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THE CANADIAN MEDIcAL ASSOCIATION JOURNAL

We have not in the past five years seen an

uncomplicated case of rapidly fatal caseating
pneumonia. It has occurred accompanying a
miliary tuberculosis, but has been rare. We
have under observation one child of 5 years who
is now well, 16 months after having the presence
of miliary tuberculosis proven by x-ray. We
have seen only three cases of the adult type of
fibro-caseous apical tuberculosis. The x-ray picture does not differ from that of adult patients.
Two of the children are dead. One is alive in
a sanatorium, with the progress of her disease
at last stayed after a dishearteningly rapid
spread. Truly when the famous "ability to
fibrose" becomes manifest, death follows apace.
The diagnosis then rests upon the triad of
history, tuberculin reaction and roentgenogram.
The treatment consists, we insist, first and above
all things on the prevention of further infection.
We do not believe that sanatorium treatment is
advisable, except in the case of the rare child
who develops the so-called adult type of phthisis.
A brief stay in hospital is at times most beneficial for the child who will not eat or will not
go to bed, just as it is in the case of non-tuber-

[Oct. 1933
1933

culous children with the same behaviour difficulties. Short stays in bed on account of fever
are occasionally necessary. For the rest good
plain wholesome food at home, and a normal
sleeping routine according to the age of the
child, are all that are necessary. Given these
few things, the prognosis in the small primary
type and the massive second type is excellent.
With unquestionable caseous pneumonia without
complications we have had no experience. For
the rare apical lesions of the adult type various
methods of rest and collapse therapy must be
instituted early under sanatorium care, and even
then the prognosis is grave. Miliary tuberculosis
without meningeal involvement is not hopeless.
WTe believe collapse therapy offers a chance. We
are willing to try pneumothorax at any age if
it is required.
We would then draw attention to the frequency of pulmonary tuberculosis in infancy
and childhood, and to its relative benignity.
But above all we would emphasize the important
part that reinfection in the home plays in determining a fatal issue in these otherwise hopeful
cases.

LICHEN SIMPLEX CHRONICUS

By D. E. H. CLEVELAND, M.D., C.M.,
Vancouver

T HE condition which is to be discussed in this

paper is, in the opinion of the author, an
exceedingly common one. It is capable of producing much distress and resultant general
impairment of health, especially as chronicity
is a prominent feature, and, except in its early
incipient stages, it is resistant to all ordinary
treatment. In spite of its frequent occurrence
the nature of the trouble is usually unrecognized
and it is regarded as some chronic type of
eczema.
Lichen simplex chronicus may accompany
eczema as well as other forms of dermatitis and
other dermatoses, but should not be confused
with them. It may be defined briefly as chronic,
dry thickening of one or more circumscribed
areas of skin, with scaling and pigment formation and intense itching. The pruritus is an
essential feature of the disease, and usually has
preceded the objective signs. When the characteristic picture appears in the course of an

eczema it often occurs upon parts which have

not participated in any of the phases of the
eczematous reaction. It may accompany or
follow other diseases also, such as psoriasis, in
which no eczematous symptoms have been present. It also very frequently appears out of a
clear sky upon a hitherto apparently normal
skin.
The phenomenon of chronic papulation, infiltration, and scaliness of the skin is commonly
spoken of as lichenification. When observed
occurring over large areas, as in the disease
named lichen ruber planus by Willan, the resemblance to a lichen growing over a tree-trunk
or boulder is not altogether fanciful. The confusion which formerly existed between lichen
planus and the skin-reaction at present under
consideration has been responsible for the
terminology of the latter.
Among the early students of this condition
was the late Louis Brocq and his school. Brocq

Oct. 1933]
193

Oct

LiCHEN
CLEVELAND:
SIMPLEX CHRONICUS
LVLN:
IHNSMLX
HoIu

designated the circumscribed type of lichenification as nevroderrnite, usually rendered into

