PRURIGO (Ram) The form of prurigo which Villan has included among the papulre, has been established as a pathological type by Ferdinand Hebra. It is an affection which begins at the end of the first or second year, attacks the extensor surfaces of the extremities, is accompanied by violent itching and is distinguished by its chronic course. The effiorescences consist of small papules, the size of a pin-head or hemp-seed, which itch considerably. Their color may be that of thc skin or pale red to white, and on account of their tough consistency and localization within the cutis are often more perceptible to the touch than to the eye.
affection often commences in earliest infancy' with spasmodic nrticarial eruptions and lasts longer than ordinary urticaria. It is only toward the end of the second or the beginning of the third year that the small prurigo papule appears, first at the extensor surface of the lower, then of the upper extremities, in the face (rare) and at the trunk. They itch considerably- and are therefore usually scratched open and (covered by a slight scab. These papules feel like a grater when rubbing the skin, and there is a striking roughness of the skin as con trasted with the smoothness of the flexor surfaces, especially of the articular flexions which are soft and smooth and free from papules. In quite a number of cases, however, these premature urtiearial eruptions are absent and the true prurigo papules appear immediately- in the first few years. The itching is exceedingly violent. The children are rubbing day and night, and for that reason there are scratch effects in all stages; in prurigo of long standing there may be (as secondary affections) eczema, impetigo, blood excociations, pigmentations and elephantiastic thicken ing of the skin. The lymphatic glands, too, especially' the inguinal ones, arc considerably swollen and known as the so-called prurigo buboes. According to whether the itching is more or less accentuated and accord ing to whether the relapses °emir more or less frequently, we distinguish between prurigo mitis and pruriga feral. seu agria.
The course of prurigo mitis is eonsiderably milder. Gradually the paroxysms cease and under proper attenticm and treatment the efflorescenees heal, the children recover from the pruritic attacks and the trouble is gradually overcome.
In prurigo ferox the relapses follow in rapid succession, the general condition of the child suffers from the attacks, it sleeps badly, becomes IleIVOUS and irritable, and generally remains puny, pale, thin, and badly developed. In consequence of the frequent relapses the skin is greatly
thickened, has a dark appearance from the many scratch effects and blood extravasations, and on it. we find all stages of prurigo, fine small white eieatriees surrounded by dark areolat, fresh prurigo papules, fresh scratch marks, impetiginous vesicles, eczematous changes. In such eases the entire body and face are usually involved.
The affection is met with in all elasses, the lowest and the highest. It usually; appears in winter, and although it has been observed by Ehlers and Dubreuilh during the summer, the majority of patients have always been observed in the eold months. The number of girls -was twice that of the boys. Heredity also seems to play a rtile.
Pathological tissue in the fresh papules is soft ened, the lymph and blood vessels are dilated, the papillary vessels and the subpapillary vascular network surrounded by small-celled infiltration to the vessels leading downward; at the same time small celled infiltration in the rete. In later stages eystie formations have been found in the cortical and also in the deeper layers by Kromeyer, Darier, Leloir and Tavernier, Unna, etc. A surprisingly large number of cosinophile cells have been found in these papules.
etiology of this affection has so far baffled us completely. Its causes are the same as those of strophulus, that is, in the first place digestive disorders, putrid intestines, etc. In favor of this assumption may be cited four cases of prurigo in which Finger demonstrated intestinal putrefaction and products of decomposition in the urine, which were cured without any other treatment than internal medication (dietetic and antifertnentative). On the other hand, there are children in which this cause is absent and where we are without a cause. Tommasoli and Besnier speak of a prurigo diathesique, with out however being able to adduce a sure proof for their opinion. Again the primary commencement of prurigo with urticaria (observed by Kaposi and later by Mehl) is remarkable and again gives rise to various explanations. Personally I am inclined to look upon the various urti carial affections as separate skin manifestations, caused by different poisons, and poisons of different virulence, from the intestine.