Chapter II: The Peculiarities of Certain Accidental Acute and Chronic Diseases (12)

Psoriasis may be defined as a chronic disease of the skin, characterized by reddish, dry, inflammatory, infiltrated patches, variable as to size, shape, and number, covered usually with abundant whitish, mother-of-pearl-colored, imbricated scales. It varies considerably in the degree of its development, but as a rule the lesions are numerous and their features clearly defined. It is the most uniform in its symptoms of all the diseases of the skin. It is therefore easy to recognize. In the first stage it appears as a small reddish spot, as large as a pinhead or a pea; it grows rapidly or slowly, and from the beginning shows signs of scaling, the scales being whitish, imbricated, and easily detached by scraping. They are reproduced readily, so that the lesion is usually well covered. In their early stages the lesions usually develop rapidly until their determinate size has been attained. The usual course is for the lesion to begin as a pinhead-sized spot, and grow to the size of a small or large coin. Several may appear side by side in close proximity, in which event they tend to coalesce, and to form larger, rounded, ovoidal, or figure-of-eight-shaped patches. Thus in time large surfaces of disease, the size of a hand or larger, may result. In other cases the lesions remain small, but through their great number may involve a considerable portion of the whole integument.

When typically developed, the lesions are of a bright- or dull-red color, and are covered with whitish, grayish, or pale-yellowish scales. The degree of inflammation varies with the case; at times it is slight, causing the lesions to assume merely a pale-pinkish, slightly inflammatory look; at other times it is more active, producing a decidedly inflammatory, strawberry- or raspberry-red hue. The majority of cases show a well-defined dull pinkish-red color of a cold inflammatory hue. The scaling, while usually active and abundant, is likewise variable; where the lesions are numerous and large it is constant, the scales being formed and shed rapidly from day to day; where the process is active, they are large, laminated, of a whitish, silvery, or mother-of-pearl-colored or slightly yellowish hue, varying somewhat with the locality involved. Sometimes they are heaped up. They are, moreover, easily detached, and can be readily picked or scraped off, leaving beneath a dry or very little excoriated, reddish surface. When deeply scratched, minute drops or points of blood, sometimes appear. They never exude serum. The lesions are, as a rule, circumscribed and sharply defined from the surrounding healthy integument, differing in this respect from similar patches of eczema. The skin between the lesions is perfectly healthy. In markedly inflammatory cases they occasionally possess a slightly raised border, and sometimes, especially in certain localities, as the hands, fissures form, as in eczema and syphilis.

The disease pursues an eminently chronic course, often lasting years or even throughout life, disappearing and recurring from time to time. Relapses at intervals of months or years are the rule, sometimes slight, at other times severe. It is a capricious disease. Usually it is better in summer than in winter, and in some cases it makes its appearance only during the latter season. It is generally unaccompanied by marked subjective symptoms, although this depends largely upon the degree of {615} inflammatory action. In most chronic cases the itching and burning are either absent or slight, and when present are generally most annoying during the period that new lesions are appearing or old ones spreading. On the other hand, where the affection is highly inflammatory and running an acute, rapid course, both sensations, especially burning, may exist to an annoying degree. The disease is not contagious.

The eruption takes on different appearances according to the size and outline of the lesions, some of which require mention. They constitute the so-called varieties of the disease, but, strictly speaking, are forms rather than varieties. Thus, when the lesions are pinhead in size the form is termed punctata; when larger, the size of peas, guttata, from their resemblance to a drop of mortar; when still larger, the size of coins, they are designated nummularis, this being the form generally encountered. Sometimes the last-named lesions become more or less clear in the centre, and spread on their circumference after the manner of ringworm of the general surface, the condition being called circinata; at other times, more rarely, they assume a figured or ribbon-like form, causing them to have a serpentine, gyrate, or festooned appearance, termed gyrata. Commonly, however, when they grow to a large size they form, by the coalition of two or more lesions, irregularly-rounded patches, covering, it may be, a considerable area, the condition being called diffusa. The disease shows preference for certain regions, among which may be mentioned the extensor surfaces of the limbs, the elbows and knees, the scalp, and the trunk. The palms and soles and nails may also be invaded alone, or, as is usually the case, in connection with the disease upon other regions. It is usually symmetrical.

The causes of the disease seem to be varied, and are by no means well understood. It is met with, as a rule, in subjects whose general health is of the best, and who have hearty and strong constitutions, with no other ailment than the cutaneous manifestation. But cases are also encountered where the general condition is at fault: sometimes the system is below standard, as during lactation; in other cases the nervous system is depressed, as from some long-continued cause like mental worry. It occurs in both sexes, and usually makes its appearance in early adult life. It is seldom met with before the age of eight, and does not show itself in infants. In some cases it is inherited, but more frequently such is not the case. It occurs in all walks of life, being found among the rich and the poor in about like proportions. Statistics show it to be one of the most common diseases of the skin. It is of more frequent occurrence in some countries than in others. According to White's report of 5000 consecutive cases of skin disease observed in Boston, 152 cases of psoriasis were recorded, while Anderson in Glasgow reports 725 cases among 10,000 cases of skin disease, the difference being more than two to one in favor of Scotland. Diet in the majority of cases possesses but little influence over the disease.

