Chapter III: Part 3

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

#Describe the mixed type of dermatitis herpetiformis.#

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

#Describe the characters of the vesicles, pustules and blebs.#

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

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

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

#Are there any constitutional symptoms in dermatitis herpetiformis?#

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

#What is the course of dermatitis herpetiformis?#

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

#What is to be said in regard to the etiology?#

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

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

#Mention the diagnostic features of dermatitis herpetiformis.#

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

#Give the prognosis of dermatitis herpetiformis.#

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

#State the treatment to be advised.#

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

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

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

#Psoriasis.#

#Give a definition of psoriasis.#

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

#At what age does psoriasis usually first make its appearance?#

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

#Has psoriasis any special parts of predilection?#

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

#Are there any constitutional or subjective symptoms in psoriasis?#

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

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

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

#Give the development and history of a single lesion.#

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

#Describe the so-called clinical varieties of psoriasis.#

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

#Is the eruption of psoriasis always dry?#

Yes.

#What course does psoriasis pursue?#

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

#Is the course of psoriasis influenced by the seasons?#

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

#What is known in regard to the etiology of psoriasis?#

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

#Is psoriasis contagious?#

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

#What is the pathology?#

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

#With what diseases are you likely to confound psoriasis?#

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

#How is psoriasis to be distinguished from squamous eczema?#

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

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

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

#How does seborrh[oe]a differ from psoriasis?#

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

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

#How does psoriasis differ from ringworm?#

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

#Give the prognosis of psoriasis.#

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

#How is psoriasis treated?#

Both constitutional and local remedies are demanded in most cases.

#Do dietary measures exert any influence?#

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

#Name the important constitutional remedies usually employed in psoriasis.#

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

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

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

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

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

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

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

#What are the indications as regards the external measures?#

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

#How are the scales removed?#

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

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

#Are soothing applications often demanded in psoriasis?#

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

#How are the stimulating remedies employed in psoriasis applied?#

As ointments, oils, and paints (pigmenta).

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

#Name the several important external remedies.#

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

#Are these several external remedies equally serviceable in all cases?#

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

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

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

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

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

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

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

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

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

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

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

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

#Pityriasis Rosea.#
(_Synonym:_ Pityriasis Maculata et Circinata.)

#What do you understand by pityriasis rosea?#

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

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

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

#Describe the symptoms of pityriasis rosea.#

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

#What course does pityriasis rosea pursue?#

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

#To what is pityriasis rosea to be attributed?#

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

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

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

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

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

#State the prognosis of pityriasis rosea.#

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

#What treatment is to be advised in pityriasis rosea?#

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

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

#Describe dermatitis exfoliativa.#

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

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

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

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

#Give the treatment of dermatitis exfoliativa.#

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

#Lichen Planus.#

#What is lichen planus?#

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

#Describe the symptoms of lichen planus.#

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

#What is the etiology of lichen planus?#

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

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

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

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

#State the prognosis.#

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

#What treatment would you prescribe in lichen planus?#

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

#Pityriasis Rubra Pilaris.#
(_Synonyms:_ Lichen Ruber; Lichen Ruber Acuminatus.)

#Describe pityriasis rubra pilaris.#

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

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

#Lichen Scrofulosus.#

#Describe lichen scrofulosus.#

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

#What is the treatment of lichen scrofulosus?#

The condition responds to tonics and anti-strumous remedies.

#Eczema.#
(_Synonym:_ Tetter; Salt Rheum.)

#What is eczema?#

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

#What are the several primary types of eczema?#

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

#What other types are met with clinically?#

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

#Describe the symptoms of erythematous eczema.#

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

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

#What course does erythematous eczema pursue?#

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

#Describe the symptoms of papular eczema.#

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

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

#What course does papular eczema pursue?#

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

#Describe the symptoms of vesicular eczema.#

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

The face in infants (_crusta lactea_, or _milk crust_, of older writers), the neck, flexor surfaces and the fingers are its favorite localities.

#What course does vesicular eczema pursue?#

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

#Describe the symptoms of pustular eczema.#

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

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

#What course does pustular eczema pursue?#

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

#Describe the symptoms of squamous eczema.#

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

The disease is not uncommon upon the scalp.

#What is the course of squamous eczema?#

Essentially chronic.

