Patches may remain almost indefinitely, or may gradually disappear and new lesions appear elsewhere, and so the disease may continue for months and, sometimes, for years; or, after continuing for a longer or shorter period, may subside and the skin remain free for several months or one or two years, and, in rare instances, may never return.



Is the course of psoriasis influenced by the seasons?

As a rule, yes; there is a natural tendency for the disease to become less active or to disappear altogether during the warm months.

What is known in regard to the etiology of psoriasis?

The causes of the disease are always more or less obscure. There is often a hereditary tendency, and the gouty and rheumatic diathesis must occasionally be considered potential. In some instances it is apparently influenced by the state of the general health. It is a rather common disease and is met with in all walks of life.

Is psoriasis contagious?

No. In recent years the fact of its exhibiting a family tendency has been thought as much suggestive of contagiousness as of heredity.

What is the pathology?

According to modern investigations, it is an inflammation induced by hyperplasia of the rete mucosum; and it is beginning to be believed that this hyperplasia may have a parasitic factor as the starting-cause.

With what diseases are you likely to confound psoriasis?

Chiefly with squamous eczema and the papulo-squamous syphiloderm; and on the scalp, also with seborrh[oe]a. It can scarcely be confounded with ringworm.

How is psoriasis to be distinguished from squamous eczema?

By the sharply-defined, circumscribed, scattered, scaly patches, and by the history and course of the individual lesions.

In what respects does the papulo-squamous syphiloderm differ from psoriasis?

The scales of the squamous syphilide are usually dirty gray in color and more or less scanty; the patches are coppery in hue, and usually several or more characteristic scaleless, infiltrated papules are to be found. The face, palms, and soles are often the seat of the syphilitic eruption; and, moreover, concomitant symptoms of syphilis, such as sore throat, mucous patches, glandular enlargement, rheumatic pains, falling out of the hair, together with the history of the initial lesion, are one, several, or all usually present.

How does seborrh[oe]a differ from psoriasis?

Seborrh[oe]a of the scalp is usually diffused, with but little redness and no infiltration; moreover, the scales of seborrh[oe]a are greasy, dirty gray or brownish, while those of psoriasis are dry and comonly whitish or mother-of-pearl colored. Psoriasis of the scalp rarely exists independently of other patches elsewhere on the general surface.

That variety of seborrh[oe]a, commonly known as eczema seborrhoicum, presents at times, both on scalp and general surface, a strong resemblance to psoriasis, but the character of the scales and distribution of psoriasis, as above stated, are distinguishing points; seborrh[oe]a, moreover, favors hairy surfaces and in extensive examples the scalp, eyebrows, sternal, and pubic regions rarely escape.

How does psoriasis differ from ringworm?

By its greater scaliness, by its higher degree of inflammatory action, and by its larger number of patches, as also by its history. In ringworm all the patches tend to clear up in the centre; in psoriasis this is rarely, if ever, so. If there is still any doubt, microscopic examination of the scrapings will determine.

Give the prognosis of psoriasis.

The prognosis is usually favorable, so far as concerns the immediate eruption, but as to recurrences, nothing positive can be stated. In rare instances, however, the cure remains permanent.

How is psoriasis treated?

Both constitutional and local remedies are demanded in most cases.

Do dietary measures exert any influence?

As a rule, no; but the food should be plain, and an excess of meat avoided.

Name the important constitutional remedies usually employed in psoriasis.

Arsenic is of first importance. It is not suitable in acute or markedly inflammatory types; but is most useful in the sluggish, chronic forms of the disease. The dose should never be pushed beyond slight physiological action. It may be given as arsenious acid in pill form, one-fiftieth to one-tenth of a grain three times daily, or as Fowler's solution, three to ten minims at a dose.

Alkalies, of which liquor potassae is the most eligible. It is to be given in ten to twenty minim doses, largely diluted. It is valuable in robust, plethoric, rheumatic or gouty individuals with psoriasis of an acute or markedly inflammatory type; it is not to be given to debilitated or anaemic subjects.

Salicin, sodium salicylate, and salophen in moderately full doses act well in some cases. Occasionally thyroid preparations have a good effect.

Potassium Iodide, in doses of thirty to one hundred grains, t.d., acts favorably in some instances; there are no special indications pointing toward its selection, unless it be the existence of a gouty or rheumatic diathesis.

Oil of copaiba, potassium acetate, oil of turpentine, oil of juniper, and other diuretics are valuable in some instances, and, while often failing, sometimes exert a rapid influence, especially in those cases in which the disease is extensive and inflammatory. Wine of antimony, given cautiously, is also sometimes of service in the acute inflammatory type in robust subjects.