English as neurodermatitis. Vidal, of the same
school, used the term lichen simplex chronicus,
which seems preferable, since it is purely
descriptive and contains no etiological implications. Both names are now in common usage,
and the malady has been accorded almost
universally a distinct nosologic identity. While,
as indicated above, it appears either primarily
upon an objectively normal skin, or secondary
to other dermatoses, the present practice, as
indicated in the comprehensive paper by Wise
published in 1919,1 is to minimize the distinction between the primary and secondary forms,
upon which distinction Brocq was insistent.
Clinical appearance and course.-The lesions
may be single or multiple. In the latter case
there is commonly a symmetrical arrangement.
They may occur anywhere upon the cutaneous
surface, but there are certain regions of predilection. The commonest sites are in the head
and neck, the occipito-nuchal and sternomastoid regions; in the extremities, the flexural
surfaces of the elbow, wrist and knee, the volar
surface of the forearm, especially over the belly
of the supinator longus, the flat expanse of the
ulna below the point of the elbow, the inner

369
6

surface of the thigh, especially in its upper

third, and the middle and lower thirds of the
leg on its anterior and outer aspects; on the
trunk, the outer surface of the axillary folds,
the groin, pubic and perineal regions, the
intergluteal cleft, and the outer or lateral
surfaces of the labia majora or scrotum.
The lesion, as most commonly encountered
by the physician, is in its full-blown development and it will be best to describe its appearance at this stage, before considering the
various stages of its unfolding, with their
variations. Sharp definition is not the inivariable rule. Nevertheless, a margin is usually
to be distinguished, sufficient to enable the
observer to speak of a characteristic outlilne.
This tends to be rectilinear rather than curved.
"Polycyclic," "gyrate," "serpiginous" and
"geographic" are not appropriate terms, but
"lozenge-shaped" or "triangular" describes
the majority of the lesions, while band-like,
and occasionally even roughly rectangular
patterns will sometimes be observed on large
flat surfaces, such as the volar surface of the
forearm, the inner side of the thigh, and on
the shin. When the lesions are not onily
thickened but appreciably raised they may be
described as "plaques." The dimensions of

FIG. 1.-A woman, aged 47, asthFIG. 2.-A Chinese cook, aged
matic. Inner side thigh. Coarse 38. Lesion generally elevated;
quadrillage upper left; colour pinkish- colour grayish-brown; smooth burgray; skin of body much pigmented, nished surface. Observe the satelintensified at margin of lesion. Cleared lite papules.
up promptly under x-ray and has remained clear for 6 years. Other lesions
have since appeared on neck and arms.

FIG. 3.-A Swedish lumberjack,

aged 35. Popliteal area. Observe
the rugose thickening and nail-hole
excoriations.

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THE CANADIAN MEDICAL AssocIATION JOURNAL

the plaque in the majority of cases range

between the extremes of 3 by 6 and 6 by 10 cm.
The colour shades from a pinkish-bistre
through various tints of yellow and brown to
a deep reddish-brown, nearer walnut or teak
than mahogany. It is usually more intense in
the central part of the lesion, and proportionately to its age, although in many old cases,
especially on the legs, there may be mottling
due to irregular loss of pigment, and even a
completely leucodermic centre surrounded by a
dark zone. The normal linear markings of the
skin are greatly intensified. They have been
described as appearing sometimes like the
strokes of a burin on a wax plate. Minute
examination will nearly always reveal also a
pattern of fine lines crossing each other at
right angles, aptly termed by Broeq quad} illage.
This appearance is extremely characteristic.
The surface may be smooth and dull with a
greyish sheen, in which case it will be found
to be covered with delicate adherent scales
which fall in a branny shower when it is
scratched or rubbed. Except in the occipitonuchal region where the scales may be larger,
more loosely attached, unctuous and sometimes
yellowish, the scales are usually almost microscopic in size. On the flexures and the bandlike lesions on the upper inner surface of the
thigh scales are frequently absent. In such
regions the numerous parallel or interlacing
deep lines remind one of a finely burnished
piece of kangaroo leather, except that the
colour is apt to be pinkish. In parts where
there is moisture and warmth, notably in the
scroto-crural and labio-crural folds and the
intergluteal cleft, the scale may be replaced
by a grayish pellicle of macerated epidermis.
ln other places, as over the shin, there may be
a dry, gritty or raspy surface like the skin of
a dog-fish. Scratching may produce seroius
oozing or even bleeding, but this results only
from trauma, and moisture is not an intrinsic
feature of the lesion. Papules may be distributed irregularly over the surface of the patch,
or more commonly grouped about its margin.
They are rounded, and hemispherical or
flattened, and may have a glistening surface.
They seldom exceed the size of a large pin-head.
Pseudo-papules, much smaller, closely aggregated and non-elevated, are also seen.
Pautrier and others have described instances
of what they call "giant lichenification" or