The pathological process is one of the most defined and constant in cutaneous medicine. It is well marked throughout its course, and is subject to little variation. According to the most recent and reliable observations, it is held to be an inflammation induced by a hyperplasia of the rete mucosum. The views put forth by Auspitz and by Tilbury Fox have been substantiated by more recent observers. A. R. Robinson, {616} and later Jamieson and Thin, have investigated the pathological anatomy of the disease with care, and have shown that the disease consists essentially of a hyperplasia of the rete mucosum, the increase taking place in the interpapillary portion of the layer. The growth extends downward, pressing upon the papillæ and corium, and setting up a variable degree of inflammation. In the later stages the superficial blood-vessels become dilated, more or less emigration of corpuscular elements occurring, the connective tissue especially in the neighborhood of the vessels becoming the seat of a round-cell infiltration. Effusion of serum, moreover, takes place, separating the connective-tissue bundles and fibres into an open meshwork. As the disease is vanishing there is a gradual return to the normal state, the hyperplasia, dilatation, and infiltration disappearing without traces. The hair is affected from the beginning in the form of hyperplasia of the external root-sheath, but the sebaceous and sweat glands are not found to be involved.

DIAGNOSIS.--The diagnosis, as a rule, offers no difficulties. The characteristic features are so constant and are usually so well marked that in ordinary cases errors are not likely to occur. When localized, as upon the scalp or upon the hands, it may be, however, readily confounded with other diseases. The general aspect of the eruption, the form of the lesions, the peculiar character of the scaling, the localities invaded, and the course of the process must be kept in view. It may be confounded with squamous eczema, especially where only one or two lesions are present, but the scales are usually more abundant, larger, and whiter than in eczema. The patches of psoriasis, moreover, are circumscribed, often sharply defined, and are always dry. In eczema there is not infrequently a history of moisture; itching is also generally an annoying symptom, much more marked than in psoriasis.

The papulo-squamous syphiloderm at times closely resembles psoriasis, especially as it occurs upon the palms and soles. Symmetry usually exists in psoriasis, but in syphilis it is often lacking, even in connection with disease of the palms and soles. Apart from the question of a history of syphilis, it will be found that psoriasis generally involves more surface, and in a more disseminate form, than the syphilitic eruption; also, that the scales are whiter, larger, and more copious than in syphilis. The color of the lesions in both diseases is similar, but in psoriasis it is pinker or redder, and free from the yellowish, brownish, ham-colored tint that generally characterizes the later syphilitic eruptions. The infiltration and thickening of the skin in a psoriatic patch are less than in syphilis, this observation being a valuable point in the diagnosis. The character of the inflammatory product in the diseases is different, that of psoriasis being simpler and less dense and firm. Finally, the course of psoriasis is peculiar, the lesions always manifesting the same general characters, often disappearing spontaneously and again reappearing.

Seborrhoea, especially of the scalp, sometimes simulates psoriasis, but the patches in the former disease are ill defined, are not so marginate, and are covered with finer, looser, and fatty scales. The lesions of psoriasis are redder and more infiltrated, and will usually be found to exist also in other localities. The disease may also be mistaken for lupus erythematosus in its early stage. The involvement of the sebaceous glands in {617} almost all cases in the latter affection, the character of the scaling, and the fact that the face is the usual locality attacked, will aid in the diagnosis. Ringworm of the general surface may also bear resemblance to psoriasis, especially to the circular form, but the parasitic disease is more superficial and more marginate, is less scaly, and runs a more acute course. In doubtful cases the microscope should always be employed to determine the question.

TREATMENT.--The disease is rebellious to treatment, sometimes even where the lesions are few and small. It must be regarded as one of the most stubborn and persistent of the inflammatory diseases of the skin, for, while many cases yield readily to either internal or external remedies, the majority will often resist the best-directed therapeutics looking toward a permanent cure. It may often be happily dissipated for the time being, but immunity from relapses is a difficult task. To relieve the patient of the lesions, and, secondly, to prevent, if possible, relapses, should be the aim. To accomplish this demands usually both external and internal treatment. Before entering upon therapeutic measures the case should be viewed from a general standpoint. The condition of the general health should be inquired into, and the cause, if possible, determined. The history of the disease in chronic cases should be learned, and, if a relapse, the behavior of the lesions on former occasions. The influence of the several well-known remedies, such as arsenic internally, and tar, chrysarobin, and the mercurials locally, should also be ascertained. Finally, the acuteness or chronicity of the attack, the activity of the process, the amount of disease present, the locality invaded, and the general circumstances of the patient and the time that can be devoted to the treatment, should all receive consideration.

Among internal remedies, arsenic and its preparations occupy the most prominent position. For the majority of cases this remedy will be found valuable, and, if administered when indicated and in suitable doses for sufficient length of time, good results may be expected. It is not indicated in every case, as is shown by the fact that sometimes, instead of relieving, it aggravates the disease. It should be used tentatively at first, with the view of determining its tolerance and effect, not only upon the skin, but on the general system and alimentary canal. It is a powerful remedy, and should always be employed with due caution. At the same time, there need be no hesitation in prescribing it, or even in employing it for a long period, if attention be directed to its effects. Toxic symptoms should never be permitted to occur. In acute stages, whether in first attacks or in relapses, where the process is active, characterized by marked redness, inflammation, and heat, it should be withheld. At these periods it usually aggravates the disease. The more chronic the process, the more useful will the remedy probably prove.

The drug is generally administered in the form of arsenious acid, liquor potassii arsenitis, and liquor sodii arsenitis. A dose of arsenious acid varies from one-fortieth to one-fifteenth of a grain thrice daily, administered in pill form. The dose of the liquor potassii arsenitis--or Fowler's solution of arsenic, as it is generally termed--varies from one to five minims three times a day, the average dose being two or three minims. It is best to begin with a small dose and gradually to increase the quantity until the maximum dose is ascertained; {618} after which the regular dose may be instituted. Patients, it will be found, vary as to the amount they can safely and beneficially take: in most cases two or three minims continued for a length of time will prove a full dose, while in others four or five minims will be tolerated. It may be given with water, elixir of calisaya, or wine of iron. The practice of prescribing it pure, directing a certain number of drops to be taken at each dose, is objectionable; it does not ensure an accurate quantity or proper dilution, and, moreover, gives the patient unnecessary trouble. A prescription such as the following possesses practical advantages:

Rx. Liq. potassii arsenitis, fluidrachm iss;
Elix. calisayæ, fluidounce iv.