Are such remedies as iron, quinine, nux vomica and cod-liver oil ever useful in psoriasis?

Yes. In debilitated subjects the administration of such remedies is at times attended with improvement in the cutaneous eruption.

What are the indications as regards the external measures?

Removal of the scales, and the use of soothing or stimulating applications, according to the individual case.

How are the scales removed?

In ordinary cases, either by warm, plain, or alkaline baths, or hot-water-and-soap washings; in those cases in which the scaling is abundant and adherent, washing with sapo viridis and hot water may be required. Baths of sal ammoniac, two to six ounces to the bath are also valuable in removing the scaliness. The tincture of green soap (tinctura saponis viridis) is especially valuable for cleansing purposes in psoriasis of the scalp. The hot vapor bath once or twice weekly is serviceable in keeping the scaliness in abeyance, and has, moreover, in some cases, a therapeutic value.

The frequency of the baths or washings will depend upon the rapidity with which the scales are reproduced.

Are soothing applications often demanded in psoriasis?

In exceptional cases; in those in which the disease is acute, markedly inflammatory and rapidly progressing, mild, soothing applications must be temporarily employed, such as plain or bran baths, with the use of some bland oil or ointment. As a rule, however, the conditions, when coming under observation, are such as to permit of stimulating applications from the start. The most efficient soothing applications are the mild lotions and ointments employed in eczema of acute type.

How are the stimulating remedies employed in psoriasis applied?

As ointments, oils, and paints (pigmenta).

An ointment, if employed, is to be thoroughly rubbed in the diseased areas once or twice daily. The same may be said of the oily applications. The paints (medicated collodion and gutta-percha solution) are applied with a brush, once daily, or every second or third day, depending mainly upon the length of time the film remains intact and adherent.

Name the several important external remedies.

Chrysarobin, pyrogallol, tar, ammoniated mercury, [beta]-naphthol, and resorcin.

Are these several external remedies equally serviceable in all cases?

No. Their action differs slightly or greatly according to the case and individual. A change from one to another is often necessary.

In what forms and strength are these remedies to be applied?

Chrysarobin is applied in several ways: as an ointment, twenty to sixty grains to the ounce, rubbed in once or twice daily; this is the most rapid but least cleanly and eligible method. As a pigment, or paint, as in the following:—

[Rx] Chrysarobini, ........................ [dram]j Acidi salicylici, .................... gr. xx Etheris, ............................. f[dram]j Ol. ricini, .......................... [minim]x Collodii, ............................ f[dram]vij. M.

Or it may be used in liquor gutta-perchae (traumaticin), a drachm to the ounce. It may also be employed in chloroform, a drachm to the ounce; this is painted on, the chloroform evaporating, leaving a thin film of chrysarobin; over this is painted flexible collodion. If the patches are few and large, chrysarobin rubber-plaster may be used.

Chrysarobin is usually rapid in its effect, but it has certain disadvantages; it may cause an inflammation of the surrounding skin, and, if used near the eyes, may give rise to conjunctivitis. As a rule, it should not be employed about the head. Moreover, it stains the linen permanently and the skin temporarily.

Pyrogallol is valuable, and is employed in the same manner and strength as chrysarobin. In collodion it should at first not be used of greater strength than three to four per cent., as in this form pyrogallol sometimes acts with unexpected energy. It is less rapid than chrysarobin, but it rarely inflames the surrounding integument. It stains the linen a light brown, however, and is not to be used over an extensive surface for fear of absorption and toxic effect. Oxidized pyrogallic acid, a somewhat milder drug in its effect, has been highly commended, and has the alleged advantage of being free from toxic action.

Tar is, all things considered, the most important external remedy. It is comparatively slow in its action, but is useful in almost all cases. As employed usually it is prescribed in ointment form, either as the official tar ointment, full strength or weakened with lard or petrolatum. It may also be used as pix liquida, with equal part of alcohol. Or the tar oils, oil of cade (ol. cadini), and oil of birch (ol. rusci) may be employed, either as oily applications or incorporated with ointment or with alcohol. Liquor carbonis detergens, in ointment, one to three drachms to the ounce of simple cerate and lanolin is a mild tarry application which is often useful. In stubborn patches an occasional thorough rubbing with a mixture of equal parts of liquor carbonis detergens and Vleminckx's solution, followed by a mild ointment, sometimes proves of value. In whatsoever form tar is employed it should be thoroughly rubbed in, once or twice daily, the excess wiped off, and the parts then dusted with starch or similar powder.