[Oct. 1933
1933

"hypertrophic neuro-dermatitis." This occurs

nmost frequently in the genito-crural and anoperineal regions. Bizzozero2 considers that the
predilection of hypertrophic forms for such
areas, where the skin is thin, delicate and relaxed, is evidence of the important part played
by regional constitution of the skin in determining locality and type of lichenification. These
lesions bear a relationship to the commoner
type similar to that of the syphilitic condyloma
to the syphilitic papule.
In its incipiency lichen simplex chronicus
may develop in connection with some other
skin disease of a chronic character. In such
cases it does not necessarily appear upon an
area previously the site of lesions of the
accompanying dermatosis. More often there is
first to be seen a pink dry roughness with no
definite margin. In the classical case peripheral extension occurs, the central portion
becomes papular and of deeper colour, and
shows evidence of excoriation. As this area
widens in turn it is replaced by a thick,
leathery deeply pigmented area. Thus is developed the text-book picture, as described by
Brocq, Darier, Pusey and others in their works,
of an outer transition zone, pink, dry, with
slightly deepened "flesh-tints"; then a median
zone of thickening wvith roughness, due to
aggregated flat or slightly rounded-up papules,
surrounding a centre of infiltrated, dark skin.
Such an ideal picture is not commonly encountered in practice. Any one of the three
zones or stages of intensity of the infiltrative
process may be absent, or almost totally masked
by one of the others. The outer zone of pinkishbistre or cafe-au-lait tinge and noticeable
quadrillage may be all that is visible. The
papular zone may be represented by a sparse
scattering of rather large, discrete hemispherical papules. Or the oldest central portion may
be a perfectly smooth burnished area with
pigment evenly distributed, broken up by leuco-

dermic spots (leucomelanodermie-Brocq), or

completely depigmented. When involution occurs, either as a result of treatment or spontaneously, these features disappear in order of
appearance, years elapsing sometimes before the
pigment goes.
So far, morphology has been dwelt upon at
length in the endeavour to make the disease
readily recognizable by its external characteristics. One constant symptom which is extremely

Oct. 1933]

Oct. 1933]

CLEVELAND: LiCHEN SIMPLEX, CHRONICUS

CLEVELAND:

LICHEN

important apart from its diagnostic significance

has not been emphasized. This is pruritus. It
is generally believed that in every primary case
pruritus precedes all objective evidence of disease. This cannot always be verified, for the
majority of patients when seen have had the
disease for so long that they cannot give a clear
history of circumscribed pruritus preceding the
eruption. In secondary cases the area upon
which the latter develops may or may not have
been involved by the original dermatosis.
Whether primary or secondary, the peculiar
quality and paroxysmal character of the pruritus, which is such a constant and striking symptom, is the same.
During the greater part of the day itching
may be absent. There is a notable vesperal
periodicity, but it may not appear until after
the patient has retired, when it is very apt to
keep him awake or rouse him from his sleep.
Special circumstances appear to precipitate its
onset, and it frequently follows them at such a
short interval that it seems to have the nature
of a reflex response. Rapid filling of the
stomach with a large and hot meal, the drinking
of hot fluids or stimulants, such as alcoholic
beverages, strong tea or coffee, the ingestion of
condiments, local heat. as from a fire-place or hot
bath, sudden exposure to cool air, as in undressing, are among the events which frequently
bring on a paroxysm. A lowered threshold to
various nervous and psychic stimuli occurring
at the end of the day and its fatigues seems to
be another factor of importance in bringing on
the attacks at this time. Habit and memory
association also has been noted by some writers,
Jacquet speaking of a "mnernodermie prurigente. " It is believed that in many of the above
instances neuro-vascular instability furnishes an
explanatory connecting link between the exciting cause and the pruritic response.
The itching is usually preceded by tingling
or tickling sensations inciting the patient to rub
or lightly scratch the parts. The first stroke or
two appears to release a torrent of itching.
Sometimes this is appalling. The sufferer is
rapt in a frenzy of furious rubbing or scratching with the nails or some other sharp instrument, scores furrows in the skin, and actually
tears off strips -of epidermis. In addition to
the local evidence of the violence of these digital
attacks, the square-ended brilliantly polished
nails, buffered on the patient 's own hide, are