M.--Sig. One teaspoonful with a wineglassful of water thrice daily, after meals. The dose here is three minims; should it prove too strong, a half teaspoonful of the mixture may be ordered. The toxic effects of arsenic should be borne in mind. Some persons are very susceptible to the remedy, half-minim or one-minim doses sometimes causing unpleasant symptoms. The usual ill effects consist of erythema of the fauces, oedema of the eyelids, injection of the conjunctivæ, watering of the eyes, pains in the head, nausea, sharp pains in the bowels, and diarrhoea, coming on within a few days or a fortnight after beginning treatment. As a rule, they pass away in a few days after ceasing the use of the remedy.

The length of time that arsenic should be given will depend upon its effects upon the general system and upon the disease. In most cases improvement is noticeable within a fortnight, though its use from one to three months is generally necessary to bring about complete recovery; and it is best to continue the medicine in small doses for a month or two longer. Arsenic is a nervine tonic. It acts as a stimulant to the skin, exerting a decided impression upon the cells of the rete mucosum; doing this, without doubt, directly through the nerves, which, as is well known, are abundantly supplied to this structure.

Phosphorus has been used by several dermatologists, but with varying results. It is liable to produce gastric disturbance, and is a disagreeable remedy. Tar, in capsule or pill form, will sometimes prove of value where arsenic and other remedies have failed. From one to three capsules, containing from three to five grains each, may be given for a dose. Carbolic acid has also been extolled by some, especially in chronic cases with slight infiltration. Anderson speaks well of it, and gives the following formula for its administration:

Rx. Acidi carbolici, drachm iij;
Glycerinæ, fluidounce j;
Aquæ, fluidounce v.

M.--Sig. One teaspoonful in a large wineglassful of water before meals.

In some cases, more particularly in strong, hearty, plethoric persons, and in those having a rheumatic or gouty habit, the free use of alkalies proves of great value. In these cases arsenic often aggravates rather than improves the condition, whereas the alkali acts most happily. It may be recommended in acute stages of the disease when the lesions are red, heated, and growing. Liquor potassæ, in from ten to twenty drop doses, diluted with a large wineglassful of water, thrice daily, is the form generally prescribed. Improvement is sometimes noted within a few days. Anderson calls attention also to the value of carbonate of ammonium, in {619} from ten to thirty grain doses, in like cases. The acetate of potassium, in thirty-grain doses, may also be referred to as being sometimes useful.

Local treatment may now be considered. This is of great value, and should be instituted in all cases, either alone or in conjunction with internal remedies, according to the case. Sometimes it may be directed alone with good results, more particularly in chronic, sluggish cases where the lesions undergo but little change from time to time and are unaccompanied by subjective symptoms. Before prescribing certain points should be ascertained. The duration of the disease; the extent of the eruption, including the number and size of the lesions, and their acuteness or chronicity; the locality involved; the circumstances and the age of the patient; and the time that can be given to the treatment,--should all be taken into consideration. In this connection it should be remembered that whatever plan of treatment is adopted, the remedies should be applied thoroughly. The disease at best yields stubbornly, and to secure satisfactory results the importance of employing the agents properly should be insisted upon. This requires in most instances considerable time once, and, in some cases, twice a day. The scales are to be removed first. Where they are thick and adherent, inunction with some simple oil, as olive oil, followed by the use of soap and water, may be employed. Ordinarily, soft soap alone, well rubbed into the lesions with a piece of wet flannel and rinsed off with water, will be found sufficient. A 5 or 8 per cent. alcoholic solution of salicylic acid may be employed for the same purpose. The bath, simple or alkaline--the latter containing, for example, borax--is also frequently of service.

In acute, highly inflammatory cases, where the skin is red, hot, scaling profusely, and the lesions spreading from day to day, soothing applications, as of olive oil, will generally prove most valuable. Instances are sometimes encountered where the use of the simple bath, followed by inunctions of olive oil or one of the petroleum ointments, will prove to be the only treatment tolerated. The majority of cases, however, seeking advice show the disease already well developed and in the chronic stage, and here stimulating remedies are demanded.

One of the most valuable and generally useful remedies is tar, employed in the form of ointment or tincture or in combination with other substances, as, for example, the mercurials or sulphur. The tarry products in common use are pix liquida, or common tar, oil of tar, oil of cade, and oleum rusci (oil of white birch). The chief objection to their employment is the penetrating odor, which is almost impossible to banish. The oil of birch is probably the least objectionable in the list. Officinal tar ointment, full strength or weakened, will be found serviceable. It should be applied with a piece of cloth or stiff brush, well rubbed into the skin, and should be used twice daily, the scales having been previously removed by one or another of the methods indicated. Similar ointments, one or two drachms to the ounce, may in like manner be prepared from any of the other preparations of tar, as, for instance, the oil of white birch. Where an ointment is not desired, the oil of tar, oil of cade, or oil of white birch may be employed, the remedy being thoroughly rubbed or worked into the skin. Attention to the mode of application should always be insisted upon.

