How is it distinguished from these several diseases?

The size, shape, inflammatory action, and the depraved general condition, the distribution and lesser-contagiousness will distinguish it from impetigo contagiosa; and the absence of concomitant symptoms of syphilis, and of positive ulceration, as well as its distribution and more rapid and inflammatory course, will exclude the pustular syphiloderm.

State the prognosis.

The disease is readily curable, disappearing upon the removal of the predisposing cause and the employment of local antiseptic applications.

What treatment is to be advised?

Good food, proper hygiene and tonic remedies; and, locally, removal of the crusts and stimulation of the underlying surface with an ointment of ammoniated mercury, ten to thirty grains to the ounce.

The following mild antiseptic lotion, which materially lessens the tendency to the formation of new lesions, may be applied to the affected region two or three times daily:--

[Rx] Acidi borici, ........................ [dram]iv Resorcini, ........................... [dram]ij Glycerinae, ........................... f[dram]ij Alcoholis, ........................... f[Oz]j Aquae, ........... q.s. ad ............ Oj. M.

A weak lotion of thymol, corrosive sublimate or ichthyol would doubtless be equally effectual.

Pemphigus.

What do you understand by pemphigus?

Pemphigus is an acute or chronic disease characterized by the successive formation of irregularly-scattered, variously-sized blebs.

Name the varieties met with.

Two varieties are usually described--pemphigus vulgaris and pemphigus foliaceus.

Describe the symptoms and course of pemphigus vulgaris.

With or without precursory symptoms of systemic disturbance, irregularly scattered blebs, few or in numbers, make their appearance, arising from erythematous spots or from apparently normal skin. They vary in size from a pea to a large egg, are rounded or ovalish, usually distended, and contain a yellowish fluid which, later, becomes cloudy or puriform.

If ruptured, the rete is exposed, but the skin soon regains its normal condition; if undisturbed, the fluid usually disappears by absorption.

Each lesion runs its course in several days or a week.

A grave type of pemphigus is exceptionally observed in the newborn--_pemphigus neonatorum_.

What course does pemphigus vulgaris pursue?

Usually chronic. The disease may subside in several months and the process come to an end, const.i.tuting the acute type. As a rule, however, the disease is chronic, new blebs continuing to appear from time to time for an indefinite period.

[Ill.u.s.tration: Fig. 30. Pemphigus (mulatto).]

In what respects does the severe form of pemphigus vulgaris differ from the ordinary type?

In the severe or malignant type the eruption is more profuse; there is marked, and often grave, systemic depression, and the lesions are attended with ulcerative action.

Describe the symptoms and course of pemphigus foliaceus.

In this, the grave type of the disease, the blebs are loose and flaccid, with milky or puriform contents, rupturing and drying to crusts, which are cast off, disclosing the reddened corium. New blebs appear on the sites of disappearing or half-ruptured lesions, and the whole surface may be thus involved and the disease continue for years, compromising the general health and eventually ending fatally.

In some cases of pemphigus (pemphigus vegetans) a vegetating or papillomatous condition develops from the base of the lesion, with an offensive discharge; it is usually a grave type of the malady.

Exceptionally cases (dermat.i.tis vegetans) are met with which have a close similarity in their symptoms to pemphigus vegetans, but in which the eruption is more or less limited to the genitocrural region. The disorder is not malignant and usually yields to cleanliness and antiseptics.

What is the character of the subjective symptoms in pemphigus?

The subjective symptoms consist variously of heat, tenderness, pain, burning and itching, and may be slight or troublesome.

What is known in regard to the etiology of pemphigus?

The causes are obscure; general debility, overwork, shock, nervous exhaustion, and septic conditions (microorganisms) are thought to be of influence. There seems no doubt that those who have to do with cattle products, especially butchers, are subjects of acute and usually grave pemphigus. Vaccination has exceptionally been responsible for the disease, probably through some coincidental infection. The disease is not contagious, nor is it due to syphilis. It may occur at any age.

It is a rare disease, especially in this country. Most of the cases diagnosed as pemphigus by the inexperienced are examples of bullous urticaria, bullous erythema multiforme, and impetigo contagiosa.

What is the pathology?

The lesions are superficially seated, usually between the h.o.r.n.y layer and upper part of the rete. Round-cell infiltration and dilated blood vessels are found about the papillae and in the subcutaneous tissue. The contents of the blebs, always of alkaline reaction, are at first serous, later containing blood corpuscles, pus, fatty-acid crystals, epithelial cells, and occasionally uric acid crystals and free ammonia.

From what diseases is pemphigus to be differentiated?

From herpes iris, the bullous syphiloderm, impetigo contagiosa and dermat.i.tis herpetiformis.

How do these several diseases differ from pemphigus?

The acute course, small lesions, concentric arrangement, variegated colors, and distribution, in herpes iris; the thick, bulky, greenish crusts, the underlying ulceration, the course, history, and the presence of concomitant symptoms of syphilis, in the bullous syphiloderm; the history, course, distribution, the character of the crusting, and the contagious and auto-inoculable properties of the contents of the lesions, in impetigo contagiosa; the tendency to appear in groups, the smaller lesions, the intense itchiness, course, multiform characters of the eruption and the disposition to change of type in dermat.i.tis herpetiformis,--will serve as differential points.

State the prognosis of pemphigus.

Its duration is uncertain, and the issue may in severe cases be fatal.

In the milder types, after months or several years, recovery may take place.

The extent and severity of the disease and the general condition of the patient are always to be considered before an opinion is expressed.