SIMPLEX

CHRONICUS

371

371

further testimony. Observers often remark that

the patient, although injuring himself, seems to
derive a peculiar pleasurable satisfaction from
the act, and that this is followed by indications
of a voluptuous sense of relief and exhaustion.
This is referred to by Darier,3 who speaks of
"onanisme cntane," although he does not imply
that he considers the resemblance to sex-orgasm
more than superficial.
Etiology.-Brocq 's view, expressed in many
of his writings on the subject and generally
accepted, was that the objective changes in the
skin resulted from an idiosyncrasy to frictiontrauma. It may be formulated as: pruritus +
idiosyncrasy = lichenification. When the pruritus was circumscribed the lichenification was
circumscribed. Circumscribed lichenification is
lichen simplex chronicus, or as Brocq called it,
"nevrodermite."
The question of etiology thus hinges uponl
the cause of the pruritus. By his terminiology
Brocq indicated that he considered it primarilv
a neurosis of the skin. This view has beeni
widely held. But it is difficult to see how ai
purely neurogenic origin can be predicated of
those cases in which the lichenified patch has
appeared on a spot where eczema, seborrhbeic
dermatitis, an occupational dermatitis, or a
dermatitis venenata has pre-existed, yet whichl
has not been confined to that spot . alone.
While it is true that neuropathic symptoms are
observed in a very large number of cases with
this disorder, this is not the case in all. While
it has a higher incidence among females, an(d
mostly in the third and fourth decades ill
either sex, it is not rare in very young children,
and in men and women of the stolid, phlegmatic
and bovine types. It is questioned if the
niervous symptoms often observed are nlot the
result of long-continued interference with sleep
and rest rather than the cause of the disease.
Patients with neurasthenia, the various functional neuroses, hysteria and organic nervous
disorders are not especially subject to neurodermatitis.
A certain number of cases appear beyonid all
question to have been initiated by local pressure
and friction, usually in connection with the
patient's occupation, or the wearing of certain
articles of clothing and appliances.
The important role of allergy as a cause of
this condition has been increasingly emphasized
in recent years. This is notable in the paper

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THE CANADIAN MmicAL ASSOCIATION JOURNAL