Other tarry preparations, such as liq. picis alkalinus, liq. carbonis {620} detergens (the formulæ for which have been given in speaking of the treatment of eczema), diluted, may also be prescribed in some cases with benefit. Hebra's modification of Wilkinson's ointment may be referred to as an energetic and useful compound:

Rx. Sulphuris sublimati,
Ol. cadini, aa. drachm iv;
Saponis viridis,
Adipis, aa. ounce j;
Cretæ præparatæ, drachm ijss.
M. Ft. ugt.

Another method of using tar consists in the so-called tar bath: the patches are deprived of scales by means of soft soap, after which tar ointment or one of the tarry oils is rubbed in, and the patient then placed in a warm bath for several hours. A stimulating tarry mixture, especially useful in circumscribed, infiltrated, obstinate patches, is composed of equal parts of tar, soft soap, and alcohol. Tar should not be applied over extensive surfaces without cautioning the patient that systemic disturbance, produced by absorption, may possibly occur. In ordinary cases, however, such an accident is very rarely noted. Creasote, turpentine, and acetic acid, remedies similar to tar in their action on the skin, may also be mentioned. The first-named may be used in the form of an ointment, from one to four drachms to the ounce. Turpentine may be applied pure or with oil, one to two or three parts. In some cases thymol in the form of an ointment, from five to thirty grains to the ounce, proves of service. The mercurials may also be referred to, but it may be stated that they are not as valuable in this disease as they are in eczema. The most useful is white precipitate in the form of ointment, from forty to eighty grains to the ounce, which is especially valuable in psoriasis of the scalp and of the face. Lotions of corrosive sublimate will also sometimes be found of service.

The treatment of psoriasis by chrysarobin--or chrysophanic acid, as it was originally termed--may now be referred to. It is a very valuable method of treatment. Care should be exercised in the selection of a reliable preparation, there being considerable difference in the strength, and therefore in the results obtained, of the remedy as found in the shops. Its disadvantages must be mentioned: It is liable to irritate and inflame the skin, causing sometimes an acute dermatitis or a follicular or furuncular inflammation and a variegated purplish or mahogany-colored staining of the skin. The hair, nails, and the linen of the patient also become stained. It may be prescribed in the form of an ointment, from ten grains to one drachm to the ounce of lard or petroleum ointment. The most desirable mode of application, that which is least objectionable, is in the form of a pigment, with flexible collodion or liquor gutta-perchæ, in the same strength as the ointment mentioned. It should be applied with a brush daily or every other day. The following formula, suggested by G. H. Fox, may be given: Chrysarobin and salicylic acid, each ten parts; ether, fifteen parts; collodion, enough to make one hundred parts. Another valuable remedy, having a similar action, to be used in the same manner as chrysarobin, is pyrogallic acid. Like chrysarobin, it stains the skin (a brownish hue), but it possesses the advantage over that substance in not being so irritating. Neither of these remedies, {621} especially the pyrogallic acid, should be applied over extensive surfaces, on account of liability to absorption and systemic poisoning.

Where the patches are not numerous a solution of sulphide of lime may sometimes be used with excellent results, as according to the following formula, known as Vleminckx's solution:

Rx. Calcis, ounce ss;
Sulphuris sublimati, ounce j;
Aquæ, fluidounce x.
Coque ad fluidounce vj, deinde filtra.

This may be perfumed with oil of anise, five or ten drops to the ounce. It may be applied diluted with two or four parts of water or full strength, and is to be rubbed into the skin with a flannel rag, after which the parts are to be bathed with water and some emollient oil or ointment applied.

Treatment is usually effective in removing the lesions, but, unfortunately, in the majority of cases, relapses sooner or later occur. It may be said relapses are the rule. The prognosis will depend upon the case.

Pityriasis Rosea.

Pityriasis rosea, known also as pityriasis maculata et circinata, is an inflammatory disease, occupying chiefly the trunk, characterized by discrete or confluent pinkish or reddish macular or slightly raised lesions varying in size from a small to a large coin. They are rounded in form, but by coalescence may assume irregular shapes and considerable size, as in the case of psoriasis. They are circumscribed, usually clearly defined, superficially seated, of a bright rosy, pinkish, or reddish hue, which sooner or later fades and is followed by yellowish, salmon-colored, or rusty tints. The surface of the lesions is from the beginning dry, and as the process advances furfuraceous or flaky scaling sets in, similar to that observed in tinea versicolor and in tinea circinata. This feature is more marked about the border, the process inclining to recover in the centre and to spread on the periphery, after the manner of tinea circinata. The skin is only slightly, if at all, thickened. At times there is slight burning or itching, but more frequently subjective symptoms are altogether wanting.

The course of the affection is variable, in many instances lasting from one to several months, while in exceptional cases it is more acute. It tends to spontaneous recovery, and is to be viewed as a mild disease, notwithstanding that the lesions at times, by their redness and size, indicate considerable cutaneous disturbance. It is met with in all ages, in our own experience more frequently in adults than in children, and occurs in both sexes and in those possessing average general health. It is one of the rarer cutaneous diseases, and is not contagious.

It is to be distinguished from ringworm of the body, from tinea versicolor, and from the macular syphiloderm, all three of which diseases it at times closely resembles. It possesses some of the peculiar features which characterize the vegetable parasitic diseases, but in some respects it differs from them in its behavior. The microscope fails to reveal fungus. Concerning treatment there is but little to be said, as the process inclines in most cases to spontaneous disappearance. Mildly stimulating ointments or {622} baths, as in eczema, may be prescribed. When involution sets in recovery usually takes place rapidly.

Pityriasis Rubra.

