Chapter II: Part 2

The eruption makes its appearance suddenly, and is usually ushered in with febrile disturbance, gastric uneasiness, malaise, and rheumatic pains and swelling about the joints. The lesions vary in size from a cherry to a hen's egg, are rounded or ovalish, tender and painful, have a glistening and tense look, and are of a bright red, erysipelatous color which merges gradually into the sound skin. At first they are somewhat hard, but later they soften and appear as if about to break down, but this, however, never occurs, absorption invariably taking place. In occasional instances they are hemorrhagic. Exceptionally the lesions of erythema multiforme are also present. Lymphangitis is sometimes observed. In rare instances symptoms pointing to visceral involvement, to cerebral invasion, and to heart complications have been observed.

#Are the lesions in erythema nodosum usually numerous?#

No. As a rule not more than five to twenty nodes are present.

#What is the course of erythema nodosum?#

Acute. The disease terminating usually in one to three weeks. As the lesions are disappearing they present the various changes of color observed in an ordinary bruise.

#What is known in regard to the etiology?#

The affection is closely allied to erythema multiforme, and is, indeed, by some considered a form of that disease. It occurs most frequently in children and young adults, and usually in the spring and autumn months. Intestinal toxins are thought responsible in some cases. Digestive disturbance and rheumatic pain and swellings are often associated with it. By many the malady is thought to be a specific infection.

#What is the pathology of erythema nodosum?#

The disease is to be viewed as an inflammatory [oe]dema, probably resulting, in some instances at least, from an inflammation of the lymphatics or an embolism of the cutaneous vessels.

#What diseases may erythema nodosum resemble?#

Bruises, abscesses, and gummata.

#How are the lesions of erythema nodosum to be distinguished from these several conditions?#

By the bright red or rosy tint, the apparently violent character of the process, the number, situation and course of the lesions.

#State the prognosis of erythema nodosum.#

Favorable, recovery usually taking place in ten days to several weeks.

#State the treatment to be advised in erythema nodosum.#

Rest, relative or absolute, depending upon the severity of the case, and an unstimulating diet; internally intestinal antiseptics, quinin and saline laxatives, and locally applications of lead-water and laudanum.

#Erythema Induratum.#
(_Synonym:_ Erythema induratum scrofulosorum.)

#What do you understand by erythema induratum?#

A rare disease characterized in the beginning by one or more usually deep-seated nodules, and, as a rule, seated in the legs, especially the calf region. The nodules gradually enlarge, the skin becomes reddish, violaceous or livid in color. Absorption may take place slowly, or the indurations may break down, resulting in an indolent, rather deep-seated ulcer, closely resembling a gummatous ulcer. The disease is slow and persistent, and is commonly met with in girls and young women, usually of strumous type. It suggests a tuberculous origin.

Treatment consists in administration of cod-liver oil, phosphorus and other tonics. Rest is of service. Locally antiseptic applications, and support with roller bandage are to be advised.

#Urticaria.#
(_Synonyms:_ Hives; Nettlerash.)

#Give a definition of urticaria.#

Urticaria is an inflammatory affection characterized by evanescent whitish, pinkish or reddish elevations, or wheals, variable as to size and shape, and attended by itching, stinging or pricking sensations.

#Describe the symptoms of urticaria.#

The eruption, erythematous in character and consisting of isolated pea or bean-sized elevations or of linear streaks or irregular patches, limited or more or less general, and usually intensely itchy, makes its appearance suddenly, with or without symptoms of preceding gastric derangement. The lesions are soft or firm, reddish or pinkish-white, with the peripheral portion of a bright red color, and are fugacious in character, disappearing and reappearing in the most capricious manner. In many cases simply drawing the finger over the skin will bring out irregular and linear wheals. In exceptional cases this peculiar property is so pronounced and constant that at any time letters and other symbols may be produced at will, even when such subjects are free from the ordinary urticarial lesions (_urticaria factitia_, _dermatographism_, _autographism_).