Ammoniated mercury is applied in ointment form, twenty to sixty grains to the ounce. Compared to other remedies it is clean and free from staining, although, as a rule, not so uniformly efficacious. It is especially useful for application to the scalp and exposed parts. It should not be used over extensive surface for fear of absorption.

[beta]-Naphthol and resorcin are applied as ointments, thirty to sixty grains to the ounce, and as they are (especially the former) practically free from staining, may be used for exposed surfaces.

Gallacetophenone and aristol also act well in some cases, applied in five- to ten-per-cent. strength, as ointments.

In obstinate patches the x-ray may be resorted to, employing it with caution and in the same manner as in other diseases.



Pityriasis Rosea. (Synonym: Pityriasis Maculata et Circinata.)

What do you understand by pityriasis rosea?

Pityriasis rosea is a disease of a mildly inflammatory nature, characterized by discrete, and later frequently confluent, variously sized, slightly raised scaly macules of a pinkish to rosy-red, often salmon-tinged, color.

Upon what part of the body is the eruption usually found?

The trunk is the chief seat of the eruption, although not infrequently it is more or less general.

Describe the symptoms of pityriasis rosea.

The lesions, which appear rapidly or slowly, are but slightly elevated, somewhat scaly, usually rounded, except when several coalesce, when an irregularly outlined patch results. At first they are pale or bright pink or reddish, later a salmon tint (which is often characteristic) is noticed. The scaliness is bran-like or flaky, of a dirty gray color, and, as a rule, less marked in the central portion; it is never abundant. The skin is rarely thickened, the process being usually exceedingly superficial.

What course does pityriasis rosea pursue?

The eruption makes its appearance, as a rule, somewhat rapidly, usually attaining its full development in the course of one or two weeks, and then begins gradually to decline, the whole process occupying one or two months.

To what is pityriasis rosea to be attributed?

The cause is not known; it is variously considered as allied to seborrh[oe]a (eczema seborrhoicum), as being of a vegetable-parasitic origin, and as a mildly inflammatory affection somewhat similar to psoriasis. It is not a frequent disease.

How is pityriasis rosea distinguished from ringworm, psoriasis and the squamous syphiloderm?

From ringworm, by its rapid appearance, its distribution, the number of patches, and, if necessary, by microscopic examination of the scrapings.

Psoriasis is a more inflammatory disease, is seen usually more abundantly upon the limbs, the scales are profuse and silvery, and the underlying skin is red and has a glazed look; moreover, psoriasis, as a rule, appears slowly and runs a chronic course.

The squamous syphiloderm differs in its history, distribution, and above all, by the presence of concomitant symptoms of syphilis, such as glandular enlargement, sore throat, mucous patches, rheumatic pains, and falling out of the hair.

State the prognosis of pityriasis rosea.

It is favorable, the disease tending to spontaneous disappearance, usually in the course of several weeks or one or two months.

What treatment is to be advised in pityriasis rosea?

Laxatives and intestinal antiseptics, and ointments of salicylic acid (5-15 grains to the ounce), of sulphur (10-40 grains to the ounce); or a compound ointment containing both these ingredients can be prescribed. The ointment base can be equal parts of white vaselin and cold cream; in some instances Lassar's paste (starch powder, zinc oxid powder, each, [dram]ij; vaselin, [dram]iv) seems more satisfactory.



Dermatitis Exfoliativa. (Synonyms: General Exfoliative Dermatitis; Recurrent Exfoliative Dermatitis; Desquamative Scarlatiniform Erythema; Acute General Dermatitis; Recurrent Exfoliative Erythema; Pityriasis Rubra.)

Describe dermatitis exfoliativa.

Dermatitis exfoliativa is an inflammatory disease of an acute type, characterized by a more or less general erythematous inflammation, in exceptional instances vesicular or bullous, with epidermic desquamation or exfoliation accompanying or following its development. Constitutional disturbance, which may be of a serious character, is sometimes present. It is a rare and obscure affection, running its course usually in several weeks or months, but exhibiting a decided tendency to relapse and recurrence. In many cases it is persistently chronic, with exacerbations and remissions. In some instances it develops from a long-continued and more or less generalized eczema or psoriasis, and in exceptional cases it is started by the careless use of mercurial ointment and of chrysarobin ointment.



In another type of the disease, formerly described as pityriasis rubra, the skin is pale red or violaceous-red, but is rarely thickened, continued exfoliation in the form of thin plates taking place. Its course is variable, lasting for years, with remissions.

An exfoliating generalized dermatitis is exceptionally observed in the first weeks of life (dermatitis exfoliativa neonatorum), lasting some weeks, and in most cases followed by recovery. There are no special constitutional symptoms, the fatal cases usually dying of marasmus.