Pityriasis rubra is an inflammatory disease, usually pursuing a chronic course, characterized by redness and abundant and continuous epidermic exfoliation. It usually develops rapidly, beginning as small, red, scaly patches. It may make its appearance on one or more regions, the spots increasing in size rapidly, and coalescing to form large patches. In a variable time the whole or a large portion of the entire surface is involved, the skin being of a pale or violaceous red color and covered with thin whitish or grayish lamellar scales. These are abundant, and are rapidly formed, cast off and replaced by new, the exfoliation being, as a rule, in the form of flakes. Thickening of the skin seldom occurs. The surface when deprived of the scales is hyperæmic and shining in appearance. The disease usually involves the whole surface. Oedema, especially of the limbs, and stiffness of the joints are sometimes observed. The disease is superficial in character, rarely involving more than the upper cutaneous layers, and is always dry. Fissuring is only exceptionally seen.

As a rule, the subjective symptoms are slight, burning and itching, if present, seldom being violent. Symptoms of constitutional disturbance may or may not be present, but chilliness is often complained of. The disease generally occurs in adults, is acute or chronic, usually the latter, with a tendency to relapses. Being a rare affection, the etiology is obscure. Anatomically, there is found more or less marked cell-infiltration of the cutaneous tissues, especially noticeable in the rete and upper layer of the corium. In severe cases the papillæ are not distinguishable; the same may be said of the sweat and sebaceous glands.

Erythematous and squamous eczema and psoriasis bear resemblance to the disease. Its superficial nature, wide or universal distribution, absence of infiltration, character and rapid formation of the scales, and the slight itching or burning will serve to differentiate it from eczema. In psoriasis the whole surface is rarely if ever involved, while there is more or less thickening of the corium, and the scales are thicker and imbricated. It can scarcely be confounded with lichen ruber or with pemphigus foliaceus.

The disease pursues a variable course. It may last for years, with exacerbations, or outbreaks may occur from time to time. Treatment is, as a rule, unsatisfactory. For external treatment applications of a bland or soothing character afford the most relief. Vaseline, cold cream, and oily substances are generally of most service. Stimulating applications seldom prove useful--in fact, will in most cases give rise to discomfort and positive aggravation. In regard to constitutional remedies general indications are to be followed. There is no drug that seems to exert a specific influence.

{623} Dermatitis Exfoliativa.

This term is employed to designate certain cases in which more or less exfoliation is the prominent characteristic, and which cannot be classified under the head of any of the other diseases in which this symptom is noted. These cases have been variously described under the names of general exfoliative dermatitis, recurring exfoliative dermatitis, desquamative scarlatiniform erythema, recurrent acute eczema, acute general dermatitis, and recurrent exfoliative erythema. The affection is characterized by an erythematous inflammation, rarely vesicular or bullous, acute in type, with desquamation or exfoliation of the epidermis accompanying or following its development. There is also usually more or less marked constitutional disturbance, in some instances of a serious nature, and a tendency to relapse and recurrence. It is possible that in some instances the disease could be properly classified under the head of eczema, psoriasis, pityriasis rubra or pemphigus foliaceus.

Lichen Ruber.

Lichen ruber is an inflammatory disease, characterized by small flat and angular or acuminated, smooth and shining or scaly, discrete or confluent red papules, having a distinctly papular or papulo-squamous course, attended with a variable degree of itching. Two varieties are met with--the plane (lichen ruber planus) and the acuminate (lichen ruber acuminatus), the first of which occurs much the more frequently in this country. The acuminate variety is met with chiefly in Austria, where it was first described by Hebra: it is very rare in the United States, only a few authentic cases being on record. In lichen ruber planus the papules vary in size from a pinhead to a pea, and are peculiar in that they are not rounded, but are quadrangular or polygonal in shape. In their early stage they have a smooth, glazed surface, and are free of scales, but later they become papulo-squamous. They are more or less flattened on their summits, and show slight umbilication with whitish puncta. They are of a dull pinkish, reddish or violaceous color, the hue varying with the individual, age, and locality. As a rule, they are numerous, and occur in variously-sized aggregations, the distribution scarcely amounting to grouping. They tend to coalesce and form patches, which are slightly elevated, flattened, and uneven, the lesions when crowded together having a mosaic pattern. In lichen ruber acuminatus the papules are smaller, pointed, scaly, and disseminated, showing no disposition to group. This variety of the disease spreads rapidly, pursues a chronic course, and is a more serious affection, sometimes terminating fatally.

Lichen ruber planus usually presents itself upon the extremities, especially upon the flexor surfaces, the forearms and wrists and backs of the feet being favorite localities. Not infrequently it appears in the form of short or long narrow bands, following the natural lines of the skin, and sometimes nerve-tracts. The course of the disease is generally slow, extending over months. Occasionally, however, especially where the lesions are acute and very numerous, it is comparatively rapid. New {624} papules continue to show themselves from to time, the older ones disappearing by absorption, leaving persistent marked reddish or brownish pigmentation, which is to be regarded as a characteristic symptom.

The etiology of the disease is at times obscure, although, according to our experience, patients usually show signs of impaired nutrition or nervous depression, arising from varied causes, as, for example, overwork or shock. It occurs at all periods of life, but is usually met with at middle age, and is more common in women than in men. Pathologically, the process is considered an inflammation of a chronic character, accompanied by more or less alterative changes in the structure of the skin, involving the several layers as well as the follicles. The lesion is always of a papular type. Later investigations (Robinson) into the anatomy of the lesions of lichen ruber acuminatus and lichen ruber planus are apparently indicative of the distinct nature of the two varieties, the former being considered a paratypical keratosis, leading to retrograde changes and atrophy, and the latter an inflammatory process occurring in and about the papillæ and upper part of the corium.