The mucous membrane of the mouth and throat may also be the seat of wheals and urticarial swellings.

#What is the ordinary course of urticaria?#

Acute. The disease is usually at an end in several hours or days.

#Does urticaria always pursue an acute course?#

No. In exceptional instances the disease is chronic, in the sense that new lesions continue to appear and disappear irregularly from time to time for months or several years, the skin rarely being entirely free (_chronic urticaria_).

#Are subjective symptoms always present in urticaria?#

Yes. Itching is commonly a conspicuous symptom, although at times pricking, stinging or a feeling of burning constitutes the chief sensation.

#In what way may the eruption be atypical?#

Exceptionally the wheals, or lesions, are peculiar as to formation, or another condition or disease may be associated, hence the varieties known as urticaria papulosa, urticaria haemorrhagica, urticaria tuberosa, and urticaria bullosa.

#Describe urticaria papulosa.#

Urticaria papulosa (formerly called _lichen urticatus_) is a variety in which the lesions are small and papular, developing usually out of the ordinary wheals. They appear as a rule suddenly, rarely in great numbers, are scattered, and after a few hours or, more commonly, days gradually disappear. The itching is intense, and in consequence their apices are excoriated. Sometimes the papules are capped with a small vesicle (vesicular urticaria). It is seen more particularly in ill-cared for and badly-nourished young children.

#Describe urticaria haemorrhagica.#

Urticaria haemorrhagica is characterized by lesions similar to ordinary wheals, except that they are somewhat hemorrhagic, partaking, in fact, of the nature of both urticaria and purpura.

#Describe urticaria tuberosa.#

In urticaria tuberosa the lesions, instead of being pea- or bean-sized, as in typical urticaria, are large and node-like (also called _giant urticaria_).

#What is acute-circumscribed [oe]dema?#

In rare instances there occurs, along with the ordinary lesions of the disease or as its sole manifestation, sudden and evanescent swelling of the eyelids, ears, lips, tongue, hands, fingers, or feet (_urticaria [oe]dematosa_, _acute_ _circumscribed [oe]dema_, _angioneurotic [oe]dema_). One or several of these parts only may be affected at the one attack; in recurrences, so usual in this variety, the same or other parts may exhibit the manifestation.

(These [oe]dematous swellings occurring alone might be looked upon, as they are by most observers, as an independent affection, but its close relationship to ordinary urticaria is often evident.)

#Describe urticaria bullosa.#

Urticaria bullosa is a variety in which the inflammatory action has been sufficiently great to give rise to fluid exudation, the wheals resulting in the formation of blebs.

#What is the etiology of urticaria?#

Any irritation from disease, functional or organic, of any internal organ, may give rise to the eruption in those predisposed. Gastric derangement from indigestible or peculiar articles of food, intestinal toxins, and the ingestion of certain drugs are often provocative. The so-called "shell-fish" group of foods play an important etiological part in some cases. Idiosyncrasy to certain articles of food is also responsible in occasional instances. Various rheumatic and nervous disorders are not infrequently associated with it, and are doubtless of etiological significance. External irritants, also, in predisposed subjects, are at times responsible.

#What is the pathology of urticaria?#

Anatomically a wheal is seen to be a more or less firm elevation consisting of a circumscribed or somewhat diffused collection of semi-fluid material in the upper layers of the skin. The vasomotor nervous system is probably the main factor in its production; dilatation following spasm of the vessels results in effusion, and in consequence, the overfilled vessels of the central portion are emptied by pressure of the exudation and the central paleness results, while the pressed-back blood gives rise to the bright red periphery.

#From what diseases is urticaria to be differentiated?#

From erythema simplex, erythema multiforme, erythema nodosum, and erysipelas.

#Mention the diagnostic points of urticaria.#

The acuteness, character of the lesions, their evanescent nature, the irregular or general distribution, and the intense itching.

