The same disease has been described with the two names given, some observers regarding it as being due to a disordered state of the sweat apparatus, others as being an inflammatory affection. We incline to the latter view, looking upon true dysidrosis as a form of miliaria. The disease under consideration is without question neurotic in origin. It occurs chiefly in those suffering from nervous debility or prostration arising from varied causes. It is due to impaired, faulty innervation. It is most liable to be mistaken for vesicular eczema or pemphigus. The treatment should be general, consisting of such remedies as quinine and arsenic, together with good food and proper hygiene. Local treatment may be prescribed as in the case of eczema, but the result in most cases is not as satisfactory as in that disease.
Pemphigus.
Pemphigus is an acute or chronic bullous disease, characterized by the successive formation of variously sized and shaped blebs. Two varieties are met with—pemphigus vulgaris and pemphigus foliaceus—the symptoms of which differ considerably. Pemphigus vulgaris, the usual form of the disease, appears with or without precursory symptoms. In marked cases headache and fever may precede the cutaneous outbreak. All portions of the body may suffer, but the extremities are more commonly the seat of the eruption. The mucous membrane of the mouth and vagina may also be involved. The lesions, as a rule, are rarely seen in large numbers, a dozen or so usually being present at one time. They vary in size from a pea to a large egg, and are generally rounded or ovalish, fully distended, and according to the size are elevated from a few lines to an inch above the surrounding skin. There is but little inflammation attending their formation. In some cases the blebs arise from erythematous spots or wheals, but generally from apparently normal skin. The fluid is yellowish, later often becoming cloudy or puriform. At times slight hemorrhage occurs, giving the lesions a reddish or purplish color. Spontaneous rupture of the lesions seldom occurs, the contents usually disappearing by absorption. Each bleb runs its course in from two to eight days. Itching and burning are rarely prominent symptoms, in some cases being scarcely noticeable or absent, in others present to a marked degree, constituting pemphigus pruriginosus. In children pemphigus vulgaris is usually attended with systemic disturbance; in adults, as a rule, only in severe cases. The disease may be acute or chronic. Acute pemphigus is rare, and occurs, as a rule, only in children. It usually runs a favorable course, except in ill-nourished children, in whom it may take on a malignant type and have a fatal termination. Chronic pemphigus may be benign or malignant. In the benign form the eruption may persist several months by successive outbreaks, and then disappear, or the blebs may form irregularly and indefinitely. In the former case there may be but the one attack, or, as commonly occurs, relapses may follow after months or years. In the malignant form the disease is more violent, with marked systemic depression and ulcerative action, and may frequently have an unfavorable termination.
Pemphigus foliaceus, the other variety of the disease, is rare. The blebs are loose and flaccid, with milky or puriform contents, rupture, and the oozing liquid dries to crusts, which are cast off, disclosing the reddened corium beneath. The blebs may coalesce and involve considerable surface, and may appear in rapid succession on other regions and on the sites of disappearing or half-ruptured lesions; even the whole surface may become involved, the process continuing for years, undermining the general health and eventually destroying the patient.
Pemphigus is a rare disease, and seems to be of even less frequent occurrence in this country than abroad. It is not contagious, nor is it due to syphilis, the so-called syphilitic pemphigus being a bullous syphiloderm and not a true pemphigus. General debility, overwork, shock, and nervous prostration are influential in producing the disease. Occasionally an hereditary tendency is traceable.
The contents of blebs are at first colorless or yellowish, consisting of serum,—later containing blood-corpuscles, pus, fatty-acid crystals, and epithelial cells, and occasionally uric-acid crystals and free ammonia. The reaction is alkaline, becoming more markedly so as the contents grow older. The lesions are superficially seated, between the horny layer and upper part of the rete and the lengthened cells of the rete and the corium. The papillæ and subcutaneous tissues show round-cell infiltration and dilated blood-vessels.
Herpes iris and the bullous syphiloderm are to be excluded in the diagnosis. In herpes iris the acute course, small lesions, variegated colors, the usually marked areola, the decided tendency to concentric arrangement of the lesions, the seat of the disease,—all tend to distinguish it from pemphigus. The thick, bulky, greenish crusts of the bullous syphilide, with the underlying ulceration, its course, and the presence of concomitant symptoms of that disease, taken with the history of the case, are points of difference. Impetigo contagiosa may at times strikingly resemble pemphigus, but the history of the case, its distribution, the contagious and auto-inoculable properties of the contents of the lesions, and the characteristic crusting of the former disease,—are all available in the differential diagnosis. The blebs of pemphigus are to be distinguished also from the accidental blebs of urticaria and of erythema multiforme. It is to be remembered also that cases sometimes come under observation in which blebs are, for the sake of feigning disease, produced artificially, the subjects being usually hysterical women.
Pemphigus is in most cases a grave disease. The unfavorable symptoms are the presence of numerous bullæ, the rapid and successive development of new lesions, flabby walls, frequent febrile attacks, loss of strength, and marasmus. It is injudicious, even in mild cases, to express an opinion as to the probable duration of the disease. Both constitutional and local treatment, especially the former, are demanded. The general health should receive careful study and faulty conditions corrected. Good food, milk, wine, or ale, eggs and meat are in most cases to be advised. Suitable hygienic regulations should also receive attention. Arsenic in appropriate doses, long continued, has in some cases almost a specific action: on the whole, it must be regarded as our most valuable remedy. Quinine in full doses, cod-liver oil, iron, and the mineral acids are also of service. External treatment is of importance, and is in many cases demanded for the comfort of the patient. The blebs are to be opened as soon as developed, and the parts anointed with oxide-of-zinc ointment. Lotio nigra, used as in eczema, will sometimes be found soothing, as also lotions containing liquor carbonis detergens or liquor picis alkalinus. Dusting-powders of zinc oxide with talc and starch are likewise useful. Baths containing bran, starch, or gelatin sometimes afford ease. Corrosive-sublimate baths, one or two drachms to the bath, and alkaline baths in some cases prove of service. After the bath an application of an ointment or mild dusting-powder may be made to advantage. Where baths prove unsuitable or are impracticable, mild ointments may be used, such as diachylon ointment, vaseline, cold cream, or zinc ointment, spread upon cloth and bound down with bandages.