THE

CANADIAN

by Wise and Ramirez4 presented in 1924. Wise

remarks later in the course of editorial comment5 " The conception of hypersensitiveness
and allergy plus the nervous factor in neurodermites is a distinct advance over the older
theories which considered the psychogenic and
neurogenic factors alone."
Stokes6 considers that in a considerable proportion of lichenification the primary pruritus
may be an expression of an underlying sexual
stress or craving. (Vide supra-Darier 's "onanisme cutane"). The pruritus may then be
primary in the psychic field without any
dermatitic foundation. On the other hand it
may be that what might be called "cutaneous
masturbation" arises as a secondary phenomenon, engrafted upon an itching dermatosis as
a result of the patient's discovery that scratching yields an approximate or exact equivalent
of the sex-orgasm.
It is probable that no single etiological
factor is constantly present, but the essential
factor is a peculiar reaction of the skin in
certain individuals, notably those with a low
threshold for neurogenic or psychogenic stimuli,
towards small frequently repeated traumata.
In most cases these injuries have the form of
localized allergic reactions, but they may be
and often are of purely external origin with no
evidenrce of allergy.
The significance of the localization upon
parts exposed to small, frequently repeated,
irritation or injury cannot be overlooked. It is
felt that even in the allergic cases where the
irritant has reached the skin from within, this
external factor plays an important part in
determining the site of the eruption. It is
likely that the scratching itself is a factor in
continuing the process, once the latter is set in
motion. A vicious circle can be supposed, the
pruritus at first necessitating scratching, which
in turn intensifies the reaction, necessitating
further and more violent scratching, structural
changes in the skin appearing pari passu. The
fact that in the therapy of this disease the first
result showing success, and an absolute
requisite, is a suppression of itching supports
this view. No other improvement can be expected as long as the itching remains unchecked.
Diagnosis.-The character of the pruritus, already described, is almost sufficient by itself to
distinguish the disease from other dermatoses

[Oct. 1933

which may have a superficial resemblance to it.

Psoriasis sometimes itches severely, but it is the
profuse guttate eruption and not the large and
less numerous patches which itch most commonly. The scales of psoriasis are generally
larger, and on account of their enclosed airspaces have a brighter metallic lustre; the large
patches have rounded or polycyclic outlines and
tend to clear centrally, producing circinate
figures. Patches of lichen planus are occasionally difficult to distinguish from lichen simplex
chronicus. The colour has much more of blue
in its composition, and the individual papules
are polygonal rather than rounded, are more
commonly shiny, and display the characteristic
minute transverse striations (Wickham's strir).
Their tendency to linear arrangement along
scratch-marks is also pathognomonic. The
rounded and polycyclic outlines of the patches,
with their yellowish greasy scale, distinguish
seborrheic dermatitis, which most frequently
involves the sternal, interseapular, temporal,
parietal and other areas not commonly the site
of lichen simplex chronicus. The latter disease
however, whether it accompanies seborrheeic
dermatitis of the scalp or not, when occurring
in the occipito-nuchal area commonly exhibits
within the bounds of the hairy scalp the typical
yellowish-gray masses of greasy scale of
seborrhoeic character which Sabouraud terms
pityriasis steatodes. Eczema is distinguished by
its polymorphic character and exudative tendency. The plaques of circumscribed sclerodermna are rarely itchy, the surface is smooth,
the outline rounded or band-like, the colour is
chiefly of bluish and reddish tints, and intensified skin-markings and scaling are absent.
Histopathology.-The microscopic picture as
described by McCarthy7 is about what would be
anticipated from the clinical appearance: generalized hyperkeratosis with circumscribed areas
of parakeratosis, active proliferation of the cells
of the rete malpighii, with resulting long narrow
rete pegs, some cedema of the tips of the papilke,
moderate lymphocytic infiltration, and increased
pigment formation in the basal and lower layer
of the rete cells.
Treatment.-Apart from the trite observation
that measures directed towards improvement of
the general health should be employed, it is
necessary to emphasize the importance of certain features of the general as well as local
treatment. The former should be along two

Oct.
1933]
Oct.
1933]