#What is the prognosis in urticaria?#

The acute disease is usually of short duration, disappearing spontaneously or as the result of treatment, in several hours or days; it may recur upon exposure to the exciting cause. The prognosis of chronic urticaria is to be guarded, and will depend upon the ability to discover and remove or modify the predisposing condition.

#What systemic measures are to be prescribed in acute urticaria?#

Removal of the etiological factor is of first importance. This will be found in most cases to be gastric disturbance from the ingestion of improper or indigestible food, and in such cases a saline purgative is to be given, probably the best for this purpose being the laxative antacid, magnesia; or if the case is severe and food is still in the stomach, an emetic, such as mustard or ipecac, will act more promptly. Alkalies, especially sodium salicylate, and intestinal antiseptics are useful. Calcium chloride in doses of five to twenty grains should be tried in obstinate cases. The diet should be, for the time, of a simple character.

#What systemic measures are to be prescribed in chronic and recurrent urticaria?#

The cause must be sought for and treatment directed toward its removal or modification. Treatment will, therefore, depend upon indications. In obscure cases, quinine, sodium salicylate, arsenic, pilocarpine, _atropia_, potassium bromide, calcium chloride, and ichthyol are to be variously tried; general galvanization is at times useful, as is also a change of scene and climate. A proper dietary and the maintenance of free action of the bowels, preferably, as a rule, with a saline laxative, is of great importance in these chronic cases.

In acute circumscribed [oe]dema treatment is essentially that of urticaria, the diet being given special attention.

#What external applications would you advise for the relief of the subjective symptoms?#

Cooling lotions of alcohol and water or vinegar and water; lotions of carbolic acid, one to three drachms to the pint; of thymol, one-fourth to one drachm to the pint of alcohol and water; of liquor carbonis detergens, one to three ounces to the pint of water, or the following:--

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

Alkaline baths are also useful, and may advantageously be followed by dusting-powders of starch and zinc oxide.

#Urticaria Pigmentosa.#
(_Synonym:_ Xanthelasmoidea.)

#Describe urticaria pigmentosa.#

Urticaria pigmentosa is a rare disease, variously viewed as an unusual form of urticaria and as an urticaria-like eruption in which there is an element of new growth in the lesions. It begins usually in infancy or early childhood and continues for months or years, and is characterized by slightly, moderately, or intensely itchy, wheal-like elevations, which are more or less persistent and leave yellowish, orange-colored, greenish or brownish stains. Exceptionally subjective symptoms are almost entirely absent. Anatomical studies show that the lesion has in some respects the structure of an ordinary wheal, with [oe]dema and pigment deposit in the epidermal portion, and cellular infiltration made up principally of mast-cells.

The nature of the disease is obscure and treatment unsatisfactory. Ordinarily as early youth or adult life is reached it spontaneously disappears. The treatment advised is usually on the same lines as that of chronic urticaria.

#Dermatitis.#

#What is implied by the term dermatitis?#

Dermatitis, or inflammation of the skin, is a term employed to designate those cases of cutaneous disturbance, usually acute in character, which are due to the action of irritants.

#Mention some examples of cutaneous disturbance to which this term is applied.#

The dermatic inflammation due to the action of excessive heat or cold, to caustics and other chemical irritants, and to the ingestion of certain drugs.

#What several varieties are commonly described?#

Dermatitis traumatica, dermatitis calorica, dermatitis venenata, and dermatitis medicamentosa.

#Describe dermatitis traumatica.#

Under this head are included all forms of cutaneous inflammation due to traumatism. To the dermatologist the most common met with is that produced by the various animal parasites and from continued scratching; in such, if the cause has been long-continued and persistent, a variable degree of inflammatory thickening of the skin and pigmentation result, the latter not infrequently being more or less permanent. The inflammation due to tight-fitting garments, bandages, to constant pressure (as bed-sores), etc., also illustrates this class.