As will be seen dermatitis exfoliativa varies considerably in degree; it may be extremely mild, resembling in appearance the scarlet-fever eruption (erythema scarlatiniforme) and running a rapid course; or the skin-condition and the systemic symptoms may be of grave and persistent character.

Give the treatment of dermatitis exfoliativa.

General treatment is based upon indications, and externally soothing applications, such as are employed in acute and subacute eczema, are to be used.



Lichen Planus.

What is lichen planus?

Lichen planus is an inflammatory disease characterized by small, flat and angular, smooth and shining, or scaly, discrete or confluent, red or violaceous-red papules, having a distinctly papular or papulo-squamous course, and attended with more or less itching.

Describe the symptoms of lichen planus.

The eruption, as a rule, begins slowly, usually showing itself upon the extremities; the forearms, wrists and legs being favorite localities. It may appear as one or more groups or in the form of short or long bands. Occasionally its evolution is rapid and a considerable part of the surface may be invaded. The lesions are pin-head to small pea-sized, irregularly grouped or so closely crowded together as to form solid patches; they are quadrangular or polygonal in shape, usually flat, with central depression or umbilication, and are reddish or violaceous in color. At first they have a glazed or shining appearance; later, becoming slightly scaly, the scaliness being more marked where solid patches have resulted. New papules may appear from time to time, the older lesions disappearing and leaving persistent reddish or brownish pigmentation. Exceptionally the eruption presents in bands or lines, like rows of beads (lichen moniliformis). Very exceptionally a vesicular or bleb tendency in some of the lesions has been noted; doubtless, in most instances at least, this has been due to the arsenic so generally administered in this disease. In rare instances lichen planus lesions are also seen on the glans penis and on the buccal mucous membrane. In some cases, especially in the region of the ankle, the papules become quite large (lichen planus hypertrophicus), and in occasional cases there is a tendency in some of the lesions or patches to clear up centrally. There is, as a rule, considerable itching. There are no constitutional symptoms.

What is the etiology of lichen planus?

In some cases the disease is distinctly neurotic in character, in others no cause can be assigned. It is more especially met with at middle age, and among the wealthier, professional, and luxurious classes.

Pathologically the first change noted in the epidermis is thought to be an acanthosis, followed by epithelial atrophy, and a hyperkeratosis, intercellular edema, and colloid degeneration of the prickle cells.

Does the disease bear any resemblance to the miliary papular syphilide, psoriasis, and papular eczema?

In some instances it does, but the irregular and angular outline, the slightly-umbilicated, flattened, smooth or scaly summits, and the dull-red or violaceous color, the history and course, of lichen planus, will serve to differentiate.

State the prognosis.

Under proper management the eruption, although often obstinate, yields to treatment.

What treatment would you prescribe in lichen planus?

A general tonic plan of medication is indicated in most cases, with such remedies as iron, quinine, nux vomica, and cod-liver oil and other nutrients. In many instances arsenic exerts a special influence, and should always be tried. Mercurials in moderate dosage have also a favorable action in most cases. Locally, antipruritic and stimulating applications, such as are used in the treatment of eczema, are to be employed, alkaline baths and tarry applications deserving special mention. Liquor carbonis detergens, applied weakened with several parts water, is a valuable application. In some cases, particularly if the disease is limited, external applications alone often suffice to bring about a cure.



Pityriasis Rubra Pilaris. (Synonyms: Lichen Ruber; Lichen Ruber Acuminatus.)

Describe pityriasis rubra pilaris.

Pityriasis rubra pilaris is an extremely rare disease, usually of a mildly inflammatory nature, characterized by grayish, pale-red or reddish-brown follicular papules with somewhat hard or horny centres; discrete and confluent, and covering a part or the entire surface. The skin is harsh, dry and rough, feeling to the touch somewhat like the surface of a nutmeg-grater or a coarse file. More or less scaliness is usually present in the confluent patches and on the palms and soles; in these latter regions the papules are rarely seen. The duration of the disease is variable, and relapses are common. It bears resemblance at times to keratosis pilaris, ichthyosis, dermatitis exfoliativa; it is considered identical with the lichen ruber acuminatus of Kaposi, and by many also with the lichen ruber of Hebra. The etiology is obscure.

Treatment, both constitutional and local, is to be based upon general principles; stimulating applications, with frequent baths, such as are advised in psoriasis, are the most satisfactory. It is rebellious, and not much more than palliation can be effected in some cases, in others the outlook is more hopeful.



Lichen Scrofulosus.