In the diagnosis of lichen ruber the papular syphiloderm, lichen scrofulosus, psoriasis, and papular eczema are to be excluded. The irregular and angular outlines of the lesions of the plane variety, taken with their flattened, slightly umbilicated, smooth, or scaly summits and the dull-red or violaceous hue, are sufficiently characteristic. The evolution of a patch of psoriasis is entirely different from that of this disease, the former appearing as small spots and enlarging by peripheral growth, the patches of the latter resulting from aggregations of lesions. In papular eczema the papules are rounded, bright-red in color, intensely itchy, and have a different history and course. The prognosis of lichen ruber planus is generally favorable, although some cases are exceedingly rebellious. According to Hebra, in the severe forms of lichen ruber acuminatus, if neglected or improperly treated, a fatal result may ensue.

A general tonic plan of treatment is almost always indicated, such remedies as iron, quinia, strychnia, and the mineral acids proving of benefit. Arsenic exercises in many cases a specific influence. When the general health is much reduced arsenic fails, as a rule, to benefit until the patient's condition is brought back to its normal tone. The remedy should be given in tolerably large doses, and continued until the lesions have entirely disappeared. On account of the itching and discomfort experienced, external applications are demanded. The various antipruritic remedies mentioned in the treatment of eczema may be employed. Alkaline baths are useful. Unna has reported a few instances of cure of well-developed cases of the disease by the use of an ointment composed of two ounces of oxide-of-zinc ointment, forty grains of carbolic acid, and from one to two grains of corrosive sublimate. Tarry applications, especially in the form of lotions, often prove of service, the liquor picis alkalinus and the liquor carbonis detergens being the preparations commonly employed.

Lichen Scrofulosus.

Lichen scrofulosus is a chronic disease characterized by milletseed-sized, flat, reddish or yellowish, more or less grouped, desquamating papules, {625} unaccompanied by itching and occurring in those of a scrofulous disposition. The lesions, of a pale red or yellowish color, are usually numerous, are seated about the hair-follicles, and show a decided tendency to group, giving rise to patches of variable size and of a rounded or crescentic shape, which sooner or later become covered with minute scales. They are always small; are seen usually about the abdomen and chest, and exceptionally about the limbs; are chronic in character; and as a rule, are unaccompanied by itching. Pit-like, atrophic depressions may or may not follow the disappearance of the lesions.

The affection is not uncommon in Austria, but in this country it is practically unknown. It was first described by Hebra. It is more common in males, and is seen chiefly in children and young people. Symptoms of a scrofulous habit, such as glandular enlargements, ulcers, bone disease, or lung complaint, are found associated in almost all cases. According to Kaposi, the process is an inflammation and cell-infiltration in and about the hair-follicles, the sebaceous glands, and papillæ around the apertures of the follicles. Each papule, as may be seen on close examination, has its seat about the opening of a follicle, the inflammation beginning around the vessels and at the bases of the follicles and glands, and subsequently the cellular infiltration invading the interior of these structures to such an extent as to give rise to distension and elevation into papules.

It is to be differentiated from papular eczema, lichen ruber, the miliary papular syphiloderm, and keratosis pilaris. According to Hebra, cod-liver oil, employed internally and externally, is the remedy to which the disease readily yields.

Eczema.

SYMPTOMS.--Eczema, known popularly as tetter, is the most important and the commonest of the diseases of the skin. It may be defined as an inflammatory, non-contagious disease of the skin, characterized in the beginning by erythema, papules, vesicles or pustules, or a combination of these lesions, pursuing an acute or chronic course, accompanied by infiltration and itching, terminating either in discharge with the formation of crusts, in absorption, or in desquamation. The disease is multiform in character, and is capable of manifesting itself in a great variety of forms; and for this reason any definition that is attempted must be broad enough to comprise all of its essential features. It may begin as a circumscribed or diffuse small or large erythematous patch, which may remain dry and become scaly, or may pass into a state of moist exudation with crusting. It may also begin with vesicles or pustules, which soon rupture, giving rise to a red, moist, oozing, weeping, excoriated surface pouring forth a scanty or abundant fluid, gummy discharge, which rapidly dries to crusts. Instead of a moist discharging surface the skin may become dry, scaly, thickened, and more or less fissured. In other cases small papules, discrete or confluent, in patches or disseminated, form, constituting papular eczema. Finally, several or all of these lesions may occur together or in the course of the process. Thus, it will be observed, the disease is markedly multiform and protean. Not {626} infrequently it is capricious in its manifestations both as to the nature of the lesions and as to the evolution. Several varieties of the disease may appear simultaneously on one or on different regions.

Infiltration is one of the most marked features, and is present in varying degree. In the discharging varieties the fluid exuded is generally considerable and often excessive, giving rise to abundant crusting. In the papular variety the exudation is plastic in character, causing thickening of the skin, followed by more or less induration. Scaling is also frequently a prominent symptom, giving to the condition known as squamous eczema its peculiar features. Itching, usually marked, is an almost constant symptom, varying in degree. As a rule, it is an annoying feature of the disease, causing the patient to scratch in spite of good resolutions. In some cases, as in the erythematous variety, the sensation is of burning rather than itching, or it may be a combination of the two. Occasionally the locality affected is the seat of pain. The course of the disease is extremely variable. As a rule, it inclines to chronicity. Relapses are common, especially in adults and elderly persons. There are many cases on record, however, where, recovery having taken place, the individual remains free of the disease. The several varieties may now be considered.