#What is the treatment of dermatitis traumatica?#

Removal of the cause, and, if necessary, the application of soothing ointments or lotions; in bed-sores, soap plaster, plain or with one to five per cent. of ichthyol.

#What is dermatitis calorica?#

Cutaneous inflammation, varying from a slight erythematous to a gangrenous character, produced by excessive heat (_dermatitis ambustionis_, _burns_) or cold (_dermatitis congelationis_, _frostbite_).

#Give the treatment of dermatitis calorica.#

In burns, if of a mild degree, the application of sodium bicarbonate, as a powder or saturated solution, is useful; in the more severe grade, a two- to five-per-cent. solution will probably be found of greater advantage. Other soothing applications may also be employed. In recent years a one-per-cent. solution of picric acid has been commended for the slighter burns of limited extent. Upon the whole, there is nothing yet so generally useful and soothing in these cases as the so-called Carron oil; in some cases more valuable with 1/2 to 1 minim of carbolic acid added to each ounce.

In frostbite, seen immediately after exposure, the parts are to be brought gradually back to a normal temperature, at first by rubbing with snow or applying cold water. Subsequently, in ordinary chilblains, stimulating applications, such as oil of turpentine, balsam of Peru, tincture of iodine, ichthyol, and strongly carbolized ointments are of most benefit. If the frostbite is of a vesicular, pustular, bullous, or escharotic character, the treatment consists in the application of soothing remedies, such as are employed in other like inflammatory conditions.

#What do you understand by dermatitis venenata?#

All inflammatory conditions of the skin due to contact with deleterious substances such as caustic, chemical irritants, iodoform, etc., are included under this head, but the most common causes are the rhus plants--_poison ivy_ (or _poison oak_) and _poison sumach_ (_poison dogwood_). Mere proximity to these plants will, in some individuals, provoke cutaneous disturbance (_rhus poisoning_, _ivy poisoning_), although they may be handled by others with impunity.

Many other plants are also known to produce cutaneous irritation in certain subjects; among these may be mentioned the nettle, primrose, cowhage, smartweed, balm of Gilead, oleander, and rue.

The local action of iodoform (_iodoform dermatitis_) in some individuals is that of a decided irritant, bringing about a dermatitis, which often spreads much beyond the parts of application, and which in those eczematously inclined may result in a veritable and persistent eczema.

#Describe the symptoms of rhus poisoning.#

The symptoms appear usually soon after exposure, and consist of an inflammatory condition of the skin of an eczematous nature, varying in degree from an erythematous to a bullous character, and with or without [oe]dema and swelling. As a rule, marked itching and burning are present. The face, hands, forearms and genitalia are favorite parts, although it may in many instances involve a greater portion of the whole surface.

#What is the course of rhus poisoning?#

It runs an acute course, terminating in recovery in one to six weeks. In those eczematously inclined, however, it may result in a veritable and persistent form of that disease.

#How would you treat rhus poisoning?#

By soothing and astringent applications, such as are employed in acute eczema (_q. v._), which are to be used freely. Among the most valuable are: a lotion of fluid extract of grindelia robusta, one to two drachms to four ounces of water; lotio nigra, either alone or followed by the oxide-of-zinc ointment; a saturated solution of boric acid, with a half to two drachms of carbolic acid to the pint; a lotion of zinc sulphate, a half to four grains to the ounce; weak alkaline lotions; cold cream, petrolatum, and oxide-of-zinc ointments.

#How would you treat the dermatitis due to other deleterious substances of this class?#

By applications of a soothing and protective character, similar to those used in eczema and burns.

#Dermatitis Medicamentosa.#

#What do you understand by dermatitis medicamentosa?#

Under this head are included all eruptions due to the ingestion or absorption of certain drugs.

In rare instances one dose will have such effect; commonly, however, it results only after several days' or weeks' continued administration. With some drugs such effect is the rule, with others it is exceptional, nor are all individuals equally susceptible.