Describe lichen scrofulosus.

Lichen scrofulosus is a chronic, inflammatory disease, characterized by millet-seed-sized, rounded or flat, reddish or yellowish, more or less grouped, desquamating papules. The lesions have their start about the hair-follicles, occur usually upon the trunk, tend to group and form patches, and sooner or later become covered with minute scales. As a rule, there is no itching. It is a rare disease, and but seldom met with in America; it is seen chiefly in children and young people of a scrofulous diathesis. Scarring, slight in character, may or may not follow.

What is the treatment of lichen scrofulosus?

The condition responds to tonics and anti-strumous remedies.



Eczema. (Synonym: Tetter; Salt Rheum.)

What is eczema?

An acute, subacute or chronic inflammatory disease, characterized in the beginning by the appearance of erythema, papules, vesicles or pustules, or a combination of these lesions, with a variable amount of infiltration and thickening, terminating either in discharge with the formation of crusts, in absorption, or in desquamation, and accompanied by more or less intense itching and a feeling of heat or burning.

What are the several primary types of eczema?

Erythematous, papular, vesicular and pustular; all cases begin as one or more of these types, but not infrequently lose these characters and develop into the common clinical or secondary types—eczema rubrum and eczema squamosum.



What other types are met with clinically?

Eczema rubrum, eczema squamosum, eczema fissum, eczema sclerosum and eczema verrucosum. Eczema seborrhoicum is probably a closely allied disease, occupying a middle position between ordinary eczema and seborrh[oe]a.

Describe the symptoms of erythematous eczema.

Erythematous eczema (eczema erythematosum) begins as one or more small or large, irregularly outlined hyperaemic macules or patches, with or without slight or marked swelling, and with more or less itching or burning. At first it may be ill-defined, but it tends to spread and its features to become more pronounced. It may be limited to a certain region, or it may be more or less general. When fully developed, the skin is harsh and dry, of a mottled, reddish or violaceous color, thickened, infiltrated and usually slightly scaly, with, at times, a tendency toward the formation of oozing areas. Punctate and linear scratch-marks may usually be seen scattered over the affected region.



Its most common site is the face, but it is not infrequent upon other parts.

What course does erythematous eczema pursue?

It tends to chronicity, continuing as the erythematous form, or the skin may become considerably thickened and markedly scaly, constituting eczema squamosum; or a moist oozing surface, with more or less crusting, may take its place—eczema rubrum.

Describe the symptoms of papular eczema.

Papular eczema (eczema papulosum) is characterized by the appearance, usually in numbers, of discrete, aggregated or closely-crowded, reddish, pin-head-sized acuminated or rounded papules. Vesicles and vesico-papules are often intermingled. The itching is commonly intense, as often attested by the presence of scratch-marks and blood crusts.



It is seen most frequently upon the extremities, especially the flexor surfaces.

What course does papular eczema pursue?

The lesions tend, sooner or later, to disappear, but are usually replaced by others, the disease thus persisting for weeks or months; in places where closely crowded, a solid, thickened, scaly sheet of eruption may result—eczema squamosum.

Describe the symptoms of vesicular eczema.

Vesicular eczema (Eczema vesiculosum) usually appears, on one or several regions, as more or less diffused inflammatory reddened patches, upon which rapidly develop numerous closely-crowded pin-point to pin-head-sized vesicles, which tend to become confluent and form a solid sheet of eruption. The vesicles soon mature and rupture, the discharge drying to yellowish, honeycomb-like crusts. The oozing is usually more or less continuous, or the disease may decline, the crusts be cast off, to be quickly followed by a new crop of vesicles. In those cases in which the process is markedly acute, considerable swelling and [oe]dema are present. Scattered papules, vesico-papules and pustules may usually be seen upon the involved area or about the border.

The face in infants (crusta lactea, or milk crust, of older writers), the neck, flexor surfaces and the fingers are its favorite localities.

What course does vesicular eczema pursue?

Usually chronic, with acute exacerbations. Not infrequently it passes into eczema rubrum.

Describe the symptoms of pustular eczema.

Pustular eczema (eczema pustulosum, eczema impetiginosum) is probably the least common of all the varieties. It is similar, although usually less actively inflammatory, in its symptoms to eczema vesiculosum, the lesions being pustular from the start or developing from preexisting vesicles; not infrequently the eruption is mixed, the pustules predominating. There is a marked tendency to rupturing of the lesions, the discharge drying to thick, yellowish, brownish or greenish crusts.

Its most common sites are the scalp and face, especially in young people and in those who are ill-nourished and strumous.

What course does pustular eczema pursue?