#Describe the symptoms of eczema rubrum.#

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

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

#What is the course of eczema rubrum?#

Chronic, varying in intensity from time to time.

#Describe the symptoms of fissured eczema.#

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

It is especially common about the hands and fingers.

#What is the course of fissured eczema?#

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

#Describe eczema sclerosum and eczema verrucosum.#

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

#State the nature of the subjective symptoms in eczema.#

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

#Is eczema accompanied by febrile or systemic symptoms?#

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

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

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

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

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

#State the character of eczema as regards duration.#

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

#Is eczema influenced by the seasons?#

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

#To what may eczema be ascribed?#

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

#Name some of the important constitutional or predisposing causes.#

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

#Is a constitutional cause sufficient to provoke an attack?#

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

#Mention some of the external causes.#

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

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

#Is eczema contagious?#

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

#What is the pathology?#

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

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

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

#What common skin diseases resemble some phases of eczema?#

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

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

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

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

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

#How does scabies differ from eczema?#

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

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

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

#How does eczema differ from sycosis?#

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

#State the general prognosis of eczema.#

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

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

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

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

#Does eczema ever leave scars?#

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

#How is eczema treated?#

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

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

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

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

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

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

#Mention the important remedies variously employed in the constitutional treatment.#

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

_Alkalies_--sodium salicylate, potassium bicarbonate, liquor potassae, and lithium carbonate.

_Alteratives_--calomel, colchicum, arsenic, and potassium iodide.

_Diuretics_--potassium acetate, potassium citrate, and oil of copaiba.

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

_Digestives_--pepsin, pancreatin, muriatic acid and the various bitter tonics.

#Are there any remedies which have a specific influence?#

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

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

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

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

#In what cases is arsenic usually contraindicated?#

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

#What should be the character of the external treatment?#

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

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

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

#How often should remedial applications be made?#

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Or the following ointment:--

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

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

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

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

A lotion containing resorcin, five to thirty grains to the ounce.

Solution of zinc sulphate, one-half to three grains to the ounce.

An ointment containing calomel or ammoniated mercury, as in the annexed formula:--

[Rx] Hydrargyri ammoniat. seu Hydrargyri
chloridi mit., ................... gr. x-xxx
Ac. carbolici, ..................... gr. v-x
Ungt. zinci oxidi, ................. [Oz]j M.

Another formula, more especially useful in eczema of the hands and legs, is the following:--

[Rx] Ac. salicylici, ...................... gr. xxx
Emp. plumbi,
Emp. saponis,
Petrolati, ...... [=a][=a] ........... [Oz]j. M.

(This is to be applied as a plaster, spread on strips of lint, and changed every twelve or twenty-four hours.)

The paste-like ointment, referred to as useful in acute eczema, may also be used with a larger proportion (20 to 60 grains to the ounce) of salicylic acid.

The following, containing tar, may often be employed with advantage:--

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

#What is to be said in regard to the use of tarry applications?#

Ointments or lotions containing tar should always be tried at first upon a limited surface, as occasionally skins are met with upon which this remedy acts as a more or less violent irritant. The coal tar lotion (liquor carbonis detergens) is the least likely to disagree and may be used as a mild ointment, one or two drachms to the ounce, or it may be diluted and used as a weak lotion as already referred to.

#What external remedies are to be employed in eczema of a sluggish type?#

The various remedies and combinations (mentioned above) useful in acute and subacute eczema may often be employed with benefit, but, as a rule, stronger applications are necessary, especially in the thick and leathery patches. The following are the most valuable:--

An ointment of calomel or ammoniated mercury; forty to sixty grains to the ounce.

Strong salicylic-acid ointment; a half to one drachm of salicylic acid to the ounce of lard.

Tar ointment, official strength; or the various tar oils, alone or with alcohol, as a lotion, or in ointment form.

Liquor picis alkalinus[B] is a valuable remedy in chronic _thickened_, _hard_ and _verrucous_ patches, but is a strong preparation and must be used with caution. It is applied diluted, one part with from eight to thirty-two parts of water; or in ointment, one or two drachms to the ounce. In such cases, also, the following is useful:--

[Rx] Saponis viridis,
Picis liq.,
Alcoholis, .......... [=a][=a] ....... [dram]iij. M.