#How is the eruption produced in dermatitis medicamentosa?#

In some instances it is probably due to the elimination of the drug through the cutaneous structures; in others, to the action of the drug upon the nervous system. The view that the drug acts as a toxin or generates some toxin or irritant material in the blood, to which the eruptive phenomena may be due, has also been advanced.

#What is the character of the eruption in dermatitis medicamentosa?#

It may be erythematous, papular, urticarial, vesicular, pustular or bullous, and, if the administration of the drug is continued, even gangrenous.

#Name the more common drugs having such action.#

Antipyrin, arsenic, atropia (or belladonna), bromides, chloral, copaiba, cubebs, digitalis, iodides, mercury, opium (or morphia), quinine, salicylic acid, stramonium, acetanilid, sulphonal, phenacetin, turpentine, many of the new coal-tar derivatives, etc.

#State frequency and types of eruption due to the ingestion of antipyrin.#

Not uncommon. _Erythematous_, morbilliform and erythemato-papular; itching is usually present and moderate desquamation may follow. Acetanilid, sulphonal, phenacetin, and other drugs of this class may provoke like eruptions.

#Mention frequency and types of eruption due to the ingestion of arsenic.#

Rare. Erythematous, erythemato-papular; exceptionally, herpetic, and pigmentary. Herpes zoster has been thought to follow its use. Keratosis of the palms and soles has also been occasionally observed, which, in rare instances, has developed into epithelioma.

#Mention frequency and types of eruption due to the ingestion of atropia (or belladonna).#

Not uncommon. _Erythematous_ and _scarlatinoid_; usually no febrile disturbance, and desquamation seldom follows.

#Give frequency and types of cutaneous disturbance following the administration of the bromides (bromine).#

Common. _Pustular_, sometimes furuncular and carbuncular and superficially ulcerative. In exceptional instances papillomatous or vegetating lesions have been observed. Co-administration of arsenic or potassium bitartrate is thought to have a preventive influence in some cases.

#State frequency and types of cutaneous disturbance due to the administration of chloral.#

Occasional. Scarlatinoid and urticarial, and exceptionally purpuric; in rare instances, if drug is continued, eruption becomes vesicular, hemorrhagic, ulcerative and even gangrenous.

#State frequency and types of eruption following the administration of copaiba.#

Not uncommon. _Urticarial_, erythemato-papular and _scarlatinoid_.

#Mention frequency and types of eruption resulting from the ingestion of cubebs.#

Uncommon. Erythematous and small papular.

#Mention frequency and types of eruption resulting from the administration of digitalis.#

Exceptional. Scarlatinoid and papular.

#State frequency and types of eruption resulting from the iodides (iodine).#

Common. _Pustular_, but may be erythematous, papular, vesicular, bullous, tuberous, purpuric and hemorrhagic. Co-administration of arsenic or potassium bitartrate is thought to have a preventive influence in some cases.

#Give the frequency and types of eruption observed to follow the administration of mercury.#

Exceptional. Erythematous and erysipelatous.

#Give the frequency and types of the cutaneous disturbance following the ingestion of opium (or morphia).#

Not uncommon. Erythematous and _scarlatinoid_, and sometimes urticarial.

#Mention the frequency and the types of eruption following the administration of quinine.#

Not infrequent. Usually _erythematous_, but may be urticarial, erythemato-papular, and even purpuric. There is, in some instances, preceding or accompanying systemic disturbance. Furfuraceous or lamellar desquamation often follows.

#State frequency and types of eruption resulting from the ingestion of salicylic acid.#

Not common. Erythematous and urticarial; exceptionally, vesicular, pustular, bullous, and ecchymotic.

#Give frequency and type of cutaneous disturbance due to the administration of stramonium.#

Not common. Erythematous.

