STROPHULUS OR LICHEN URTICATUS Synonyms.—Lichen urticatus (ViIlan, Bateman), strophulus (Caze nave), varicellar prurigo (Hutchinson), prurigo simplex (Brocq), prurigo temporanea (Tommasoli), urticaria papulosa Wolcott Fox-Hebra), lichen simplex acutus (Vidal).
Clinical Picture (see Plate 62).—The affection described by VIIlan, de Rayer, Hardy, and Colcott Fox pertains closely to the urticaria series. It consists of large whealy efflorescence* which occur in earliest infancy, disappear more or less rapidly and itch considerably. The wheals become flatter toward the periphery and, in contrast to urticarial wheals, have a conelike, blunt prominence in the centre. The eruption is generally found on the trunk, then the extremities (elbow, knee, flexor surface of the wrist, etc.). Frequently these wheals are covered with a central vesi cle, similar to chicken-pox, particularly at the hands and feet.
Course.—The affection generally occurs in the third month, tainly within the first year, ancl lasts till the third or fourth year, rarely up to the eighth. A few authors (Jarisch) have observed strophulus as early as in the first few weeks of life. The wheals which develop, especially in the evening, are vivid red and itch considerably, so that children show great restlessness prior to an attack and are unable to sleep. After a time the eruption heals until occasionally there is a fresh relapse. The bullous form of strophulus is comparatively not rare (Fox has found 163 eases with vesicles among 209). If the child is taken to the physician in this condition, the vesicles may be able to completely hide tbe pathological picture, so that it is almost impossible to make a nosis. The affection usually occurs during the summer and disappears in winter. In December it is least quent, in June and July the most frequent. Sometimes it follows in the wake of chicken-pox (hence the name varieellar prurigo —Hutchinson), of measles and dentition (hence the name feu de dentition). Nearly always it is met with in the course of gastric ders. The papules themselves may last for several (lays, and as they itch considerably, and as there is quently- a great deal of scratching, they hare formed a small scab by the time they come to the healing point. If these spasmodic attacks are of quent recurrence, the affection may last months and years, taxing the little patients severely by sleeplessness and pruritus. Often the neighboring lymph-glands are found to be enlarged and the skin in consequence of the many scratch effects is in a thickened condition as is also seen in prurigo. Pathology.—The affection presents the picture of urticaria com plieated by an inflammatory element. This is the central portion of the lesion which grows upon the wheals (Fox-Darier).
Etiology.—The causes of strophulus are almost universally ac
cepted to be fermentation in the intestine, the toxins of which are responsible for the eruption. Blaseliko has observed rachitis in 50 per cent. of his cases, and often dyspncea and dilatation of the stomach. Funk and Grunzach nearly always found rachitis in 45 cases, Blasehko besides found anemia disproportionately often. Others have held flea bites (Hutchinson) and dentition (Zahnpocken, feu de dents) re sponsible for it. Personally I have almost invariably found strophulus following in the wake of intestinal disorders and generally obtained improvement and cure by changing the diet. Whether hereditary syph ilis can also be held responsible for this affection, is as yet not proven.
Diagnosis.—For purposes of differential diagnosis come in question urtiearia, prurigo (see next paragraph) and chicken-pox. From urticaria it is distinguished by the inflammatory cone; from chicken-pox by its long duration, frequent recurrences and nightly exacerbations.
Prognosis.—The prognosis is generally favorable, and the affection nearly always heals spontaneously.
Treatment.—The treatment is in the first place. directed to the removal of the cause, and in the second place to give relief to the patient. Therefore, according to prevailing eonditions, the first step will be either to attend to the intestinal disorder, treat the rachitis or remove the anmmia. The cleansing of the intestine is done on the principles already explained in urticaria, etc.; in my own cases (and also Zappert's) pure milk diet has proved best. Lassar recommends pulvis compositus (P.G.) which has also rendered excellent service in a number of my cases. The general condition should he improved by iron preparations and codliver oil with phosphorus.
The local treatment consists in the first place in procuring a cool night's rest and using linen underclothing in order to relieve the itching. Besides, sulphur baths are to be recommended, especially combined with application of sulphur soap foarn (Berger's, Unna's, Eichhoff's soaps); also lukewarm salt baths have an excellent effect in some cases. On the other hand, simple warm baths without any addition seem to have an injurious effect. Cooling ointments with carbolic acid (0.5 per cent. caution!) or with 2 per cent. naphthol (Joseph) are applied locally, or cool washings with acetic water and spirits of thyrnol, menthol or carbolic acid. To relieve the excessive itching Blasehko recommends internally: Antipyrin 1.5 Gm. (22 gr.), aqua destill., syrup, gumnios. aa. 25.0 Gna. (1 oz.), one teaspoonful in the evening; also baker's yeast (once or twice daily one teaspoonful in milk) or menthol 0.1 Gin. (11 gr.), ol. amygd. 0.25 Gm. (4 gr.) three times daily 1 capsule) is to be recommended for older children.