Usually chronic, continuing as the same type, or passing into eczema rubrum.

Describe the symptoms of squamous eczema.

Squamous eczema (eczema squamosum) may be defined as a clinical variety, the chief symptoms of which are a variable degree of scaliness, more or less thickening, infiltration, and redness, with commonly a tendency to cracking or fissuring of the skin, especially when the disease is seated about the joints. It is developed, as a rule, from the erythematous or papular type. Itching is slight or intense.

The disease is not uncommon upon the scalp.

What is the course of squamous eczema?

Essentially chronic.



Describe the symptoms of eczema rubrum.

Eczema rubrum is characterized by a red, raw-looking, weeping, oozing or discharging surface, attended with more or less inflammatory thickening, infiltration and swelling; the exudation, consisting of serum, sometimes bloody, dries into thick yellowish or reddish-brown crusts. At one time the whole diseased area may be hidden under a mass of crusting, at other times a red, raw-looking, weeping surface (eczema madidans) is the most striking feature. Itching is slight or intense, or the subjective symptom may be a feeling of burning. It is an important clinical type, usually developing from the vesicular, pustular or other primary variety.

It is common about the face and scalp in children, and the middle and lower part of the leg in elderly people.

What is the course of eczema rubrum?

Chronic, varying in intensity from time to time.

Describe the symptoms of fissured eczema.

The conspicuous symptom is a marked tendency to fissuring or cracking of the skin (eczema fissum; eczema rimosum). This tendency is usually a part of an erythematous or squamous eczema, the fissuring constituting the most conspicuous and troublesome symptom. Chapping is an extremely mild but familiar example of this type.

It is especially common about the hands and fingers.

What is the course of fissured eczema?

It is more or less persistent, the tendency to fissuring varying considerably according to the state of the weather, often disappearing spontaneously in the summer months.

Describe eczema sclerosum and eczema verrucosum.

In eczema sclerosum the skin is thickened, infiltrated, hard, and almost horny. Eczema verrucosum presents similar conditions, but, in addition, displays a tendency to papillary or wart-like hypertrophy. In both varieties the disease is usually seated about the ankle or the foot, developing from the papular or squamous type. They are uncommon, and obstinately chronic.

State the nature of the subjective symptoms in eczema.

Itching, commonly intense, is usually a conspicuous symptom; it may be more or less paroxysmal. In some cases burning and heat constitute the main subjective phenomena.

Is eczema accompanied by febrile or systemic symptoms?

No. In rare instances, in acute universal eczema, slight febrile action, or other systemic disturbance, may be noted at the time of the outbreak.

Is the eczematous eruption (patch or patches) sharply defined against the neighboring sound skin?

No. In almost all instances the diseased area merges gradually and imperceptibly into the surrounding healthy integument.

What is the character of eczema as regards the degree of inflammatory action?

The inflammatory action may be acute, subacute or sluggish in character, and may be so from the start and so continue throughout its whole course; or it may, as is usually the case, vary in intensity from time to time.

State the character of eczema as regards duration.

As a rule, it is a persistent disease, showing little, if any, tendency to spontaneous disappearance.

Is eczema influenced by the seasons?

Yes. With comparatively few exceptions the disease is most common and much worse in cold, windy, winter weather.

To what may eczema be ascribed?

Eczema may be due to constitutional or local causes, or to both. It may be considered, in fact, as a reaction of the skin tissues against some irritant, and the latter may have its origin from within or without.

Name some of the important constitutional or predisposing causes.

Gouty diathesis, rheumatic diathesis, disorders of the digestive tract, general debility or lack of tone, an exhausted state of the nervous system, dentition and struma.

Is a constitutional cause sufficient to provoke an attack?

Yes; but often the attack is brought about in those so predisposed by some local or external irritant.

Mention some of the external causes.

Heat and cold, sharp, biting winds, excessive use of water, strong soaps, vaccination, dyes and dyestuffs, chemical irritants, and the like. There is a growing belief that some cases presenting eczematous aspects are probably parasitic in origin. In fact, some observers hold to the microbic view of all cases of eczema.

Contact with the rhus plants, while producing a peculiar dermatitis, usually running an acute course terminating in recovery, may, in those predisposed, provoke a veritable and persistent eczema. In fact, in our examination as to causes in a given case, especially of the hands and face, all possible exciting factors should be inquired into, such as the handling of plants, chemicals, dyes, etc.



Is eczema contagious?

No. The acceptance of a parasitic cause for the disease, however, necessarily carries with it the possibility of contagiousness under favoring conditions. Such is not supported, however, by practical experience.