#State frequency and types of eruption resulting from the administration of turpentine.#

Not uncommon. _Erythematous_, and small-papular; exceptionally vesicular.

#X-Ray Dermatitis.#

#What several grades of x-ray dermatitis (x-ray burns, Rontgen-ray burns) are observed?#

Three grades are usually described: erythema, superficial vesication, and necrosis. The first and second may come on shortly--a few hours to several days--after exposure; occasionally later. The third grade may present also in the first several days, but in many cases one to several weeks may elapse before it appears; it is quite commonly preceded by erythema and vesication. The necrosis may be superficial or deep, and quite usually results in a persistent ulcer covered by a leathery coating; it is usually painful.

#Give the prognosis and treatment of x-ray dermatitis.#

The first grade--the erythematous--usually disappears in one to ten days; the second grade requires one to several weeks, and may be quite sore and tender; the severe or necrotic burns are persistent, sometimes lasting for months and several years, with little tendency to spontaneous disappearance, and rebellious to treatment.

Treatment of the milder types is that of erythema (_q. v._); the necrotic type occasionally demands thorough curetting and skin-grafting before it will heal.

#Dermatitis Factitia.#
(_Synonym:_ Feigned Eruptions.)

#What do you understand by feigned eruptions?#

Feigned, or artificial, eruptions, occasionally met with in hysterical females and in others, are produced, for the purpose of exciting sympathy or of deception, by the action of friction, cantharides, acids or strong alkalies; the cutaneous disturbance may, therefore, be erythematous, vesicular, bullous, or gangrenous. It is usually limited in extent, and, as a rule, seen only on parts easily reached by the hands.

#Dermatitis Gangraenosa.#

#What do you understand by dermatitis gangraenosa?#

Dermatitis gangraenosa (_erythema gangraenosum_, _Raynaud's disease_, _spontaneous gangrene_) is an exceedingly rare affection, characterized by the formation of gangrenous spots and patches. It may be idiopathic or symptomatic. Some of these cases, especially in hysterical subjects, belong under the "feigned eruptions," being self-produced.

As an idiopathic disease, it begins as erythematous, dark-red spots--usually preceded and accompanied by mild or grave systemic disturbance--which gradually pass into gangrene and sloughing; the eventual termination may be fatal, or recovery may take place. As a symptomatic disease, it is occasionally met with in diabetes and in grave cerebral and spinal affections.

In Raynaud's disease (symmetric gangrene) the parts affected are the extremities, such as fingers and toes, the ears and nose, only occasionally other parts. The first symptoms observed are coldness and paleness of the part; followed sooner or later by congestion of a dark red, livid, or bluish color, with sometimes swelling, and tenderness and shooting pains. The termination is usually in gangrene of a dry character, with, in some instances, vesicles and blebs along the edges; in other cases the parts become atrophied, withered, and indurated.

Treatment is based upon general principles.

#Erysipelas.#

#What is erysipelas?#

Erysipelas is an acute specific inflammation of the skin and subcutaneous tissue, commonly of the face, characterized by shining redness, swelling, [oe]dema, heat, and a tendency in some cases to vesicle- and bleb-formation, and accompanied by more or less febrile disturbance.

#Describe the symptoms and course of erysipelas.#

A decided rigor or a feeling of chilliness followed by febrile action usually ushers in the cutaneous disturbance. The skin at a certain point or part, commonly where there is a lesion of continuity, becomes bright red and swollen; this spreads by peripheral extension, and in the course of several hours involves a portion or the whole region. The parts are shining red, swollen, of an elevated temperature, and sharply defined against the sound skin. After several days or a week, during which time there is usually continued mild or severe febrile action, the process begins to subside, and is followed by epidermic desquamation.

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, .............[=a][=a].....[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, .......... [=a][=a] ..... [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, .......... [=a][=a] ........ gr. v
Glycerinae,
Alcoholis, ......... [=a][=a] ........ [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.#