CLEVELAND: LICHEN SIMPLF-X CHRONICUS

373

CLEVELAND: LICHEN SIMPLEX CHRONICUS

373~~~~~~~~~~~~~~~~~~-

definite lines of attack; first a search for definite evidence of allergy, attempting to identify
when possible the substances to which the patient
reacts, and endeavouring either to remove them
from the patient's environment, or to neutralize
him to their effects; secondly, a search for
sources of nervous or psychic depression, tension
or irritation, and again an endeavour towards
elimination or neutralization.
In the investigation of allergy we should O11
theoretical grounds anticipate much help from
skin-tests. If anything of practical value is to
be obtained from this method it would appear
to be essential that this testing be conducted by
an experienced allergist. When such assistanee
is not available it will be worth wvhile to
climinate certain classes of foods from the diet
which are more frequently incriminated on the
charge of setting off allergic "explosionis," or
otherwise acting as cutaneous irritanits. The
prinieipal ones are shell-fish, eggs, red meats,
cheese, raws fruits (citrus fruits are occasionally
permissible) and vegetables, preserved meat
anid fish, tomatoes, alcohol, tea, coffee, vinegar
and condiments. Carbohydrates should be
limited to strict caloric requirements. Tobacco,
especially cigars, should be indulged in only
wTith much circumspection. Hasty eating and
extremes of temperature of ingesta are to be
avoided. The patient may furnish extremely
valuable clues, in the case of certain foods,
gathered from his owvn observations. Such
knowledge of a general and particular character is a safer guide for dietary restriction
than that furnished by skin-tests, which are
niotoriously unreliable in the hands of inexperieneed workers.
In case of failure to obtain assistanee from
this form of investigationi, and especially wvhere
the integumeintary, respiratory, gastrointestinal
or other systems furnish other evidenee of
allergy, the empirical procedure of foreigniproteini therapy may be attempted. Of the
various ageneies used, the author prefers initranmuscular injection of the patient's ownl blood.
The results are quite as good as those obtained
from milk preparations, vaccines, organ-extracts, etc., and severe reactions are extremely
rare. Its effect in stopping itching in many
allergic dermatoses is often quite astoniishing
and gratifying. The method of desensitization
by isolating and inijeetinig a proteose from the
urine, advocated by Barber anid Oriels in the

treatment of many allergic diseases, has possibilities which if realized may revolutionize the
methods of handling them now in vogue.
Revision of the patient 's habits of work,
recreationi and rest, a study of his temperament,
obtaining his cooperation, and sometimes that
of his relatives as well, in effecting adjustments resulting in fewer overheated bearings,
nmay well repay the trouble which this takes.
In some of these cases the neuropsychiatrist
may be a valuable conisultant.
Among other diseases which may coexist anid
play leading or secondary roles in the etiology
are blood dyserasias, hepatic dysfunctioni, pancreatic or renal disease, gastrointestinal deranigemenit, focal infections and malignant
disease. Treatment of these, if found, thus
becomes part of the therapy of the cutalneous

disease.
LUider the headinig of measures of local treatment the x-ray gives the greatest number of satisfactory resuilts. Large doses at long intervals
do not give as good results as smaller, more frequently repeated, doses. Several cases have been
seen in whieh there was involvement of the
occipito-nuchal region in women, in which epilation had resulted from one or two intensive or
sub-intensive doses without any appreciable dinmintution in the pruritus. Bv careful fractional
treatment such cases are usually cleared up
entirely withouit even a temporary defluvium.
M1ost cases wiill be greatly improved or cured
by six or eight fractional doses. If this fails
to effect anly conisiderable improvenment it is
un'wise to conitinue the radiationi. There is nio
general agreement that the effects of filtered
radiationi are superior to those of unfiltered.
Frequent recurrence in the same area will of
course necessitate the use of other measures.
Amoing those to be considered are intensive
treatment with water-cooled ultra-violet radiatioin, sufficienit to produce exfoliation. The
author has succeeded on several occasions in
euring cases with x-rays whieh had resisted exfoliatin,, doses of ultra-violet, hence feels that
ultra-violet is not the first method of choice.
Sutton prefers radium to x-rays, but the size
of most lesions prohibits this method as one of
choice with most private practitioners. Results
similar to those obtained by ultra-violet have
been rel)orted by several writers, using strong
chemical agents suclh as cresol (IT.S.P.) or
Cutler's solution (pheniol. chloral hydrate and