Eczema Erythematosum.--This begins as an erythematous spot or macule, or as a patch, variable as to color, size and outline. It is most frequently met with upon the face, occupying a portion or the greater part of this region, usually in the form of several discrete or confluent patches. It generally begins as a coin-sized, ill-defined lesion, rounded or irregular in outline, of a pale-red hue, accompanied by itching and burning. The patch at first may be insignificant, but from time to time it spreads and becomes redder, thicker, and the surface slightly scaly. When fully developed, as is perhaps most frequently encountered upon the forehead, it consists of a more or less broken-up patch of considerably thickened somewhat swollen skin of a mottled or streaked pale-reddish, yellowish-red or violaceous hue. The surface is dry or excoriated and very slightly moist in places, and is covered with a thin film of dried, ragged epidermis or with thin adherent scales. The disease varies from time to time, being paler and less marked one week than another. Scratch-marks and excoriations, punctate or linear, are generally present, indicative of the scratching and rubbing to which the skin has been subjected. As stated, several patches generally exist, the disease tending to symmetry. The forehead, sides of the nose, and cheeks are the localities most frequently invaded, but other regions, as the back of the neck, axillæ, and flexures, are all common seats.

Its course is variable. As a rule, it inclines to assume chronicity, varying in intensity from time to time, or even disappearing and reappearing at irregular intervals. It is exceedingly liable to relapse, perhaps more so than any other variety. Having established itself, it may remain erythematous in character or may pass into other varieties of the disease. Thus, a moist or weeping surface may take the place of the erythema, followed by crusting, giving rise to eczema madidans, or eczema rubrum. Not infrequently the patch becomes markedly scaly, and continues in this form, producing eczema squamosum. When it occurs in regions where two opposing surfaces come in contact, as under the mammæ, between the {627} nates, and about the genitalia, an excoriated moist condition is produced known as eczema intertrigo, or eczema mucosum.

Eczema Vesiculosum.--This may be regarded as the typical and perfect expression of the disease. It is characterized in the beginning by a diffuse redness with puncta, which rapidly become small pinpoint- to pinhead-sized, more or less perfect vesicles, accompanied with heat and usually intense itching. As a rule, the lesions are small and are discrete or confluent. They soon mature and burst, the fluid oozing forth on and over the surface, forming yellowish honeycomb-like scanty or abundant crusts. The skin of such a patch is generally slightly swollen, and at times considerably infiltrated with serum (eczema oedematosum). The disease may thus develop upon a small surface, or, as is oftener the case, over an extensive area, as, for example, the flexor surface of the forearm. There is no disposition for the lesions to group, but they incline to appear in areas, a large patch being usually composed of several smaller patches. The amount of serous fluid poured forth is often great, large bulky crusts forming which in time completely mask the skin beneath. The exudation may take place rapidly in the course of a few days and cease, or it may continue, oozing slowly from day to day or with intermissions from time to time indefinitely, constituting acute, subacute or chronic vesicular eczema. The amount will, moreover, depend somewhat upon the locality involved and whether the disease be properly treated or irritated.

Vesicular eczema may show itself typically, the whole of the affected skin taking on vesicular formation, or, as frequently happens, it may be associated with other varieties of the disease, more particularly pustules and papules. Abortive vesicles and vesico-pustules and vesico-papules are common, occurring here and there mixed with the vesicles and about the circumference of the patch. The amount of surface invaded varies. The disease often manifests itself in different regions simultaneously, as, for example, upon the neck and flexor surfaces of the forearms or upon the trunk and the thighs. In infants the face is the locality usually attacked, constituting the so-called crusta lactea, or milk-crust, of former writers. While the disease tends to manifest itself upon the thin skin of the flexor surfaces of the extremities and upon the face, such is not always the case, for the hands and fingers are also often invaded.

Eczema Pustulosum.--This variety of the disease (designated by some writers eczema impetiginosum) is closely allied to the preceding variety. The lesions may develop as pustules or may become pustular from pre-existing vesicles; both lesions are not infrequently found together, although one of the two will usually predominate. In pustular eczema the swelling, heat, and itching are seldom so marked as in the vesicular variety, and the lesions are generally larger and firmer. As in the case of the vesicles, they rupture and dry, forming yellowish or greenish bulky crusts. This variety is most frequently encountered about the face and scalp, and in those--especially young people--who are strumous, ill-nourished, or in a depraved state of health.

Eczema Papulosum.--Eczema papulosum is characterized by small, rounded or acuminated papules about the size of a pinhead. Sometimes they are well defined and circumscribed, but more frequently they possess no sharply-marked outline or form. They are reddish in color, the tint varying with the individual and with other circumstances, and are usually {628} discrete, although not infrequently they are so numerous and so crowded together as to coalesce and form patches or aggregations of disease, which often show considerable infiltration. They begin as papules, and usually preserve this character throughout their course. Vesicles or vesico-papules not infrequently coexist. Sooner or later the lesions disappear, but are usually replaced by others, the process in this manner continuing its course for weeks or months. The itching is in almost all cases severe and persistent, the patient generally scratching himself to the extent of producing excoriations and blood-crusts. Papular eczema shows a preference for certain regions, notably the extremities, especially the flexor surfaces. The face is seldom attacked. It is one of the most obstinate varieties of the disease.