SIG. To be well rubbed in.

[Footnote B:
[Rx] Potassae, ............................. [dram]j
Picis liq., .......................... [dram]ij
Aquae, ................................ [dram]v.

Dissolve the potash in the water, and gradually add to the tar in a
mortar, with thorough stirring.]

In similar cases, also, the parts may be thoroughly washed or scrubbed with sapo viridis and hot water until somewhat tender, rinsed off, dried, and a mild ointment applied as a plaster.

Lactic acid, applied with one to ten or more parts of water is also of value in the sclerous and verrucous types. Caustic potash solutions, used cautiously, may also be occasionally employed to advantage in these cases.

Another remedy of value in these cases, as well as in others of more or less limited nature, is the _x_-ray. Exposures every few days, of short duration and 4 to 10 inches distance, with medium vacuum tube. This method has served me well in occasional cases; caution is necessary, and it should not be pushed further than the production of the mildest reaction. The repeated application of a high-frequency current, by means of the vacuum electrodes, is a safer and sometimes an equally beneficial method.

#Is there any method of treating eczema with fixed dressings?#

Several plans have been advised from time to time; some are costly, and some require too great attention to details, and are therefore impracticable for general employment. The following are those in more common use:--

The _gelatin dressing_, as originally ordered, is made by melting over a water-bath one part of gelatin in two parts of water--quickly painting it over the diseased area; it dries rapidly, and to prevent cracking glycerine is brushed over the surface. Or the glycerine may be incorporated with the gelatin and water in the following proportion: glycerine, one part; gelatin, four parts, and water eight parts. Medicinal substances may be incorporated with the gelatin mixture.

A good formula is the following:--

[Rx] Gelatin, ............................. [Oz]j
Zinci oxidi, ......................... [Oz]ss
Glycerini, ........................... [Oz]iss
Aquae, ................................ [Oz]ii-[Oz]iij.

This should be prepared over a water-bath, and two per cent. ichthyol added. A thin gauze bandage can be applied to the parts over which this dressing is painted, before it is completely dry; it makes a comfortable fixed dressing and may remain on several days.

_Plaster-mull_ and _gutta-percha plaster_. The plaster-mull, consisting of muslin incorporated with a layer of stiff ointment, and the gutta-percha plaster, consisting of muslin faced with a thin layer of India-rubber, the medication being spread upon the rubber coating.

_Rubber plasters._ These are medicated with the various drugs used in the external treatment of skin diseases, and are often of service in chronic patches.

Two new excipients for fixed dressings have recently been introduced--bassorin and plasment; the former is made from gum tragacanth, and the latter from Irish moss.

The following is a satisfactory formula for a tragacanth dressing:

[Rx] Tragacanth, .......................... gr. lxxv
Glycerini, ........................... [minim] xxx
Ac. carbolici, ....................... gr. x-xx
Zinci oxidi, ......................... [dram]iss-[dram]iiss. M.

This is painted over the parts and allowed to dry, and a mild dusting powder sprinkled over. It cannot be used in warm weather or in folds, as it is apt to get sticky. The following is a bassorin paste which may be variously medicated.

[Rx] Bassorin, ............................ [dram]x
Dextrin, ............................. [dram]vj
Glycerini, ........................... [Oz]ij.
Aquae, ....................... q.s. ad. [Oz]iij.

It should be prepared cold.

Another "drying dressing" which may be used in cool weather is:

[Rx] Zinci oxidi, ......................... [Oz]j
Glycerini, ........................... [Oz]ss
Mucilag. acaciae, ..................... [Oz]ii-[Oz]iv.

It may be variously medicated.

The plaster-mull is used in all types, especially the acute; the gelatin dressing, and the gutta-percha plaster, in the subacute and chronic; and the rubber plaster in chronic, sluggish patches only. Acacia, tragacanth, bassorin and plasment applications are used in cases of a subacute and chronic character.

#Prurigo.#

#Define prurigo.#

Prurigo is a chronic, inflammatory disease, characterized by discrete, pin-head- to small pea-sized, solid, firmly-seated, slightly raised, pale-red papules, accompanied by itching and more or less general thickening of the affected skin.

#Describe the symptoms and course of prurigo.#