What is the pathology?

The process is an inflammatory one, characterized in all cases by hyperaemia and exudation, varying in degree according to the intensity and duration of the disease. The rete and papillary layer are especially involved, although in severe and chronic cases the lower part of the corium and even the subcutaneous tissue may share in the process.

Do the cutaneous manifestations of the eruptive fevers bear resemblance to the erythematous type of eczema?

Scarlatina and erysipelas may, to a slight extent, but the presence or absence of febrile and other constitutional symptoms will usually serve to differentiate.

What common skin diseases resemble some phases of eczema?

Psoriasis, seborrh[oe]a, sycosis, scabies and ringworm.

How would you exclude psoriasis in a suspected case of eczema (squamous eczema)?

Psoriasis occurs in variously-sized, rounded, sharply-defined patches, usually scattered irregularly over the general surface, with special predilection for the elbows and knees. They are covered more or less abundantly with whitish, silvery or mother-of-pearl colored imbricated scales. The patches are always dry, and itching is, as a rule, slight, or may be entirely absent. Eczema, on the contrary, is often localized, appearing as one or more large, irregularly diffused patches; it merges imperceptibly into the sound skin, and there is often a history of characteristic serous or gummy oozing; the scaling is usually slight and itching almost invariably a prominent symptom.

How would you exclude seborrh[oe]a (eczema seborrhoicum) in a suspected case of eczema?

Seborrh[oe]a of the scalp is more commonly over the whole of that region and is relatively free from inflammatory symptoms; the scales are of a greasy character and the itching is usually slight or nil. On the other hand, in eczema of this region the parts are rarely invaded in their entirety; there may be at times the characteristic serous or gummy oozing; inflammatory symptoms are usually well-marked, the scales are dry and the itching is, as a rule, a prominent symptom. These same differences serve to differentiate the diseases in other regions.

How does scabies differ from eczema?

Scabies differs from eczema in its peculiar distribution, the presence of the burrows, the absence of any tendency to patch formation, and usually by a clear history of contagion.

How would you exclude ringworm in a suspected case of eczema?

Ringworm is to be distinguished by its circular form, its fading in the centre, and in doubtful cases by microscopic examination of the scrapings.

How does eczema differ from sycosis?

Sycosis is limited to the hairy region of the face, is distinctly a follicular inflammation, and is rarely very itchy; eczema is diffused, usually involves other parts of the face, and itching is an annoying symptom.

State the general prognosis of eczema.

The disease is, under favorable circumstances, curable, some cases yielding more or less readily, others proving exceedingly rebellious. The length of time to bring about a result is always uncertain, and an opinion on this point should be guarded.

Upon what would you base your prognosis in the individual case?

The extent of disease, its duration and previous behavior, the removability of the exciting and predisposing causes, and the attention the patient can give to the treatment.

In eczema involving the lips, face, scrotum, and leg, and especially when this last-named exhibits a varicose condition of the veins, a cure is effected, as a rule, only through persistent and prolonged treatment.

Does eczema ever leave scars?

No. Upon the legs, in long-continued cases, more or less pigmentation usually remains.

How is eczema treated?

As a rule, eczema requires for its removal both constitutional and external treatment.

Certain cases, however, seem to be entirely local in their nature, and in these cases external treatment alone will have satisfactory results.

What general measures as to hygiene and diet are commonly advisable?

Fresh air, exercise, moderate indulgence in calisthenics, regular habits, a plain, nutritious diet; abstention from such articles of food as pork, salted meat, acid fruits, pastry, gravies, sauces, cheese, pickles, condiments, excessive coffee or tea drinking, etc. As a rule, also, beer, wine, and other stimulants are to be interdicted.

Upon what grounds is the line or plan of constitutional treatment to be based?

Upon indications in the individual case. A careful examination into the patient's general health will usually give the cue to the line of treatment to be adopted.

Mention the important remedies variously employed in the constitutional treatment.

Tonics—such as cod-liver oil, quinine, nux vomica, the vegetable bitters, iron, arsenic, malt, etc.

Alkalies—sodium salicylate, potassium bicarbonate, liquor potassae, and lithium carbonate.

Alteratives—calomel, colchicum, arsenic, and potassium iodide.

Diuretics—potassium acetate, potassium citrate, and oil of copaiba.

Laxatives—the various salines, aperient spring waters, castor oil, cascara sagrada, aloes and other vegetable cathartics.

Digestives—pepsin, pancreatin, muriatic acid and the various bitter tonics.

Are there any remedies which have a specific influence?

No; although arsenic, in exceptional instances, seems to exert a special action. Cod-liver oil is also of great value in some cases.