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In addition to the principal varieties of eczema, just described, there are other forms of the disease which on account of their peculiar features require mention. Of these eczema rubrum, or eczema madidans, may first be spoken of. It is to be viewed as a secondary condition resulting from one or another of the primary varieties. Thus it usually follows eczema vesiculosum or pustulosum. It is characterized by a reddish, moist or discharging surface, the serum, sometimes bloody, usually exuding freely and forming thick yellowish or brownish crusts, together with more or less thickening of the skin and other secondary changes. In other cases discharge is wanting. The condition varies with the stage of the process and with other circumstances: at one time the red, inflammatory dry or oozing skin is the most striking feature, while in other cases this is completely obscured by large, diffuse masses of crust. It may occur upon any region, but it is most frequently met with on the legs, especially in adults, and more particularly in elderly people. It is usually chronic in its course, and may continue for years, better and worse from time to time, but usually evincing no disposition to spontaneous recovery.

Another clinical form of the disease is known as eczema squamosum, which frequently has been preceded by the erythematous variety, and in many cases is to be viewed as a stage of that variety. It may also follow other varieties. It appears in the form of reddish, dry, more or less infiltrated, scaly patches, the amount of scaling being variable. The scales are usually small or fine, and as a rule are scanty. The condition is generally chronic, and is often met with on the scalp.

Fissures, superficial or deep, are not infrequently met with in eczema, usually in the chronic or recurrent forms of the disease, and may be so pronounced as to give rise to the so-called eczema fissum. This is often seen about the fingers and hands, especially the palms. In localized infiltrated patches of chronic eczema a peculiar warty condition is occasionally met with, which is known as eczema verrucosum; or if simply hard, rather than wart-like, eczema sclerosum.

Eczema is divided into acute and chronic, the several forms of the disease being so different in their clinical pictures as to demand such a division, which relates rather to the pathological changes than to time. Thus the disease may show acute symptoms throughout its course, or, on the other hand, may in the beginning take on a chronic action. As a rule, it tends to chronicity, secondary changes in the skin usually manifesting themselves early in the course of the process.

{629} ETIOLOGY.--Eczema is the commonest of the cutaneous diseases, and seems to be of more frequent occurrence in this country than in Europe. It is met with among all classes of society and at all ages. Individuals with light hair and florid complexions are more often subjects of the disease than those of the opposite temperament. Not infrequently the disease is hereditary, although examples are very common in which no such history obtains. So-called eczematous subjects, in which at longer or shorter intervals throughout life and under variable conditions the disease manifests itself, are of frequent occurrence in practice. The state, though well known clinically, is difficult to define, consisting of a peculiar inherent condition of the system at large and of the skin itself which under favorable circumstances permits the disease to assert itself from time to time. The association in some cases of chronic bronchitis and allied affections of the respiratory tract with eczema, and the clinical observation that as one disease improves the other becomes worse, has led some dermatologists to regard eczema as being catarrhal in its nature.

The constitutional causes which may produce the disease are numerous, and are worthy of careful study as bearing directly upon the treatment. Disorders of the digestive tract, including dyspepsia in its many forms and constipation, are not infrequently found to be the exciting cause of an attack, while faulty excretion through the several emunctories, and the existence of a gouty or rheumatic disposition, may all prove potent factors. Deterioration in the tone of the system, arising from varied causes, with impaired nutrition--as seen, for example, during pregnancy and lactation--is sometimes accompanied with an outbreak of the disease, while nervous exhaustion and other neurotic states, as is now well established, are not infrequently active causes.

In some cases excitants, external or internal--as, for example, cutaneous irritants and intestinal worms--may determine an outbreak. In like manner, dentition and vaccination may call forth the disease. Among the local causes producing the so-called artificial eczemas the preparations of mercury, sulphur, croton oil and tincture of arnica are most notable. Contact with the several varieties of the rhus plant, though usually producing a peculiar dermatitis, may in eczematous subjects provoke a genuine eczema. Heat and cold, especially the rays of the sun, are also factors to be considered, while it is well known that the disease in many instances is influenced by the seasons, being, as a rule, worse in winter than in summer. There are many subjects who suffer only in winter. In sensitive skins water, soap, alkalies and acids, all prove more or less injurious, giving rise to harshness or chapping of the skin, and sometimes to eczema. In the same manner the presence of parasites and the consequent scratching are productive of more or less simple dermatitis, and in eczematous subjects the disease under discussion. Eczema is not contagious, a question which is frequently asked by the patient.

PATHOLOGY.--The changes which occur in the skin in the various eczematous conditions are somewhat different as the process is of short or long duration and mild or intense in character. In all cases hyperæmia and exudation, constant symptoms of all inflammations, are present, varying according to the activity and duration of the process. The rete mucosum is also involved in all cases, being oedematous and infiltrated. In {630} the erythematous form the blood-vessels of the papillary layer are dilated, exudation and congestion as well as increasing activity of the rete taking place. In the papular variety the process is mainly limited, primarily at least, to the follicles. The exudation is confined to small circumscribed areas and gives rise to papular elevations. In the vesicular variety fluid exudation occurs in the upper strata of the corium and in the rete, and the formation of vesicles results. The contents of the vesicles consist of a clear liquid containing a few rete-cells and later some pus-corpuscles. In the pustular form the process is more intense in character, and the cell-emigration and multiplication increased. In the chronic forms of the disease the infiltration involves the deeper parts of the corium and even the subcutaneous tissues, which, in addition to the new connective-tissue formation sometimes taking place, gives rise to considerable thickening. The papillæ are enlarged, and at times are considerably hypertrophied, as exemplified by the so-called verrucous eczema. The exudation and cell-infiltration are especially marked along the blood-vessels. In squamous eczema the blood-vessels of the corium and papillæ are dilated, and these parts infiltrated with round cells and changed connective-tissue corpuscles. Pigmentation may take place in the deeper layers of the rete and in the corium, especially about the vessels. The pathological process in eczema seems to have its starting-point in disturbance of the capillary circulation, the origin and nature of which it is difficult to determine.