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THE CANADIAN MEDICAL AssocIATION JOURNAL

iodin, equal parts) to produce exfoliation. The

author has found useful in a few cases a method
recommended by Graham Little,9 which consists
in painting the area every five days with a lotion
consisting of phenol, glycerin and liquor carbonis
detergens, of each 4 parts, water to 60 parts,
and applying calamine lotion several times daily
in the intervals. Where there is much scaly
thickening, the active medicament, coal tar or
one of its derivatives, such as liquor carbonis
detergens, should be incorporated in a Lassar
paste containing from 3 to 5 per cent of salicylic acid.
Sabouraud's method (based upon the assumption that local infection with a strain of streptococcus is the prime etiological factor), painting with a 1 per cent solution of iodin crystals
in alcohol, followed by coal-tar ointment and
free exposure to open air and summer sunlight,
has not proved in the author's hands superior
to the use of coal tar alone, or as detailed previously. Occlusive dressings of gelatin or some
other impermeable substance have been advocated by some. On a priori grounds these
would appear to be unsuitable, and other writers
have recorded unfavourable effects from their
use.
Prognosts. - This would appear to depend
principally upon the success with which endeavours to discover and control the source of
irritation are met. In untreated cases spontaneous recovery has been known to occur not rarely,
although usually after a course of many years.
In such cases attacks of itching become progressively less frequent, softness, smootlhness
and pliability of the skin gradually return, and
last of all the pigmentation fades. Unifortunately, however, even in treated cases, there is
a tendency to recur, though not always on the
original site. It is felt that this is due to failure
to achieve curative rather than merely palliative
results. This may be due in turn to undue concentration upon the local lesion, with resulting
neglect of a thorough study of the allergic,
A NEW USE FOR FISH LIVER.-In the Brit. M. J.,

1932, 2: 347, the subject of the treatment of pernicious

anawmia has been discussed, and Professor L. S. P.
Davidson. UJniversity of Aberdeen, has proved that an
extract frorm the livers of whiting, haddock and cod is
a specific cure for this baffling disease. The oil from
fislh livers is found to be quite as effective as extracts

[Oct. 1933
1933

neurological, occupational and other possible

features in the background.
SUMMARY
Lichen simplex chronicus, often known as
neuro-dermatitis, is a distinct nosological entity,
not to be confused with eczema, although it is
often associated with this disease.
In nature it is a dermatological reaction to
repeated or continuous irritation, arising either
from internal or external causes, occurring in
subjects whose skins have a constitutional tendency to react in this- particular manner.
Allergic, psychoneurological and occupational
factors play an important part in creating the
background upon which the symptomatology is
displayed.
Treatment must be general as well as local.
In addition to the usual considerations to be regarded in the plan of campaign against any
constitutional malady, special attention must be
directed towards the factors mentioned in the
preceding paragraph; they must be sought ouit
and overcome.
In local treatment the x-ray properly employed is the most frequently successful agenicy,
but its limitations must be recognized. Wheni
these are reached other methods must replace
it, the most valuable of which are ultra-violet
radiation and coal tar with its derivatives.
The prognosis is uncertain, and largely dependent upon the degree of success which meets
the efforts of the medical attendant to discover
and deal with the constitutional elemenits in the
disease. Spontaneous recovery after a vrery
protracted course not infrequently occurs.
REFERENCES
1. WISE, J. G'wtan. Dis., 1919, 37: 590.
2. BIZZOZEPO, Annt. de dermat. & syph., 1924. 5: 331.
3. DARIER, Precis de Dermatologie, Massoni et Cie., Paris. 192:;,
607.
4. WISE AND RAMIREZ, Arch. Dernnat. & Syph., 1925, 11: 751.
5. WISE, Dermatology, Practical Medicine Series, Year B-ok
Publishers, Chicago, 1931, 165.
6. STORES, Arch. Dermat. & Syph.. 1930. 22: 803.
7. MCCARTHY, Histopathology of Skin Diseases, C. V. Mosby,
St. Louis, 1931, 190.
8. BARBER AND ORIEL, The Lancet, 1928, 2: 1009, 1064.
9. IATTLE, The Practitioner, 1932, 128: 224.

from mammalian livers. With the assistance of the

Food Investigation Board, an apparatus is being usedI
to deal with a hundred pounds of fish liver each week.
This amount of liver yields about five pounds of tfle
extract. The daily dose for a patient is approximately
two ounces. Treatment of nine patients showedl that
the extract strongly stimulates blood formation.