Upon the whole the most important remedies are those which keep in view the maintenance of a proper and healthful condition of the gastro-intestinal tract, and especially with regular and rather free action of the bowels.

In what class of cases does arsenic often prove of service?

In the sluggish, dry, erythematous, scaly and papular types.

In what cases is arsenic usually contraindicated?

It should never be employed in acute cases; nor in any instance (unless its action is watched), in which the degree of inflammatory action is marked, as an aggravation of the disease usually results.

What should be the character of the external treatment?

It depends mainly upon the degree of inflammatory action; but the stage of the disease, the extent involved, and the ability of the patient to carry out the details of treatment, also have a bearing upon the selection of the plan to be advised.

What is to be said about the use of soap and water in eczema?

In acute and subacute conditions soap and water are to be employed, as a rule, as infrequently and as sparingly as possible, as the disease is often aggravated by their too free use. Washing is necessary, however, for cleanliness and occasionally, also, for the removal of the crusts. On the other hand, in chronic, sluggish types the use of soap and water frequently has a therapeutic value.

How often should remedial applications be made?

Usually twice daily, although in some case, and especially those of an acute type, applications should be made every few hours.

Mention several remedies or plans of treatment to be used in the acute or actively inflammatory cases.

Black wash and oxide-of-zinc ointment conjointly, the wash thoroughly dabbed on, allowed to dry, the parts gently smeared with ointment; or the ointment may be applied spread on lint as a plaster.

Boric-acid wash (15 grains to the ounce) and oxide-of-zinc ointment, applied in the same manner as the above.

A lotion containing calamine and zinc oxide, the sediment drying and coating over the affected surface:—

[Rx] Calaminae, Zinci oxidi, ... āā ......... [dram]ij-[dram]iij Glycerinae, Alcoholis, ..... āā ......... f[dram]ss Liq. calcis, ...................... f[Oz]ij Aquae, .......... q.s. ad .......... f[Oz]vj. M.

Another excellent lotion somewhat similar to the last, but of oily character, is made up of three drachms each of calamine and zinc oxide, one drachm of boric acid, ten to thirty drops of carbolic acid, and three ounces each of lime-water and oil of sweet almonds.

Carbolic-acid lotion, about two drachms to the pint of water, to which may be added two or three drachms each of glycerin and alcohol; or, if there is intense itching, carbolic acid may be added to the several washes already mentioned.

A lotion made of one or two drachms of liquor carbonis detergens[A] to four ounces of water.

The following wash, especially in the dry form of the disease:—

[Rx] Ac. borici, .......................... [dram]iv Ac. carbolici, ....................... [dram]j Glycerinae, ........................... [dram]ij Alcoholis, ........................... [dram]ij Aquae, ............. q.s. ad .......... Oj. M.

[Footnote A: Liquor carbonis detergens is made by mixing together nine ounces of tincture soap bark and four ounces of coal tar, allowing to digest for eight days, and filtering. The tincture of soap bark used is made with one pound of soap bark to one gallon of 95 per cent. alcohol, digesting for a week or so. Instead of the proprietary name above, Prof. Duhring has suggested that of tinctura picis mineralis comp.]

Dusting-powders, of starch, zinc oxide and Venetian talc, alone or severally combined, applied freely and often, so as to afford protection to the inflamed surface:—

[Rx] Talci venet, Zinci oxidi, ....... āā ........ [dram]iv Amyli, ............................... [Oz]j M.

If washes or dusting-powders should disagree or are not desirable or practicable, ointments may be employed, such as—

Oxide-of-zinc ointment, cold cream, petrolatum, plain or carbolated, diachylon ointment (if fresh and well prepared), and a paste-like ointment, as the following, usually called "salicylic-acid paste"; in markedly itchy cases, five to fifteen grains of carbolic may be added to each ounce:

[Rx] Ac. salicylici, ...................... gr. v-x Pulv. amyli, Pulv. zinci oxidi, .... āā ..... [dram]ij Petrolati, ........................... [dram]iv M.

Or the following ointment:—

[Rx] Calaminae, ............................ [dram]j Ungt. zinci oxidi, ................... [dram]vij. M.

Name several external remedies and combinations useful in eczema of a subacute or mildly inflammatory type.

The various remedies and combinations useful when the symptoms are acute or markedly inflammatory (mentioned above), and more especially the several following:—

[Rx] Zinci oxidi, ......................... [dram]ij Liq. plumbi subacetat. dilut., ....... f[dram]vj Glycerinae, ........................... f[dram]ij Infus. picis liq., ................... f[Oz]iij M.